/I/I  ?.  3  197, 

92fiM 


TREATISE 


ON 


DISEASES  OF  THE  SKIN 


FOR  THE  USE  OF 


Advanced  Students  and  Practitioners 


L 


BY 

HENRY  w.  STELWAGON,  M.D.,  PH.LX 

Professor  of  Dermatology  in  the  Jefferson  Medical  College,  Philadelphia ;   Dermatologist  to 
the  Philadelphia  Hospital;   Consulting  Dermatologist  to  the  Howard  Hospital,  to   the 
Pennsylvania  Institution  for  the  Deaf  and  Dumb,  to  the  Pennsylvania  Institution  for 
Feeble-Minded  Children,  and  to  the  Widener  Memorial  Training  School  for  Crippled 
Children  5   Member  of  the  American  Dermatological  Association ;    Honorary 
Member   of  the  Society  of  Dermatology  and   Syphilography  of  Italy  t 
Associate  Member  of  the  Society  of  Dermatology  and  Syphilogra- 
phy of  France,  of  the  Vienna  Dermatological  Society,  and  of 
the  Berlin  Dermatological  Society 

Seventb  Edition,  Uborougblp  1Re\>teefc 


With  334  Illustrations  in  the  Text,  and  33  Full-page 
Colored  and  Half-tone  Plates 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS   COMPANY 
J9J4 


Copyright,  1902,  by  W.  B.  Saunders  and  Company.     Set  up,  electrotyped,   printed,  and 
copyrighted  June,  1902.      Reprinted  and  recopyrighted    February,  1903.     Revised, 
reprinted,  and  recopyrighted  January,  1904.     Reprinted  November,  1904.    Re- 
vised, reprinted,  and  recopyrighted  October,   1905.     Reprinted  August, 
1906.     Revised,  reprinted,  and  recopyrighted  August,  1907.     Re- 
printed July,  1908,  and  November,  1909.    Revised,  reprinted, 
and  recopyrighted  July,  1910.     Reprinted  July,  1911. 
Revised,  entirely  reset,  reprinted,  and  recopy- 
righted   January,     1914 


Copyright,  1914,  by  W.  B   Saunders  Company. 


Reprinted  December,  1914 


PRINTED    IN    AMERICA 


PRESS    OF 

W.    B.    SAUNDERS    COMPANY 
PHILADELPHIA 


TO   THE    MEMORY  OF 

LOUIS   A.  DUHRING,  M.D.,  LL.D. 


PREFACE  TO  SEVENTH  EDITION. 


THE  past  several  years  have  been  a  period  ot  active  investigation 
in  several  of  the  chief  dermatologic  diseases,  notably  syphilis,  lep- 
£<•)  rosy,  sporotrichosis,  pellagra,  ringworm,  and  tropical  affections,  and 
the  results  of  such  investigations,  partly  considered  in  the  edition 
of  1910  of  this  work,  will  be  found,  with  the  increased  knowledge 
and  advances  since  that  date,  more  fully  presented  in  the  present 
volume.  In  many  of  the  other  diseases  besides  those  just  named 
new  facts,  some  of  considerable  importance,  have  also  been  brought 
forward  and  likewise  incorporated.  Descriptions  of  new  or  more  or 
less  recently  acknowledged  independent  disorders  are  presented  for 
the  first  time,  among  which  may  be  mentioned  prurigo  nodularis, 
granuloma  pyogenicum,  benign  sarcoid,  and  keratosis  blenorrhagica. 
The  value  of  illustrations  has  again  been  recognized  by  the  addition 
of  about  forty  new  cuts,  the  most  important  being  several  of  leprosy, 
prurigo  nodularis,  lupus  vulgaris,  Oriental  sore,  dermatitis  vegetans, 
annular  syphiloderm,  the  ring  type  of  impetigo  contagiosa,  and  cul- 
tures (Sabouraud)  of  the  main  ringworm  fungi.  In  order  that  the 
vast  amount  of  text  changes,  new  matter,  and  additional  illustrations 
should  have  fair  presentation  without  too  great  an  increase  in  the 
number  of  pages,  much  that  was  old  and  more  or  less  obsolete  has 
been  eliminated.  The  revision  has  been,  therefore,  as  will  readily  be 
seen,  of  more  than  average  character — so  extensive,  in  fact,  as  to 
necessitate  a  complete  resetting  of  the  book.  As  heretofore,  the  new 
literature  references  are  largely  those  of  papers,  which  give  an  ana- 
lytical review  of  previous  contributions  on  the  subject. 

H.  W.  S. 
1634  SPRUCE  STREET, 
PHILADELPHIA. 


PREFACE. 


IN  the  preparation  of  this  book  I  have  endeavored  to  keep  one 
aim  predominantly  in  view — to  present  the  practical  part  of  the  sub- 
ject in  a  sufficiently  complete  manner  as  to  make  the  work  one 
that  will  give  those  engaged  in  general  practice  a  full  comprehension 
of  the  symptomatology,  diagnosis,  and  treatment  of  the  various  affec- 
tions with  which  they  are  most  likely  to  come  in  contact.  The  symp- 
toms are,  therefore,  detailed  at  some  length,  and  often  in  the  plain, 
elementary  way  that  I  have  found  in  college  and  postgraduate  teach- 
ing most  successful  in  giving  a  clear  grasp  of  the  essential  characters. 
As  a  preliminary  to  this  the  primary  and  consecutive  lesions  which 
are  essentially  the  groundwork  of  dermatology  are  allotted  more 
than  the  usual  space.  Diagnosis,  apparently  the  most  difficult  and 
confusing  part  of  cutaneous  medicine,  has  been  given  considerable 
attention.  The  elaborated  remarks  under  General  Diagnosis  may, 
it  is  hoped,  be  of  substantial  aid  in  surmounting  some  of  the  diffi- 
culties. With  the  purpose  of  emphasizing  the  clinical  and  diagnostic 
aspects  I  have  made  use  of  a  large  number  of  illustrations  from  my 
own  collection  of  original  photographs,  supplemented  by  those  gener- 
ously placed  at  my  disposal  by  my  dermatologic  colleagues,  to  whom 
I  wish  to  express  my  sincere  thanks,  and  who  will  be  found  specifi- 
cally mentioned  and  credited  in  connection  with  the  individual  cuts. 
To  strengthen  this  feature  also  the  publishers  have  kindly  permitted 
the  insertion  of  a  number  of  selected  colored  plates  from  their  well- 
known  Mracek  Hand- Atlases  of  Diseases  of  the  Skin  and  Syphilis! 

The  other  practical  part  of  dermatology — treatment — has  in  the 
most  important  diseases  been  described  more  or  less  in  detail,  in  some 
places,  to  those  who  are  experienced,  possibly  to  the  point  of  tedious 
simplicity,  but  observation  has  taught  me  that  student  and  practitioner 
should  have  pointed  out  not  only  what  in  a  general  way  is  to  be 
prescribed,  but,  when  possible,  some  definite  directions  as  to  selection 
and  method.  In  addition  to  the  remedies  and  methods  used  in  my 
own  practice,  I  have  referred  largely  also  to  those  employed  and 
advised  by  others,  the  various  standard  treatises  and  contributions 
by  other  writers  being  frequently  cited,  not  only,  in  fact,  in  this, 
but  likewise  in  other  divisions  of  this  work. 

Although  the  practical  parts,  including  etiology,  have  been  allotted 
the  greater  space,  it  has  not  been  my  intention  to  neglect  pathol- 
ogy and  pathologic  histology,  but  to  give  these  in  a  sufficiently 
ample  manner  as  to  be  a  complete,  but  relatively  brief,  reflex 
of  our  present  knowledge.  In  the  presentation  of  the  pathologic 
histology,  the  studies  and  observations  of  those  who  are  especially 

1  These  have  been  replaced  by  cases  from  my  own  collection. 

7 


8  PREFACE. 

skilled  and  known  in  this  department  are  largely  drawn  upon  and 
the  sources  acknowledged ;  illustrations  have,  when  space  permitted, 
been  inserted  to  aid  in  an  understanding  of  the  text.  But  while  the 
writing  of  this  work  was  approached  from  the  standpoint  of  its  prac- 
tical use,  it  is  hoped  that  the  somewhat  exacting  labor  of  gathering 
together  and  sifting  the  writings,  investigations,  and  opinions  of  others 
will  be  of  value  not  only  to  the  practitioner  who  may  desire  to  follow 
up  the  study  of  a  particular  disease,  but  also  prove  of  time-saving 
help  to  my  dermatologic  colleagues.  Most  references  are  to  litera- 
ture published  within  the  past  twenty-five  years,  but  many  of  those 
given,  as  mentioned  therewith,  cover  by  review  and  references  con- 
tributions which  had  preceded. 

I  am  indebted  to  several  gentlemen  for  aid  in  the  preparation  of 
this  book :  To  Dr.  William  M.  Welch,  of  the  Municipal  Hospital 
(for  exanthemata),  for  the  papers  on  small-pox,  scarlet  fever,  and 
measles ;  to  Dr.  Emanuel  J.  Stout,  Instructor  in  Dermatology  in  the 
Jefferson  Medical  College,  for  the  framework  of  some  articles ;  to  Dr. 
Samuel  H.  Brown,  Assistant  in  the  Skin  Dispensary  of  the  Howard 
Hospital,  for  preparing  some  schedules  of  important  literature ;  to 
Dr.  Franklin  Machette,  Assistant  in  the  Skin  Dispensary  of  the  Jef- 
ferson Medical  College  Hospital,  for  the  well-prepared  index  ;  and  to 
Mr.  Charles  P.  Fisher,  Librarian  of  the  College  of  Physicians  of 
Philadelphia,  for  materially  facilitating  the  consultation  and  verifica- 
tion of  literature.  I  also  desire  to  acknowledge  the  courtesy  of 
D.  Appleton  and  Company  and  William  Wood  and  Company,  of  New 
York,  and  J.  B.  Lippincott  Company  and  F.  A.  Davis  Company,  of 
Philadelphia,  for  their  permission  to  use  matter  previously  contributed 
to  their  publications  ;  and  although  this  privilege  has  been  but  scantily 
drawn  upon,  the  cordial  consent  given  to  do  so  is  not  the  less 
appreciated. 

The  formulae  and  other  medicinal  measures  are  expressed  both 
according  to  the  usual  apothecaries'  scale  and  the  metric  system,  the 
quantities  in  the  latter  always  being  given  in  grams.  The  spelling 
and  the  fusing  of  compound  words  in  the  text  are  in  accord  with  the 
desire  of  the  publishers  that  their  books  be  uniform  in  this  respect. 

H.  W.  S. 
PHILADELPHIA,  1634  Spruce  Street. 


CONTENTS. 


Anatomy  and  Physiology  of  the  Skin 1^- 

General  Symptomatology 5S^ 

Subjective  Symptoms 55 

Objective  Symptoms 56 

Elementary  or  Primary  Lesions 57 

Consecutive  or  Secondary  Lesions 66 

Lesional  Configuration,  Distribution,  and  Other  Features 73 

General  Etiology 75 

General  Pathology 85 

General   Diagnosis 87 

General  Remarks  on  Treatment 105 

Constitutional  Treatment 106 

Local  Treatment '    '  115 

Classification 136 

CLASS  I.-HYPEREMIAS. 

Erythema 143 

Erythema  Hypersemicum 143 

Erythema  Intertrigo 147 

Erythema  Scarlatinoides , 150 

CLASS  n.-INFLAMMATIONS. 

Erythema  Multiforme 153 

Erythema  Nodosum 161 

Erythema  Induratum •  165 

Erythema  Elevatum  Diutinum 168 

Granuloma  Annulare 17° 

Pellagra 173 

Urticaria 179 

Urticaria  Pigmentosa 188 

OZdema  Angioneuroticum 191 

Pityriasis  Rosea 194 

Dermatitis  Exfoliativa 199 

Dermatitis  Exfoliativa  Epidemica 204 

Dermatitis  Exfoliativa  Neonatorum 206 

Prurigo 208 

Prurigo  Nodularis 2I° 

Lichen  Planus  - 2I3 

The  Chronic  Resistant  Macular  and  Maculopapular  Scaly  Erythrodermias  ....  224 

Lichen  Scrofulosus 227 

Pityriasis  Rubra  Pilaris    .    .    •    • •  23l 

Psoriasis 23° 

Eczema 2D1 

Regional  and  Infantile  Eczema 3*4 

Dermatitis  Seborrhoica 33 * 

Herpes  Simplex 343 

9 


IO  CONTENTS. 


Herpes  ?x>ster  ..............................  34& 

Hydroa  Vacciniforme  ...........................  35^ 

Pompbolyx    ...............................  36° 

Dermatitis  Herpetiformis   .........................  3^4 

Pemphigus    .................  •  ..............  371 

Dermatitis  Vegetans    ,    ......................    ....  3°7 

Epidermolysis  Bullosa    ..........................  3^9 

Dermatitis  Repens  ............................  393 

The  Impetigos      .............................  395 

Impetigo  Contagiosa    .........................  397 

Ecthyma    ................................  4°5 

Impetigo  Herpetiformis  ..........................  406 

Furunculus    ...............................  4°8 

Carbunculus  ...............................  412 

Phlegmona  Diffusa  ............................  414 

Dissection  Wounds  ............................  415 

Postmortem  Pustule    ...........................  416 

Equinia  .................................  416 

Pustula  Maligna  .............................  418 

Erysipelas  ...............    .................  421 

Erysipeloid   .........    ......................  426 

Sphaceloderma  ..............................  427 

Dermatitis  Gangrsenosa  Infantum  ......................  427 

Multiple  Gangrene  of  the  Skin  in  Adults  ..................  429 

Diabetic  Gangrene  ............................  431 

Symmetric  Gangrene  ...................    ;    .......  432 

Dermatitis  Calorica  ............................  435 

Dermatitis  Ambustionis  ........................  435 

Dermatitis   Congelationis   .......................  436 

Dermatitis  Traumatica    ..........................  437 

Dermatitis  Venenata    .....  '.'..'   ...................  438 

X-Ray  Dermatitis    ............................  444 

Dermatitis  Factitia   ............................  448 

Dermatitis  Medicamentosa  .........................  451 

The  Exanthemata    ............................  465 

Scarlatina  ..............................  465 

Rubeola  —  Measles  ..........................  471 

RStheln  ...............................  474 

Varicella    .....    .........................  476 

Variola  ...............................  480 

Vaccinal  Eruptions  ............................  486 

CLASS  DL-HEMORRHAGES. 

Purpura  .................................  492 

CLASS  IV—  HYPERTROPHIES. 

Lentigo  .................................  502 

Chloasma  ..............................    ...  504 

Naevus  Pigmentosus    ...........................  515 

Acanthosis  Nigricans  ...  ..........    ...............  521 

Clavus    .................................  524 

Callositas  ..................    ..............  526 

Keratosis  Palmaris  et  Plantaris  .......................  528 


CONTENTS.  1 1 

PAGE 

Keratosis  Blenorrhagica 532 

Keratosis  Senilis 534 

Keratosis  Pilaris 537 

Keratosis  Follicularis 541 

Verruca 546 

Cornu  Cutaneum 558 

Ichthyosis 561 

Porokeratosis 571 

Angiokeratoma 575 

Scleroderma 578 

Sclerema  Neonatorum 589 

(Edema  Neonatorum 591 

Elephantiasis 592 

Myxedema 601 

Dermatolysis 604 

CLASS  V.-ATROPHffiS. 

Albinismus 608 

Vitiligo 610 

Glossy  Skin „ 616 

Atrophia  Senilis „ ^    .  617 

Striae  et  Maculae  Atrophicae 619 

Diffuse  Idiopathic  Atrophy  of  the  Skin .  622 

Kraurosis  Vulvas 625 

Ainhum 626 

Perforating  Ulcer  of  the  Foot    . ,    .  629 

Morvan's  Disease ^ 631 

CLASS  VI.— NEW  GROWTHS. 

Cicatrix 634 

Keloid 636 

Dermatitis  Papillaris  Capillitii 643 

Molluscum  Contagiosum £45 

Multiple  Benign  Cystic  Epithelioma 652 

Adenoma  Sebaceum 656 

Adenoma  of  the  Sweat-Gland 659 

Lymphangioma 661 

Lymphangioma  Circumscriptum 663 

Multiple  Benign  Tumor-Like  New  Growths 667 

Xanthoma 668 

Xanthoma  Diabeticorum 674 

Colloid  Degeneration  of  the  Skin 678 

Naevus  Vasculosus 680 

Telangiectasis 688 

Angioma  Serpiginosum , 690 

Granuloma  Pyogenicum 692 

Fibroma 693 

Lipoma 700 

Myoma 702 

Neuroma 704 

Rhinoscleroma 705 

Tuberculosis  Cutis 708 

Tuberculosis  Ulcerosa 709 

Tuberculosis  Disseminata 710 


12  CONTENTS. 

PAGE 

Tuberculosis  Verrucosa 712 

Scrofuloderma 7*7 

Lupus  Vulgaris 7'9 

Lupus  Erythematosus 753 

Syphilis 769 

Cutaneous  Manifestations  of  Acquired  Syphilis „ 77° 

Macular  Syphiloderm 776 

Pigmentary  Syphiloderm 778 

Papular  Syphiloderm 780 

Palmar  and  Plantar  Syphiloderm 786 

Moist  Papule 792 

Vesicular  Syphiloderm 794 

Pustular  Syphiloderm 795 

Bullous  Syphiloderm 802 

Tubercular  Syphiloderm 803 

Gummatous  Syphiloderm 809 

Cutaneous  Manifestations  of  Hereditary  Syphilis 813 

Oriental  Sore 845 

Frambesia 850 

Gangosa    ....        857 

Verruga  Peruana 859 

Tropical  Ulcers 862 

Carcinoma  Cutis 864 

Paget's  Disease 866 

Epithelioma 870 

Xeroderma  Pigmentosum .  889 

Sarcoma  Cutis 893 

Multiple  Benign  Sarcoid 902 

Granuloma  Fungoides ,  904 

Leukemia  Cutis;  Pseudoleukemia  Cutis , 91 1 

Lepra .  914 

CLASS  VIL— NEUROSES. 

Hyperesthesia •  939 

Dermatalgia •   •  94° 

Erythromelalgia 941 

Pruritus 942 

Anesthesia 95 l 

CLASS  VIIL— DISEASES  OF  THE  APPENDAGES. 
i.     DISEASES  OF  THE  NAILS. 

Onychauxis 952 

Atrophia  Unguium 957 

Onychomycosis 961 

2.     DISEASES  OF  THE  HAIR  AND  THE  HAIR-FOLLICLES. 

Hypertrichosis 9^4 

Atrophia  Pilorum  Propria • 973 

Fragilitas  Crinium 973 

Trichorrhexis  Nodosa 974 

Monilethrix 97$ 

Piedra 98° 

Tinea  Nodosa 981 

Lepothrix 982 


CONTENTS.  13 

PAGE 

Canities 983 

Alopecia - 987 

Alopecia  Areata 995 

Folliculitis  Decalvans 1010 

Sycosis  Vulgaris 1014 

3.     DISEASES  OF  THE  SEBACEOUS  GLANDS. 

Seborrhea 1021 

Asteatosis 1028 

Milium 1028 

Steatoma 1030 

Comedo . ,  1032 

Acne 1036 

Acne  Varioliformis 1054 

Acne  Rosacea 1060 

4.     DISEASES  OF  THE  SWEAT-GLANDS. 

Hyperidrosis 1068 

Anidrosis 1074 

Bromidrosis 1075 

Chromidrosis 1077 

Hematidrosis 1080 

Uridrosis 1081 

Sudamen 1082 

Hydrocystoma .  1084 

Granulosis  Rubra  Nasi 1087 

Miliaria 1088 


CLASS  IX.-PARASITIC  AFFECTIONS. 

A.     DISEASES  DUE  TO  VEGETABLE  PARASITES. 


Favus 


1093 


Ringworm IIO4 

Ringworm  of  the  General  Surface 1109 

Ringworm  of  the  Scalp m^ 

Ringworm  of  the  Bearded  Region 1119 

Tinea  Imbricata 1144 

Tinea  Versicolor i'47 

Erythrasma „ 1151 

Pinta  Disease " 1153 

Myringomycosis 1 154 

Actinomycosis H55 

Mycetoma 1160 

Blastomycosis „•••...  1162 

Sporotrichosis , 1167 

B.     DISEASES  DUE  TO  ANIMAL  PARASITES. 

Pediculosis H73 

Pediculosis  Capitis 1 1 75 

Pediculosis  Corporis 1 177 

Pediculosis  Pubis !'79 


14  CONTENTS. 

PAGE 

Other  Animal  Parasites,  of  Minor  Importance,  Attacking  the  Skin 1181 

Scabies 1188 

Other  Animal  Parasites,  of  Minor  Importance,  Penetrating  the  Skin 1195 

SUPPLEMENTARY  SECTION. 

Leukoplakia ;    .    .    .  1203 

Furrowed  Tongue 1209 

Transitory  Benign  Plaques  of  the  Tongue 1209 

Black  Tongue 1212 

Cheilitis  Glandularis 1214 

Fordyce's  Disease 1215 

La  Perleche 1217 


INDEX 


1219 


EXPLANATION  OF  ABBREVIATIONS. 


four.  Cutan.  Dis.  =  Journal  of  Cutaneous  and  Venereal  Diseases,  1883-87,  Journal  of 
Cutaneous  and  Genito- Urinary  Diseases,  1888-1902,  and  Journal  of  Cutaneous  Dis- 
eases, since  1903,  New  York. 

Arch.  Derm.  =  Archives  of  Dermatology,  1875-82,  New  York. 

Brit.  Jour.  Derm.  =  British  Journal  of  Dermatology,  London. 

Annales  =  Annales  de  dermatologie  et  de  syphiligraphie ,  Paris. 

Jour.  mal.  cutan.  =  Journal  des  maladies  cutanees  et  syphilitiques,  Paris. 

Revue  pratique •=  Revue  pratique  des  maladies  cutanees,  syphilitiques  et  veneriennes,  Paris. 

Annales  mal.  ven.  =  Annales  des  maladies  veneriennes,  Paris. 

Monatshefte  =  Monatshefte  fur  praktische  Dermatologie,  Hamburg. 

Dermatolog.  Wochenschr.  =  Dermatologische  \Vochenschrift,  Hamburg  (formerly  Monats- 
hefte fur  praktische  Dermatologie). 

Archiv  =  Archiv  fur  Dermatologie  und  Syphilis,  1869-73;  Vierteljahresschrift  fiir 
Dermatologie  und  Syphilis,  1874—88  ;  and  Archiv  fiir  Dermatologie  und  Syphilis 
since  1889. 

Dermatolog.  Zeitschr.  —  Dermatologische  Zeitschrift,  Berlin. 

Dermatolog.  Cenlralbl.  =  Dermatologisches  Centralblatt,  Leipzig. 

Giorn.  ital.  =  Giorne  italiano  delle  malattie  veneree  e  delle  malattie  della  pelle,  Milan. 

Unna,  Histopathology  =  Histopathology  of  the  Diseases  of  the  Skin,  by  P.  G.  Unna. 
English  translation  of  the  German  work  by  Norman  Walker,  Edinburgh. 

Besnier  and  Doyon's  French  translation  of  Kaposi's  treatise  (Die  Pathologie  und  Therapie 
der  Hautkrankheiteti}  refers  to  Besnier  and  Doyon's  notes  in  the  same.  Paris. 

Leloir  and  Vidal,  Traiti  descriptif,  refers  to  their  work,  Traitl  descriptif  des  maladies 
de  la  Peau,  Paris. 

Kaposi,  Diseases  of  the  Skin,  refers  to  the  English  translation  of  Kaposi's  treatise  by 
James  C.  Johnston,  New  York. 

International  Atlas  refers  to  the  International  Atlas  of  Rare  Diseases  of  the  Skin. 

Bangs  and  Hardaway's  American  Text-book  =  An  American  Text-book  of  Genito- Uri- 
nary Diseases,  Syphilis,  and  Diseases  of  the  Skin,  edited  by  L.  Bolton  Bangs  and 
W..A.  Hardaway  (W.  B.  Saunders  Company,  Philadelphia). 

Morrow's  System  =  A  System  of  Genito- Urinary  Diseases,  Syphilology,  and  Dermatology, 
edited  by  Prince  A.  Morrow  (D.  Appleton  and  Company,  New  York). 

Twentieth  Century  Practice  =  Twentieth  Century  Practice  of  Medicine,  edited  by  Thomas 
L.  Stedman  (William  Wood  and  Company,  New  York). 


ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 


ANATOMY 

THE  integument  is  not  to  be  viewed  merely  as  the  protective  en- 
velope or  covering  of  the  body,  but  as  an  integral  and  closely  associated 
part  of  the  general  economy,  with  correlated  and  independent  func- 
tions, and  with  duties  to  perform  that  give  it  a  good  claim  to  be  looked 
upon  additionally  as  an  independent,  and  probably  much  underrated, 
organ.  A  proper  understanding  of  its  histologic  construction  and  of  its 
important  physiologic  functions  is  necessary  in  order  to  obtain  a  clear 
idea  of  the  various  pathologic  processes  that  take  place  in  its  component 
tissues,  and  the  clinical  external  objective  lesions  to  which  they  give  rise. 

The  integument  is  a  somewhat  complex  elastic  fibrous  structure, 
enveloping  the  whole  body,  and  merges  into  the  mucous  membrane, 
with  which  it  is  continuous,  at  all  the  natural  mucous  orifices.  Through 
its  own  connective  tissue,  its  numerous  blood-vessels,  nerves,  lymphatics, 
etc.,  it  forms  a  close  and  firm  association  with  the  structures  of  the 
body  beneath.  Although  the  surface  is,  as  a  whole,  approximately 
smooth,  close  inspection  shows  innumerable  ridges,  furrows,  and  pores, 
and  the  presence  of  variously  sized  hairs,  and,  at  the  end  of  the  terminal 
phalanges  of  the  extremities,  the  hardened  nail  formations.  The  ridges 
are  due  to  the  row-like  arrangement  of  the  papillae  of  the  skin,  some- 
times straight,  slightly  wavy,  and  crescentic ;  the  crescentic  are  more  pro- 
nounced in  certain  parts.  In  many  regions  the  surface  is  divided  up  by 
fine  lines  and  furrows  into  many  irregularly  sized  triangular,  quadri- 
lateral, polygonal,  elongated,  and  oval-shaped  areas  or  spaces.  The 
larger  furrows  are  much  more  pronounced  about  the  joints,  whereas  the 
smaller  or  surface  lines  are  more  noticeable  on  the  extensor  surfaces. 
The  pores — minute  depressions — represent  the  orifices  of  the  follicles 
and  glands  of  the  skin.  According  to  Philippson,  some  of  the  lines  and 
ridges,  which  might  be  termed  "primary,"  are  dependent  upon  prolifera- 
tion of  the  rete  and  linear  depressions  of  the  horny  layer;  and  others 
"secondary,"  or  physiologic  furrows,  in  the  neighborhood  of  the  articu- 
lations, resulting  from  the  constant  creasing  induced  by  the  incessant 
joint  motion.  It  is  probable,  too,  that  the  distribution  of  the  connec- 
tive-tissue fibers  and  bundles  to  which  presumably  are  due  the  lines 
of  cleavage  of  Langer,  may  have  an  important  and  contributory  bearing 
on  the  production  of  these  furrowrs  and  folds. 

In  a  general  way  and  in  its  gross  features  the  skin  can  be  divided 
into  two  parts — the  epidermis  and  the  corium;  commonly  a  third 
division,  of  subcutaneous  tissue,  is  added,  but  this  last  is  in  reality  an 
2  17 


i8 


ANATOMY  AND  PHYSIOLOGY  OF  THE   SKIN 


extension  or  part  of  the  corium,  the  natural  connecting  tissue  that 
joins  the  skin  proper  to  the  underlying  body  structures.  Inasmuch, 
however,  as  it  is  closely  associated  with  the  corium  proper  and  often 
contains  the  deeper  glandular  organs  of  the  skin  and  the  fat-cells,  and  as 
many  of  the  pathologic  processes  invade  its  substance,  a  knowledge 


Fig-  i- — Vertical  section  through  the  skin:    general  diagrammatic  view  (after  Heitz- 

mann). 

of  its  anatomic  structure  and  characters  becomes  a  necessary  part 
of  cutaneous  histology.  The  epidermis  is  subdivided  into  several 
layers.  In  addition  to  these  parts  the  sebaceous  glands,  the  sweat- 
glands,  the  hairs,  hair-follicles,  and  nails,  commonly  known  as  the 
appendages  of  the  skin,  together  with  the  blood-vessels,  lymphatics, 
nerves,  and  muscles  connected  with  the  integument  and  its  nutrition 


19 

and  functions,  are  all  to  be  considered  as  parts  of  its  structure,  and 
are  sometimes  involved  jointly  or  independently  in  its  various  morbid 
processes.1 

THE  EPIDERMIS 

The  epidermis,  also  called  the  cuticle,  cuticula,  scarf-skin,  or  epi- 
thelial layer,  is  the  outer  or  surface  part  of  the  skin,  and  is  conveniently 
divided  into  four  layers — 
the  outermost  layer,  or 
stratum  corneum,  known 
as  the  horny  layer;  below 
this  an  ill-defined,  shin- 
ing layer,  or  stratum  luci- 
dum;  and  beneath  this  a 
granular  layer,  or  stratum 
granulosum;  and,  finally, 
the  innermost  layer,  or 
rete  Malpighii,  commonly 
spoken  of  as  the  mucous 
layer,  rete,  or  Malpighian 
layer.  The  outermost 
part  of  the  epidermis  is 
constituted  of  closely 
packed  cells,  of  horny 
and  dry  character,  the 
cells  becoming  less  dense 
and  less  closely  crowded, 
and  softer  and  even  suc- 
culent as  the  lowest  layer 
of  the  rete  is  approached. 
It  varies  considerably  in 
thickness  in  different  parts 
of  the  body,  its  thickest 
development  being  ob- 
served on  the  palms  and 
soles,  and  its  thinnest  on 
such  parts  as  the  eyelid, 


Fig.    2. — Lines    indicating    cleavage    of    the    skin 
(Langer). 


1  In  the  preparation  of  this  section  I  am  considerably  indebted  to  Professor  Duhr- 
ing's  admirable  description  and  judicial  review,  embodying  the  investigations  of 
Ranvier,  Kolliker,  Heitzmann,  Robinson,  Unna,  Sappey,  Bowen,  and  others  contained 
in  his  work,  Cutaneous  Medicine,  Part  I.  Moreover,  in  order  to  combine  terseness  and 
brevity  with  clearness  in  this  description,  I  have  frequently  consulted  and  often  bor- 
rowed expressions  from  the  shorter  and  graphic  contributions  by  Robinson,  in  his 
Manual  of  Dermatology;  by  Louis  Heitzmann,  in  Morrow's  System,  vol.  iii  (Derma- 
tology); by  Allen,  in  Twentieth  Century  Practice,  vol.  v  (Diseases  of  the  Skin);  and  by 
Bowen,  in  Bangs-Harda way's  American  Text-Book.  For  a  complete  account  of  the 
development  of  the  chief  cutaneous  structures  the  articles  "On  the  Development  of 
the  Human  Epidermis  and  Its  Appendages,"  by  Macleod,  in  the  British  Journal  of 
Dermatology,  beginning  with  1898,  p.  183,  may  be  consulted,  which,  besides  containing 
much  original  work  and  many  original  illustrations,  give  a  full  and  impartial  presen- 
tation of  the  contributions  of  others;  and  which  together  with  much  other  pertinent 
matter  is  also  to  be  found  in  his  recent  publication,  Practical  Handbook  of  the  Pathology 
of  the  Skin.  See  also  a  valuable  but  briefer  account  in  Piersol's  Histology. 


2O 


ANATOMY  AND  PHYSIOLOGY  OF  THE   SKIN 


the  prepuce,  etc.,  and  due  to  different  thicknesses  of  the  corneous 
layer,  the  rete  remaining  relatively  uniform.  It  is  developed  from 
the  ectoderm.  In  earliest  embryonic  life  this  latter  is  primarily  com- 
posed of  but  one  layer  of  cells — epitrichial  layer — below  which  several 

rows  of  epithelial  cells  develop,  the  epi- 
trichial layer  finally  disappearing  toward 
the  sixth  month  of  fetal  life  (Bowen). 

Stratum  Corneum — The  stratum 
corneum,  horny  layer,  or  dead  layer,  is 
the  outer  or  surface  division  of  the  epi- 
dermis, and  is  composed  of  several  layers 
of   flattened,   imbricated   epithelial    cells 
that  have  undergone  various  degrees  of 
keratinization,  and  that,  in  vertical  sec- 
tion, appear  spindle  shaped,  irregular,  and 
wrinkled.     In  the  outermost  layer  these 
cells  have  lost  their  cell  characteristics 
or    appearance,    and    appear    simply    as 
thin,  flattened,  dry  scales.    This  appear- 
•m.   ance  pervades  to  some  extent  the  whole 
thickness  of  the  corneous  layer,  but  is 
',      less   marked   as   the   lower   part   is   ap- 
proached,   the    cell    character    becoming 
more   and   more    recognizable,    although 
not  conspicuously  so,  as  the  rete  or  liv- 
ing  layer   of   the   epidermis   is   reached. 
"     In  the  lowest  cells,  with  their  sometimes 
c     still  visible  polygonal  outlines,  a  nucleus 
e.    is   often   faintly   indicated.      The    outer 


Fig.    3. — The  epidermis:     c, 
Corneous       (horny)      layer;      g, 

granular  layer;    m,  mucous  layer  scales    are    being    continuously    cast    off 

(rete     Malpighn);    the    stratum  ,      .        ,.r             .                                                   , 

lucidum  is  the  layer   just  above  during  life,  and  are  constantly  renewed 

the  granular  layer;    d,  corium.  by  the  lower  layer  of  the  epidermis,  with 

Nerve  terminations:    n.  Afferent  M  h    jt    j      histogenetically    connected, 

nerve;    b,  terminal  nerve-bulbs;  111111' 

/,  cell  of   Langerhans  (Ranvier).  This  layer  can  readily  be  called  the  dead 

layer  of  the  epidermis,  as  it  gives  no  evi- 
dence of  life,  granular  protoplasm  being  found,  according  to  Unna, 
only  in  the  basal  and  superbasal  layers. 

Stratum  I/ucidum.— The  stratum  lucidum,  so  designated  by 
Oehl,  or  translucent  or  shining  layer,  is  a  thin,  ribbon-like,  not  always 
well-defined  layer,  situated  immediately  below  the  stratum  corneum, 
of  which  it  is  considered  by  some  to  be  a  part.  It  is  constituted  of 
closely  set  glistening  or  translucent  epithelia,  flattened  and  running 
parallel  with  the  surface,  the  separate  cells  not  always  being  distin- 
guishable. According  to  Kaposi,  this  layer  is  supposed  to  be  due  to 
some  chemicobiologic  change  that  the  immediately  underlying  granular 
or  rete  cells  must  undergo  in  order  to  become  horny  cells.  It  presents 
no  evidence  of  the  granules  of  the  subjacent  layer,  which  have  disap- 
peared presumably  as  a  result  of  the  peculiar  change  or  in  consequence 
of  the  process  of  keratinization.  According  to  Bowen,  it  is  deeply 


THE   EPIDERMIS  21 

stained  by  certain  reagents,  especially  those  that  have  an  affinity  for 
horny  tissue. 

Stratum  Granulosum.— The  stratum  granulosum,  as  designated 
by  Langerhans,  or  the  granular  or  hyaline  layer,  is  next  below  the 
stratum  lucidum,  and  lies  immediately  upon  the  rete,  of  which  it  is 
usually  considered  to  be  a  part — the  uppermost  layer.  It  is  composed 
of  one  or  two,  rarely  more,  strata  of  coarsely  granular,  nucleated  epi- 
thelia.  This  granular  material,  composed  of  some  peculiar  chemical 
substance,  is,  beyond  the  now  generally  accepted  belief  of  its  rela- 
tionship to  the  process  of  cornification,  still  a  subject  of  discussion. 
It  takes  the  hematoxylin  and  picrocarmin  or  methyleosin  stains  well. 
Ranvier,  who  considered  it  of  partially  fluid  form,  called  it  eleidin, 
whereas  Waldeyer  named  it  keratohyalin,  believing  it  to  be  of  more 
solid  character  and  to  resemble  the  nature  of  hyalin,  and  to  be  con- 
cerned in  the  process  of  keratinization.  According  to  Buzzi,  these  are 
two  distinct  substances:  the  first  is  fluid,  and  is  found  chiefly  in  the 
lowest  part  of  the  horny  layer,  the  second  (keratohyalin)  representing 
the  granules  found  in  the  cells  of  the  stratum  granulosum.  On  the  other 
hand,  the  granular  material  is  thought  by  some  to  be  a  nitrogenous 


Fig.  4. — Section  of  developing  skin  from  human  fetus  of  three  and  one-half  months: 
a,  Layer  of  cuboidal  cells  representing  rete  mucosum;  b,  polyhedral  elements  forming 
superficial  layers;  c,  outermost  flattened  plates,  probably  the  remains  of  the  epitrichial 
layer;  d,  mesodermic  tissue  forming  corium  (Piersol). 

substance  known  as  chitin,  which  is  also  found  in  the  skin  of  insects  and 
in  the  shells  of  Crustacea.  The  precise  character  and  nature  of  these 
granules  cannot,  therefore,  as  yet  be  considered  as  settled,  Kromayer 
even  denying  that  they  are  concerned  in  the  process  of  cornification. 

Rete  Malpighii. — The  rete,  rete  mucosum,  mucous  layer,  germ 
layer,  or  Malpighian  layer,  as  it  is  variously  known,  is  an  important 
layer  of  the  epidermis,  and  is  concerned  in  most  of  the  pathologic  proc- 
esses of  the  skin.  It  lies  immediately  upon  the  papillary  layer  of  the 
corium,  the  granular  layer  forming  its  uppermost  layer  or  boundary. 
It  is,  therefore,  the  deepest  stratum,  and  might  be  known  as  the  living 
stratum  of  the  epidermis.  In  fact,  as  the  studies  of  Carl  Heitzmann  and, 
subsequently,  Strieker  indicate,  the  epithelia  composing  it  together  con- 
stitute a  layer  of  reticulated  protoplasmic  living  matter.  It  consists 
of  several  strata  of  distinctly  nucleated  cells,  irregularly  polyhedral  in 
shape,  especially  in  the  upper  part,  rich  in  protoplasm,  and  arranged  in 
parallel  rows.  They  readily  take  the  carmin  stain,  as  well  as  other 
coloring-matters.  The  upper  rows  of  cells,  compared  to  those  adjacent 
to  the  corium,  are  somewhat  broad  and  slightly  flattened.  The  cells  of 
the  lowermost  part  are  columnar  or  cylindric  in  shape,  with  the  nuclei 


22  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

correspondingly  elongated,  arranged  in  a  palisade-like  manner,  and 
with  the  lower  broad  or  basal  portion  firmly  fused  with  the  papillary 
layer  of  the  corium  by  an  interlacing  of  the  projecting  papillae,  and  the 
dipping-down  elongations  of  the  mucous  layer.  In  addition,  the  cells 
of  the  rete  are  furnished  with  radiating  spines  or  prickles,  and  these 
project  into  the  corium  and  lock  into  one  another;  this  interlocking, 
together  with  the  presence  of  a  transparent  albuminous  substance  or 
cement  that  permeates  the  rete,  makes  this  layer  of  the  epidermis  a 
compact,  resisting  mass. 

Owing  to  these  prickles,  spines,  thorns,  or  spokes,  the  rete  cells  are 
also  known  as  "prickle-cells"  and  the  layer  as  the  "prickle  layer"  or 
"thorny  layer"  of  the  epidermis.     They  are  of  the  same  structure  as 
the  cells  themselves,  and  result  in  a  firm  inter- 
lacing, becoming  less  prominent  as  the  upper- 
most layer  of  the  rete  is  approached.     These 
prickles  have  been  thought  to  be  canals  for 
the  transference  of  fluid,  but  are  now  generally 
considered  to  be  simply  outgrowths  of  proto- 
plasm, although  it  is  not  improbable  that  the 
resulting  interlacing  channels  left  facilitate  the 
circulation  of  lymph  and  give  space  possibly 
for  nerve-threads,  etc.     It  is  in  the  lower  cells 
of  the  rete  that  the  coloring-matter  or  pig- 
fied  (Robinson).  ment  of  the  skin  is  found,  varying  in  different 

individuals  and  in  different  races,  as  will  be 

referred  to  further  on.  The  so-called  Herxheimer's  spiral  fibers  and 
Langerhans's  cells  remain  to  be  described. 

The  Herxheimer's  "spiral  fibers"  or  "epithelial  fibers"  are  delicate 
fibrils  found  at  the  basal  portion  of  the  rete,  close  to  or  at  its  junction 
with  the  papillary  layer  of  the  corium,  projecting  upward  parallel  with 
the  columnar  cells,  usually  in  a  spiral  or  tortuous  manner,  anastomos- 
ing with  one  another.  They  are  made  clearly  definable  only  by  special 
methods  of  staining.  Their  origin  and  purpose  are  not  clearly  under- 
stood. Various  opinions  have  been  advanced:  that  they  are  canals  for 
the  transference  of  nutritive  material  to  the  rete,  projections  of  fibrin 
from  the  corium,  pigment-carrying  wandering  cells  from  the  latter, 
and  epithelial  fibers — the  last  being  the  more  generally  accepted  view. 
The  cells  of  Langerhans  are  occasional  cell-bodies  found  usually  in  the 
deeper  strata  of  the  rete,  and  variously  viewed  as  colorless  tissue  cor- 
puscles, wandering  cells,  lymphoid  cells,  and  as  pigment-cells  deprived 
or  devoid  of  pigment.  They  are  without  nucleus,  and  are  elongate  and 
irregularly  stellate  in  shape. 

CORIUM 

The  corium,  or  true  skin,  also  known  as  the  cutis,  cutis  vera,  or 
derma,  is  a  development  from  the  mesoblast;  and,  according  to  Unna, 
even  at  birth  the  most  superficial  portion,  wrhich  forms  the  foundation 
of  the  subsequent  papillary  layer,  consists  of  young  granulation  tissue 


CORIUM  23 

with  very  few  fibrillae,  whereas  the  cutis  proper,  or  pars  reticularis,  has 
at  this  time  already  acquired  considerable  thickness  and  density,  in 
consequence  of  the  continuous  deposition  of  collagenous  substance 
between  its  cells.  It  immediately  underlies  the  row  of  columnar  cells 
of  the  rete,  with  which,  by  its  papillary  projections  and  the  corresponding 
interpapillary  dippings  of  the  rete  and  the  prickles  of  the  cells  of  the 
latter,  it  makes  a  firm  connection  that  is  not  readily  disturbed.  It  is 
composed  of  masses  of  fibrous  and  elastic  tissue,  especially  the  former, 
which  are  closely  intertwined,  forming  a  dense  and  firm  meshwork,  most 
compact  at  the  uppermost  part,  becoming  less  so  as  the  subcutaneous 
tissue  is  approached.  The  bundles  of  anastomosing  fibrous  connective 
tissue  run  parallel  to  the  surface  of  the  skin,  and  are  arranged  on  a 
definite  plan,  to  which  are  due  the  lines  of  cleavage  of  the  skin.  They 
are  most  numerous  and  in  greatest  abundance  on  those  parts  where 
resistance  and  not  elasticity  is  essential,  as  on  the  sole  of  the  foot. 
On  the  other  hand,  the  elastic  fibers  are  in  greater  number  in  regions 
where  motion  and  extensibility  are  necessary,  as  about  the  joints. 
Compared  to  the  amount  of  fibrous  connective  tissue,  however,  the 
elastic  tissue  is  relatively  scanty,  becoming  more  abundant  with  advanc- 
ing years.  It  is  only  during  late  years  that  the  elastic  fibers  have  received 
much  attention,  more  especially  by  Lustgarten,  Unna,  and  C.  J.  White,1 
this  being  rendered  possible  by  means  of  new  staining  methods,  the 
ordinary  methods  not  sufficing  to  make  them  visible.  In  addition  to 
these  fibrous  components,  spindle-shaped  connective-tissue  corpuscles 
or  cells  are.  seen  here  and  there,  and  there  is  a  cement-like  substance 
permeating  the  parts. 

The  corium  constitutes  the  elastic  and  fibrous  envelope  of  the  body, 
and  contains  blood-vessels,  lymph- vessels,  glandular  structures,  hairs, 
fat-cells,  muscle  elements,  and  the  nerves  with  their  terminal  organs  of 
touch  and  sensation.  It  varies  in  thickness  on  different  parts,  at  differ- 
ent ages,  and  in  different  individuals;  it  is  thickest  over  the  palms,  soles, 
back,  and  buttocks,  and  thinnest  on  the  eyelids  and  prepuce.  It  is 
conveniently  divided  into  two  parts  or  layers — the  papillary  layer,  or 
pars  papillaris,  and  the  reticular  layer,  or  pars  reticularis,  although  it  is 
an  arbitrary  division,  and  one  that  is  not  sharply  defined. 

Pars  Papillaris. — The  pars  papillaris,  or  papillary  layer,  is  the 
upper  portion  of  the  corium,  which  touches  the  rete  above  and  extends 
to  just  below  the  basal  portion  of  the  papillae.  The  papillary  layer  is 
not  an  even  or  a  level  one,  but  is  a  wavy  or  zigzag  line  made  so  by 
the  innumerable  glove-finger-like  projections  or  upward  prolongations 
of  the  corium  into  the  rete — the  so-called  papillae.  The  rete  layer  fills 
up  the  intervening  gaps  by  corresponding  downward  juttings — the 
interpapillary  rete  prolongations.  The  papillae,  composed  of  fine  con- 
nective-tissue fibers  running  parallel  to  their  long  axis,  vary  considerably 
in  size,  more  especially  in  different  regions,  but  even  in  the  same  place 
there  is  often  some  variation.  The  largest,  the  so-called  "compound 
papillae,"  are  due  to  a  bunching  or  an  apparent  fusing  together  of  the 

1  C.  J.  White,  "The  Elastic  Tissue  of  the  Skin,"  Jour.  Cutan.  Dis.,  1910,  pp.  163, 
217  (an  elaborate  paper,  with  bibliography). 


24  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

basal  portions  of  several  or  more,  the  upper  parts,  of  various  length, 
projecting  like  so  many  crowded  fingers  or  like  teats  from  an  udder. 
Probably  most  of  them  are,  however,  small  conic  or  blunt  protrusions. 
They  are  arranged  in  rows,  which  may  be  straight,  curved,  or,  as  on  the 
finger-tips,  concentric  or  crescentic,  readily  recognizable  by  the  naked 
eye.  Their  number  is  beyond  computation:  according  to  Sappey's 
calculation,  there  are  about  150,000,000  over  the  entire  surface,  and 
100  on  a  square  millimeter.  They  are  more  numerous  in  some  situations 
than  in  others,  and  inasmuch  as  they  contain  the  nerve  terminals  or 
organs,  they  are  found  most  abundantly  on  parts  where  sensitiveness  or 
the  sense  of  touch  is  most  acute,  as  on  the  terminal  phalanges,  penis, 
clitoris,  nipple,  etc.  Some  of  the  papillae  contain  loops  of  blood-vessels 
^-vascular  papillae;  others,  the  nerve  terminals  or  organs — nervous 
papillae.  The  latter  have,  as  a  rule,  only  a  limited  vascularity,  but  some 


Fig.  6. — Section  of  palm  of  hand  showing  single  and  compound  papillae  and  their 
blood-vessels,  with  terminal  vascular  loops:  i,  2,  3,  4,  5,  Compound  papillae,  contain- 
ing one  or  more  vascular  loops;  6,  6,  network  of  blood-vessels;  7,  7,  7,  7,  7,  vascular 
loops;  8,  8,  8,  beginning  subpapillary  nerve-plexus;  9,  9,  and  10,  n,  tactile  corpuscles 
with  from  two  to  four  nerve-fibers  (Sappey). 

papillae  contain  both  nerve-endings  and  vascular  loops,  especially  the 
compound  papillae. 

Pars  Reticularis.— The  papillary  layer  passes  imperceptibly 
into  the  reticular  layer,  this  latter  merging  into  the  subcutaneous  tissue 
beneath.  It  is  of  looser  texture  than  the  pars  papillaris,  and  the  bundles 
of  connective-tissue  fibers  are  larger  and  coarser.  The  fasciculi,  espe- 
cially in  the  lower  part,  have  a  more  oblique  direction.  It  has  received 
the  name  reticular  layer  from  its  reticulated  appearance.  It  consti- 
tutes the  bulk  of  the  corium.  It  contains  some  of  the  glandular  struc- 
tures, hair-roots,  and  muscles,  and,  like  the  papillary  layer,  is  liberally 
supplied  with  blood-vessels,  etc. 

SUBCUTANEOUS  TISSUE 

The  subcutaneous  tissue,  or  hypoderm,  as  it  is  designated  by  Besnier* 
immediately  underlies  the  reticular  layer  of  the  corium,  and  probably, 
as  Unna  states,  owes  its  recognition  as  a  distinct  layer  "only  to  the 
circumstance  that,  in  consequence  of  the  macroscopically  appreciable 


BLOOD-  VESSELS  2 5 

deposit  of  fat  in  it,  a  distinct  border-line  is  visible  even  to  the  naked  eye." 
The  division  is,  however,  usually  considered  higher  up  than  the  layer 
of  fat-cells,  although  most  authors  agree  that  it  is  a  purely  arbitrary 
one,  with  no  sharp  or  appreciable  boundary-line. 

Like  the  corium,  the  subcutaneous  tissue  is  composed  of  a  network 
of  interlacing  and  anastomosing  fasciculi  and  bundles  of  connective 
tissue,  less  densely  arranged  than  those  in  the  corium,  and  inclosing  irreg- 
ular and  rhomboidal  spaces  containing  the  masses  of  fat-cells.  Lym- 
phoid  corpuscles  are  present  in  this  layer,  especially  in  the  neighborhood 
of  the  blood-vessels  and  glands.  It  is  essentially  a  continuation  of  the 
reticular  layer,  so  far  as  its  connective-tissue  formation  is  concerned, 
with  looser  meshes,  and  gradually  disappears  into  and  is  attached  to  the 
fasciae  and  aponeuroses  of  the  muscles  and  the  deeper  structures  beneath. 

The  roundness  and  fulness  of  the  integumental  covering  are  due 
to  the  presence  of  the  masses  of  fat-cells  contained  within  its  interstices, 
and  should  they  disappear  by  absorption  or  depletion  in  consequence 
of  starvation,  fever,  or  emaciating  disease,  a  looseness  or  wrinkling 
results. 

The  fat-globules  are  spheric  vesicles  consisting  of  an  elastic  capsule, 
with  an  oval  nucleus  at  one  point,  and  a  drop  of  oil  filling  the  cavity. 
They  are  grouped  in  a  lobular  manner,  and  are  separated  from  one 
another  by  delicate  fibrous  connective  tissue  with  a  comparatively 
abundant  supply  of  blood-vessels  having  an  afferent  artery,  one  or  two 
efferent  veins,  and  a  capillary  plexus  (Louis  Heitzmann).  Owing  to 
the  abundance  of  the  fat-cells  present  this  structure  is  designated 
panniculus  adiposus,  stratum  adiposum,  or  adipose  tissue.  Warren's 
studies  showed,  especially  where  the  cutis  is  thick,  fat  columns  (columnae 
adiposse)  projecting  from  the  subcutaneous  tissue  obliquely  upward 
through  the  corium  to  the  bulb  of  the  smaller  hairs,  and  some  containing 
a  coil-gland  that  they  help  to  support,  their  axes  being  parallel  with  the 
arrectores  pilorum.  The  fat-globules  are  absent  in  certain  regions,  as  on 
the  eyelid,  in  the  auricles,  on  the  penis,  scrotum,  and  labia  minora.  The 
subcutaneous  tissue  contains  the  sweat-gland  coils,  the  deeper-lying 
hair-follicles,  trunks  of  blood-  and  lymph-vessels,  nerves,  corpuscles 
of  Vater,  and  the  Pacinian  bodies. 

BLOOD-VESSELS 

Both  the  corium  and  the  subcutaneous  tissue  are  highly  vascular 
and  liberally  supplied  with  truncal  and  capillary  vessels.  The  epi- 
dermis has  no  vascular  supply.  Two  horizontal  and  parallel  plexuses 
are  to  be  seen — a  deep  and  coarser  one,  in  the  subcutaneous  tissue,  and 
a  fine,  delicate,  and  minutely  ramifying  layer  just  beneath  the  papillae, 
and  loops  from  this  system  extending  up  into  the  latter.  In  some  of  the 
papillae  the  loops  are  quite  well  defined,  but  in  those  containing  the 
developed  nervous  structures  the  vascular  supply  is  not  so  clearly 
recognizable,  some,  according  to  Robinson,  frequently  having  no  blood- 
vessels, although  Thin  believed  that  the  nervous  papillae  contained  loops, 
these  being  of  an  extremely  fine  and  delicate  character.  This  upper 


26  ANATOMY  AND  PHYSIOLOGY  OF   THE  SKIN 

plexus  is  connected  with  the  lower  vascular  network  by  numerous  large 
truncal  vessels.  The  vessels  forming  this  lower  plexus  consist  of  fairly 
large  arterial  and  venous  channels,  from  which  ramifications  extend 
to  the  coil-glands  and  to  the  fat-cells.  The  coil-glands  are  liberally 
supplied,  being  more  or  less  surrounded  by  a  delicate  plexus  of  arterioles 
that  empty  into  two  or  three  small  veins,  one  of  which  always  follows 
the  duct  upward,  finally  anastomosing  with  the  veins  of  the  papillary 
layer.  The  sebaceous  glands  and  hair-follicles  are  likewise  abundantly 
supplied,  the  hair  papilla  having  its  own  arteriole  branching  into  looped 
capillaries;  transversely  arranged  capillaries  are  found  between  the  layers 
of  the  follicles,  which  also  penetrate  their  inner  sheath,  and  the  venous 
plexuses  accompany  the  arterial  in  all  parts,  the  venous  vessels  being 
usually  somewhat  larger  than  the  arterial. 

According  to  Tomsa,  as  cited  by  Louis  Heitzmann,  the  skin  has 
three  distinct  vascular  districts,  each  of  which  is  supplied  with  its  own 
arterioles  and  roots  of  veins;  the  deepest  is  that  of  the  subcutaneous 
fatty  tissue,  the  middle  that  supplying  the  sweat-glands,  and  the  upper- 
most belonging  to  the  derma  with  its  hair-follicles  and  sebaceous  glands. 

LYMPHATICS 

Lymphatic  vessels  are  abundantly  supplied  to  the  integumentary 
tissues,  and  have  been  studied  especially  by  Sappey,  Biesiadecki, 
Neumann,  Klein,  and  a  few  others.  They  are  found  forming  numer- 
ous plexuses  (Klein),  but  more  particularly  a  superficial  and  a  deep 
network.  The  former  is  just  below  the  superficial  plexus  of  blood- 
vessels, and  consists  of  minute  ramules,  from  which  blind  shoots  or 
short  loops  extend  into  the  larger  papillae.  Intercellular  lymph-spaces 
are  to  be  found  in  the  epithelial  layer  of  the  epidermis,  and  seem,  from 
injection  demonstrations,  to  be  in  some  manner  connected  with  the 
lymphatic  system  of  the  derma.  Indeed,  lymph-channels  and  spaces 
without  independent  walls  exist  in  all  parts  of  the  skin  (Neumann, 
Unna,  and  others),  and  especially  in  the  interstices  of  the  fibrous  tissue 
of  the  corium,  and,  although  a  part  of  the  lymphatic  system,  their  rela- 
tion to  the  lymphatic  vessels  is  still  not  known  definitely.  Klein  believes 
that  the  lymphatics  have  open  communication,  by  true  stomata,  with 
these  spaces,  which  he  looks  upon  as  lymph-rootlets.  The  deeper  plexus 
of  lymphatics  is  situated  close  to  the  subcutaneous  network  of  blood- 
vessels; in  fact,  blood-vessels  and  lymphatics  are  found  for  the  most 
part  accompanying  one  another  (Louis  Heitzmann).  The  superficial 
and  deeper  layers,  as  well  as  other  lymphatics,  are  joined  by  anastomos- 
ing branches.  Many  of  the  larger  vessels  have  valves  and  corresponding 
constrictions.  According  to  Neumann,  the  hair-follicles,  as  well  as  the 
sebaceous  and  sweat-glands,  have  their  own  system  of  lymphatic  capil- 
laries, and  Klein  likewise  divides  them  into  several  systems,  correspond- 
ing to  these  parts  and  also  to  the  connective-tissue  matrix  and  the  adi- 
pose tissue. 


NER  VES  27 

NERVES 

The  skin  is  well  endowed  with  both  medullated  and  non-medul- 
lated  sensory  nerve-fibers,  the  former  sometimes  losing  their  sheath 
and  continuing  as  non-medullated  fibers.  They  are  found  often  in  com- 
bination. The  medullated  are  most  abundant  where  the  Pacinian  and 
tactile  corpuscles  are  numerous.  They  arise  from  nerve-bundles  that 
are  found  spread  out  in  the  form  of  plexuses  corresponding  to  the  sub- 
papillary  and  subcutaneous  vascular  network. 

The  glands,  blood-vessels,  and  Pacinian  corpuscles  are  supplied  from 
the  nerve-bundles  in  the  subcutaneous  tissue  and  lower  corium — 
from  the  lower  plexus.  These  bundles  pass  upward,  the  fibers  spread- 
ing out  and  running  horizontally,  and  forming  a  subpapillary  plexus 
consisting  of  a  close  and  fine  network  of  non-medullated  fibers.  Within 
the  papillae,  around  the  capillaries,  they  form  a  dense  plexus  of  thick 
or  fine  varicose  fibers  with  many  nuclei  (Robinson).  From  this  plexus, 
again  quoting  Robinson,  non-medullated  fibers  pass  toward  the  epi- 
dermis and  enter  it  either  directly  or  after  running  a  short  distance 
parallel  to  its  surface.  Penetrating  the  rete,  they  lie  between  the  epi- 
thelial bodies  and  form  a  plexus.  Langerhans  believes  that  they  anas- 
tomose between  the  cells  and  end  in  minute  swellings  or  club-shaped 
extremities,  whereas,  according  to  Unna's  observations,  the  final  distri- 
bution is  intracellular,  each  cell  containing  a  pair  of  nerve-endings. 

The  nerve-fibers  do  not  all,  however,  terminate  in  this  way,  for 
many,  as  previously  stated, — and  this  concerns  especially  the  medul- 
lated nerves, — end  in  the  Pacinian  corpuscle,  whereas  some  of  those 
projecting  upward  to  the  surface  terminate  in  the  tactile  corpuscles 
of  the  papillae — the  so-called  corpuscles  of  Meissner  or  Wagner,  and 
of  Krause — and  in  Merkel's  touch-cells.  A  large  number  of  the  medul- 
lated fibers,  however,  pass  upward  to  the  papillae,  where  they  form  loops 
and  return  to  the  subpapillary  region,  and  several  of  these  looped  medul- 
lated fibers  are  sometimes  present  in  a  single  papilla  (Robinson). 

The  exact  or  relative  purpose  and  function  of  these  various  bodies 
are  not  fully  known,  except  that  it  is  generally  agreed  that  they  are 
sensory  organs.  According  to  Merkel,  cited  by  Duhring,  the  tactile 
corpuscles  and  the  touch-cells  are  organs  for  the  finer  perceptions,  and 
the  bulb-corpuscles  and  Pacinian  bodies  for  localization  and  common 
sensation;  the  free  nerve-endings  in  the  epidermis  may  subserve  touch 
as  well  as  temperature,  and  those  in  the  hair,  both  touch  and  sensation. 

Pacinian  Corpuscles. — The  Pacinian  corpuscles,  also  known 
as  the  corpuscles  of  Vater,  are  most  numerous  in  the  subcutaneous 
tissue  of  the  last  phalanges  of  the  fingers  and  toes  and  the  palms  and 
soles.  They  are  also  abundantly  met  with  on  the  nerves  of  the  joints 
(Duhring).  As  many  as  95  have  been  found  upon  the  index-finger,  and 
608  on  the  entire  hand  (Herbst).  Their  function  is  not  clearly  under- 
stood, but,  as  Bowen  states,  their  situation  in  parts  especially  sensitive 
indicates  some  connection  with  the  tactile  sense,  although  this  view  is 
seemingly  opposed  by  their  deep  position.  They  are  clearly  defined,  oval, 
elliptic,  or  pear-shaped  grayish  bodies,  made  up  of  concentrically  arranged 


28 


ANATOMY  AND  PHYSIOLOGY  OF  THE   SKIN 


capsules — 20  to  60,  according  to  Kolliker — with  an  elongated  central 
clear  space  containing  a  transparent  matrix  and  limiting  membrane  and 
inclosing  a  stalk-like  nerve  terminal — the  ending  of  a  medullated  nerve- 
fiber  that  enters  at  the  lower  extremity  of  the  corpuscle. 

The  various  concentric  layers  are  separated  by  septa  into  smaller 
and  larger  spaces,  containing  a  clear  serous  fluid,  and  lined  with  a 
single  layer  of  epithelium ;  they  are  composed  of  connective-tissue  fibers 
and  connective-tissue  corpuscles.  The  fibers  are  arranged  in  a  longi- 
tudinal layer,  especially  toward  the  inner  portion,  and  in  a  circular  layer 
toward  the  outer  portion;  these  two  layers  are,  according  to  Ranvier, 
connected  or  crossed  by  transverse  or  "radial"  fibers.  The  medullary 
sheath  and  sheath  of  Schwann  cease  at  the  entrance  of  the  nerve  into  the 


Fig.  7.— Pacinian  corpuscles  from  the  derma  of  the  palm  of  the  hand;  stained  with 
aurum  chlond  (X  5°o):  a,  Transverse  section;  b,  longitudinal  section  (Louis  Heitz- 
mann). 

central  clear  space  (Robinson).  Unna  considers  the  corpuscle  due  to  an 
enormous  enlargement  of  the  latter  sheath  into  concentric  lamella?,  with 
nuclei  and  endothelial  lining. 

Tactile  Corpuscles — The  tactile  or  touch-corpuscles,  also 
known  as  the  corpuscles  of  Meissner  or  of  Wagner,  are  ovoid  or  round- 
ish fibrous^  bodies  found  in  the  papilla;,  occupying  the  greater  portion 
and  sometimes  the  entire  extent,  and  usually  those  papillae  that  have 
no  vascular  loop.  Occasionally  they  are  found  somewhat  beneath,  in 
the  papillary  layer.  They  are  exceedingly  numerous,  varying  in  number 
on  different  parts,  being  most  abundant  on  the  fingers,  especially  the  last 
phalanges,  where,  according  to  Meissner,  one  papilla  in  every  four  con- 
tains a  tactile  corpuscle.  Occasionally  two,  rarely  three,  are  found  in  one 
papilla,  although  in  some  instances,  according  to  Robinson,  one  corpuscle 


NER  VES 


29 


has  the  semblance  of  two,  this  resulting  from  a  constriction  caused  by  the 
nerve.  They  are  well  denned,  with  transverse  bands  or  striations,  and 
small  nuclei  (Bowen),  the  mass  of  the  body  consisting  of  nucleated  con- 
nective tissue  (Langerhans,  Thin),  although  their  exact  structure  is  in- 
volved in  some  uncertainty.  One  or 
two  medullated  nerves,  ascending 
from  the  corium,  enter  the  corpuscle 
at  its  extremity  or  side,  their  myelin 
sheath  being  lost  in  the  fibrous  mass 
of  the  capsule;  dividing  into  delicate 
fibrillae,  they  wind  spirally  in  a  vari- 
able course  along  and  through  its 
structure,  anastomosing  with  one  an- 
other, their  termination  being  a  mat- 
ter of  some  doubt — in  a  number  of 
terminal  fibrils  (Bowen),  in  slight 
pear-shaped  or  cylindric  enlarge- 
ments (Louis  Heitzmann),  or,  after  a 
greater  or  lesser  number  of  wind- 
ings, leave  the  corpuscle  at  its  apex 
as  one,  sometimes  as  two,  efferent 
fibers  (Robinson).  In  fact,  accord- 
ing to  Robinson,  each  corpuscle  has 
an  afferent  and  an  efferent  nerve. 

Corpuscles  of  Kratise, 
bulb-corpuscles,  or  end- 
bulbs,  originally  described  and 
designated  by  Kolliker  as  "papillae 
fungiformes,"  and  regarded  by  him 
as  undeveloped  touch-corpuscles,  re- 
semble the  inner  structure  of  the 
Pacinian  body,  and  seem  to  be  the 
terminal  corpuscle  of  some  of  the 
medullated  nerves  coming  from  the 
deeper  plexus.  They  vary  somewhat 
in  form  between  this  and  that  of  the 
tactile  corpuscle,  although  Krause 
believes  that  they  possess  features 
that  serve  to  distinguish  them. 

They  are  observed  especially  about  the  sensory  mucous  membrane — the 
vermilion  of  the  lips,  the  tongue,  the  conjunctiva,  the  glans  penis,  and 
the  clitoris;  in  the  two  last-named  regions  they  are  larger  and  mul- 
berry shaped,  and  lie  deeply  under  the  papillae — the  genital  nerve- 
corpuscles  of  Krause. 

Merkel'S  Touch-cells — Merkel  has  described  minutely  a  touch- 
cell  in  which  a  medullated  nerve  terminates,  situated  in  the  epidermis 
and  superficial  corium.  These  touch-cells  have  since  been  studied 
by  Kolliker  and  Ranvier.  They  are  ovoid  in  shape,  with  a  nucleus 
and  nucleolus,  and  are  found  in  regions  where  tactile  corpuscles  are 


Fig.  8. — Tactile  corpuscle  from 
finger-end,  treated  with  osmium, 
showing  the  two  afferent  nerves  (pur- 
posely accentuated),  disappearing  in 
the  upper  part.  The  transverse  nuclei 
belong  to  the  neurilemma  of  the 
nerve-fibers  (after  Kolliker). 


30  ANATOMY  AND   PHYSIOLOGY  OF  THE   SKIN 

few  in  number,  as  upon  the  abdominal  surface.  According  to  Kolli- 
ker's  observations,  they  are  numerous  also  on  the  finger-tips  and  plantar 
surface.  There  is  still  considerable  diversity  of  opinion  both  as  to  their 
nature  and  their  function. 

Vasomotor  and  Motor  Nerves. — The  sensory  nerves  are  not 
the  only  nerves  of  the  skin,  as,  according  to  Kolliker,  cited  by  Duhring, 
motor  nerves  are  found  on  the  smooth  muscles  and  on  all  glands  that 
have  a  muscular  layer.  The  vasomotor  nerves  also  probably  play 
an  important  role,  but  although  they  are  often  spoken  of  in  discussing 
the  pathology  of  diseases,  but  little  in  reality  is  known  concerning  them. 
The  general  belief  is  that  they  probably  exist  in  two  varieties,  those 
having  connection  or  association  with  the  central  nervous  system,  and 
those  connected  with  the  ganglionic  plexuses  adjacent  to  the  integument 
itself.  Being  particularly  abundant  around  the  cutaneous  arterioles, 
it  can  readily  be  seen  how  they  can,  by  increase  or  diminution  of  the 
circulation,  and  by  dilatation  or  tension,  exercise  a  marked  influence 
upon  the  vascular,  muscular,  and  glandular  systems  of  the  integument. 

The  well-known  occurrence  of  flushing  and  blanching  of  the  skin, 
the  "cold  sweat"  in  sudden  nervous  perturbation,  the  production  of 
"goose-flesh,"  etc.,  all  point  to  the  possibly  profound  pathologic 
action  that  emotional,  toxinic,  or  other  disturbance  of  these  nerves 
may  excite. 

MUSCLES 

The  skin  is  supplied  with  both  striated  and  smooth  muscles,  the 
latter  being  much  more  abundant  than  the  former. 

The  Striated  muscles  are  found  chiefly  in  certain  regions,  as 
on  the  face  and  neck,  and  arise  from  the  subcutaneous  tissue  and  deeper- 
seated  muscles,  and  extending  upward  vertically  or  obliquely  between 
the  glands  into  the  corium. 

The  non- striated  or  smooth  muscles  are  very  numerous, 
and  run  obliquely  or  parallel  to  the  general  surface;  if  the  latter,  they 
run  either  in  a  straight  or  in  a  circular  direction.  The  straight  muscles 
anastomose  with  one  another  and  form  a  network  or  plexus,  as  in  the 
scrotum, — constituting  the  tunica  dartos, — prepuce,  and  perineum; 
those  running  circularly  form  a  ring-like  muscle,  as  in  the  areola  of  the 
nipple.  According  to  Unna,  fasciculi  arranged  in  strata,  and  lying 
almost  perpendicularly  to  the  direction  of  cleavage,  are  found  in  the 
corium.  The  majority  of  the  obliquely  running  muscles  are  connected 
with  the  hair-follicles  and  sebaceous  glands,  although  they  are  also 
observed,  according  to  Tomsa,  Unna,  and  others,  in  many  regions,  as 
on  the  forehead,  the  cheeks,  the  back,  etc.,  independently  of  these 
structures. 

The  follicular  muscles — the  arrectores  or  erectores  pilorum 
— extend  from  their  point  of  origin  in  the  inner  sheath  of  the  follicle 
obliquely  upward,  close  to  the  lower  surface  of  the  sebaceous  gland, 
to  the  papillary  layer  of  the  corium.  In  its  course  upward  it  frequently 
divides  into  two  or  more  bundles,  these  secondary  bundles  afterward 


PIGMENT  3 1 

pursuing  different  directions,  or  uniting  with  fibers  from  other  muscles 
and  forming  a  network  in  the  corium;  occasionally  several  secondary 
bundles  run  nearly  parallel  to  one  another,  and  terminate  either  sepa- 
rately or  conjointly  (Robinson).  According  to  Klein,  Unna,  Nekam, 
Balzer,  and  others,  they  have  an  abundance  of  traversing  and  surround- 
ing elastic  fibers,  and  terminate  in  veritable  tendons  of  similar  elastic 
tissue.  It  is  probable  that  the  muscular  and  elastic  fibers  together  play 
an  important  part  in  influencing  and  regulating  circulatory  and  glandular 
action.  The  arrector  muscles  are  of  general  distribution;  they  are  seen 
most  completely  developed  and  in  greatest  abundance  in  the  scalp,  on 
the  mons  veneris,  and  on  the  scrotum,  whereas  in  certain  hairy  regions, 
according  to  Kolliker,  as  in  connection  with  the  hairs  of  the  eyelashes, 
eyebrows,  and  the  axillae,  they  are  wanting.  The  erectile  condition 
known  as  "goose-flesh,"  or  cutis  anserina,  is  produced  by  the  sudden 
contraction  of  these  muscles  over  the  general  surface.  Overlying  the 
sebaceous  glands  as  they  do,  their  contraction  naturally  tends  to  com- 
press and  evacuate  these  structures,  this  probably  being  an  important 
part  of  their  function. 

PIGMENT 

The  pigmentation  of  the  skin  has  its  chief  seat  in  the  lower  strata 
of  the  rete,  appearing  as  a  darkened  stratum  above  the  papillary  layer 
of  the  corium.  It  is  due  to  a  faint  staining  of  the  cells  themselves, 
most  pronounced  in  the  nuclei,  and  to  the  deposition  of  fine  granules 
of  pigment — melanin — in  the  cell  cavity.  The  resulting  color  of  the 
skin  is  naturally  considerably  influenced  or  modified  by  the  degree  of 
vascularity.  Unna  is  strongly  of  the  opinion  that  the  color  of  the  white 
race  is  due  largely  to  the  presence  of  the  granular  layer,  whereas  Kro- 
mayer,  as  cited  by  Duhring,  attributes  it  to  several  conjoint  factors — 
principally  to  translucency  of  the  epidermis  and  corium,  the  anemic 
condition  of  the  papillary  layers,  and  the  presence  of  fat  in  the  subcu- 
taneous connective  tissue.  In  the  dark-skinned  races  the  quantity  of 
pigment  deposit  is  markedly  greater,  varying  according  to  the  degree  of 
coloration  of  the  skin.  The  pigment-cells  are  more  highly  colored,  and 
staining  involves  the  whole  rete  and  upper  corium,  and  usually  extends 
to  some  degree  to  the  cells  of  the  horny  layer.  The  pigment  granules 
are  much  darker,  and  occur  in  greater  abundance  than  in  the  white  race. 
The  children  of  dark-skinned  races  are  usually  born  apparently  white, 
or  relatively  so,  coloration  then  taking  place  rapidly.  Morison's  investi- 
gations as  to  the  negro  skin  show,  however,  that  beginning  pigment  de- 
posits are  found  several  weeks  or  more  before  birth.  Thomson,  cited  by 
Macleod,  detected  pigment  granules  in  the  skin  of  a  negro  fetus  as  early 
as  the  fifth  month,  forming  a  yellow  stain  in  the  deeper  cells  of  the 
prickle-cell  layer.  According  to  Karg,  white  skin  transplanted  upon  the 
negro  becomes  pigmented,  and  the  color  of  the  negro  skin  transferred 
to  the  white  man  soon  disappears. 

The  origin  of  the  pigment  is  involved  in  some  uncertainty.  Various 
views  are  held,  among  them  being  the  following:  That  it  is  carried  up 


32  ANATOMY  AND  PHYSWLOGY  OF   THE   SKIN 

by  the  leukocytes  from  the  underlying  subcutaneous  tissue  (Bichat, 
Riehl,  Aeby,  and  Ehrmann),  that  it  is  due  to  the  migration  of  the  pig- 
mented  cells  of  the  adjacent  connective  tissue  (Kb'lliker) ;  or  that  it  is 
formed  within  the  protoplasm  of  the  cells  in  loco,  the  earliest  pigment 
appearing  within  mesoblastic  cells  that  have  entered  the  epidermis  while 
still  uncolored  (Piersol).  Unna  considers  that  the  pigment  is  formed 
from  the  coloring-matter  of  the  blood,  and  is  carried  up  to  the  epidermis 
by  "chromatophores"  or  "wandering  cells,"  a  view  practically  shared  by 
List.  Macleod  thinks  it  probable  that  the  "chromatophores"  are 
lymph-cells,  and  that  the  pigment  formed  from  the  blood  in  the  cutis  is 
carried  in  the  lymph-stream  to  the  interepithelial  spaces,  and  reaches 


Fig.  9. — Section  of  negro  skin,  including  epidermis  (a)  and  papillary  layer  (b) 
of  the  corium.  The  pigment  is  contained  in  the  deepest  layer  (c)  of  the  epidermis 
(Piersol). 

the  nuclear  region  of  the  cells  by  passing  along  the  tracks  of  the  nerve- 
fibers.  Both  Meirowsky  and  Dyson  consider  that  the  epidermis  pro- 
duces its  own  pigment,1  Meirowsky's  investigations  showing  that  pig- 
ment is  of  autochthonous  origin,  probably  produced  by  the  action  of 
a  ferment  on  the  protein  molecule  of  the  cell.  Dyson2  believes  that  it 
is  a  lipochrome  in  origin,  the  melanin  being  the  chromatic  protein  por- 
tion after  its  separation  from  the  complex  lipoid  granules,  and  that  it 
is  a  product  of  the  nucleus. 

1  McDonagh,  Brit.  Jour.  Derm.,  1910,  p.  316,  gives  a  good  review  of  the  pigment 
question  to  date. 

2  Dyson,  "Cutaneous  Pigmentation,"  ibid.,  1911,  p.  205  (with   illustrations  and 
good  review  to  date,  with  bibliography). 


SWEAT-GLANDS 

SWEAT-GLANDS 


33 


The  sweat-  or  coil-glands,  also  known  as  sudoriparous  glands, 
glandulse  sudoriferae,  glandulae  glomiformes,  are  seated  in  the  subcu- 
taneous tissue  and  in  the  lowermost  part  of  the  reticular  layer  of  the 
corium.  They  consist  of  a  simple  tubule 
coiled  upon  itself,  forming  an  ovoid  or 
globular  convoluted  body  with  a  blind 
end  in  the  central  or  outer  part  of  the 
coil,  and  the  excretory  duct.  This  lat- 
ter is  essentially  a  continuation  of  the 
tubule  somewhat  altered,  beginning 
usually  in  the  middle  or  upper  central 
portion  of  the  mass,  and  traversing  the 
corium  directly  and  generally  straight 
upward  and  between  the  papillae,  its 
course  becoming  somewhat  less  regular 
in  the  rete,  and  passing  through  the 
corneous  layer  in  a  peculiar  wavy,  spiral, 
or  cork-screw  manner,  and  opening  upon 
the  surface  in  a  rounded,  funnel-shaped 
aperture — the  so-called  sweat-pore. 


Fig.  10. — Sweat-glands  of  different  size  (of 
moderate  magnification)  showing  coil  or  convo- 
lutions forming  gland  proper,  the  blind  end  of 
tubule,  and  excretory  duct  (Sappey). 


Fig.  1 1 . — Section  through 
sweat-gland,  duct,  and  outlet  (of 
greater  magnification) :  a,  Coils 
forming  gland;  b,  beginning  of  ex- 
cretory duct;  d,  excretory  duct;  e, 
sweat-pore;  /,  corneous  layer;  g, 
stratum  lucidum;  h,  granular  layer 
(von  Brunn). 


The  coil  or  gland  proper  is  the  secreting  part  of  the  tubule,  and  con- 
sists of  a  lining  of  secreting  cuboidal  or  polygonal,  somewhat  granular- 
looking  epithelia,  of  a  basement  or  investing  membrane  made  up  of 
flattened  endothelial  cells  and,  between  the  latter  and  the  layer  of  secret- 
ing cells,  some  unstriped  muscular  fibers.  A  layer  of  such  fibers  is  also 
found  in  certain  glands,  especially  those  of  the  axillae,  external  to  the 
investing  membrane  (Robinson).  Virchow  states  that  the  covering 
membrane  is  made  up  of  connective-tissue  fibers  and  connective-tissue 
nucleated  cells,  running  longitudinally  with  the  canal,  the  inner  portion 
representing  the  membrana  propria. 


34 


ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 


The  secreting  epithelial  layer  is  made  up  of  a  single  layer  of  cells, 
with  nuclei  and  one  or  two  nucleoli,  and,  according  to  Reynold,  their 
inner  surface  shows  a  delicate  limiting  membrane,  especially  defined 


Fig.  12. — Section  through  a  sweat-gland  (^  about  400) :  a,  a,  Secreting  part  of  coil; 
b,  gland-cells;  c,  smooth  muscle-fibers;  d,  membrana  propria  of  the  duct;  e,  e,  e,  cross- 
cut of  duct;/,  cuticular  lining  of  duct;  g,  blood-vessel  (Rabl). 

in  the  larger  glands.  There  is  a  well-marked  lumen  in  which,  as  well 
as  in  the  cell-body,  oil-globules  are  usually  present.  The  glandular 
structure  is  embedded  in  considerable,  but  somewhat  loose,  fibrous  con- 
nective tissue,  which  is  denser  and 
contains  a  larger  number  of  lym- 
phoid  cells  between  the  tube-coils. 
The  vascular  supply  is  abundant, 
the  blood-vessels  from  the  deep 
plexus  surrounding  the  coils  like  a 
network,  with  numerous  vessels 
penetrating  between  the  coils. 
Ranvier  has  shown  also  the  exist- 
ence of  an  inclosing  network  of 
nerve-fibers,  some  of  which  pene- 
trate through  the  investing  mem- 
brane to  the  muscular  layer. 

The  excretory  duct  presents  a 
somewhat  different  structure  from 
that  of  the  coil.  As  the  duct  ex- 
tends upward  there  is  an  increase 
in  the  number  of  epithelial  cells, 
these  forming  a  double  layer  and 
gradually  showing  a  distinct  lining 

or  cuticular  covering.  The  duct  loses  its  investing  membrane  and 
muscle-fibers  when  it  enters  the  rete,  and,  in  this  region,  eleidin  granules 
have  been  observed  in  the  cells.  In  the  stratum  corneum  the  duct-wall 
is  formed  of  cells  of  this  layer. 


Fig.  13. — Section  of  skin  of  human 
fetus,  showing  developing  sweat-glands. 
The  latter  grow  as  epithelial  cylinders 
from  the  rete  mucosum  of  the  epidermis 
into  the  underlying  corium;  the  character- 
istic coil  appears  later  (Piersol). 


SEBACEOUS   GLANDS 


35 


The  first  recognizable  signs  of  the  development  of  the  sweat-glands 
are  observed  in  the  fifth  month  of  fetal  life,  and  consist  of  an  ingrowing 
or  budding  of  the  rete  cells  in  the  form  of  conic  epithelial  processes  into 
the  corium.  By  the  sixth  month  elongation  has  taken  place,  and  from 
that  time  on  the  coil-formation  gradually  progresses;  in  the  seventh 
month  the  canal  appears,  and  the  lower  end  of  the  tube  is  observed  to 
be  dilated  and  somewhat  twisted ;  by  the  ninth  month  the  tube  is  coiled 
upon  itself  and  the  gland  proper  is  formed  (Robinson).  Their  distribu- 
tion is  extensive  and  general,  although  Klein  and  Robinson  failed  to  find 
them  on  the  margin  of  the  lips  and  on  the  glans  penis.  Their  number  is 
extremely  large — estimated  to  be,  for  the  entire  surface,  slightly  over 
2,000,000  (Krause,  Sappey).  They  are  most  numerous  on  the  palms 
and  soles,  where,  according  to  Krause,  from  2600  to  2700  exist  in  a  square 
inch.  They  vary  somewhat  in  size  in  different  situations,  being  largest 
in  the  axilla  and  in  the  anal  region.  The  larger  coils  sometimes  show 
irregularly  distributed  constrictions  and  dilatations,  and,  according  to 
Kolliker,  the  tubules  of  some  of  the  large  glands  of  the  axilla  exhibit  a 
number  of  fork-shaped  branching  sacs. 


SEBACEOUS  GLANDS 

The  sebaceous  glands,  known  also  as  oil-glands,  glandulae  sebaceae, 
glandulae  sebiferae,  and  hair-follicle  glands,  are  racemose  or  acinous 
glands  usually  connected  with  or  in  close  relation  to  the  hair-follicle, 


Fig  14  —Sebaceous  glands  of  the  face— simple  pouch  to  compound  lobular,  with  lanugo 
hair  and  small  or  rudimentary  hair-follicle,  the  largest  from  the  nose  (Sappey). 

and  seated  in  the  corium.  They  are  also  observed  in  regions  where  there 
are  no  hairs,  as  on  the  glans  penis,  inner  surface  of  the  prepuce,  labia 
minora,  and  red  border  of  the  lips.  Unna  would  designate  the  glands 


36  ANATOMY  AND   PHYSIOLOGY  OF  THE  SKIN 

of  these  several  regions  as  the  "sebaceous  glands  of  the  mucous  orifices." 
They  are,  therefore,  to  be  found  upon  almost  all  parts,  although  they 
are  absent  on  the  palms,  soles,  and  dorsum  of  the  third  phalanges. 
In  connection  with  large  hairs  the  gland  is  essentially  an  appendage  of 
the  hair-follicle,  into  which  it  empties;  this  is  especially  shown  with  the 
scalp-hairs.  With  small  lanugo  hairs,  on  the  contrary,  the  reverse  ap- 
pears to  be  the  case,  the  glandular  structure  and  duct  being  relatively 
much  larger  than  the  hair  and  follicle,  as  conspicuously  noticeable  in 
the  nose-glands.  The  largest  are  found  upon  the  nose,  especially  at  the 
labionasal  fold,  the  cheeks,  eyelids  (Meibomian  glands),  the  areola 
of  the  nipple,  the  mons  veneris,  the  labia  majora,  the  scrotum,  and 
about  the  anus.  The  glands  found  upon  the  penis  and  inner  surface  of 
the  prepuce— Tysonian  glands,  unconnected  with  hair  and  opening 


aj 


Fig.    15. — Model    of   sebaceous        Fig.  16. — Cross-section  of  skin  of  scalp  on  a 

gland  group  of  a  scalp  hair:     a,  level  with  the  sebaceous  glands:   a1,  a2,  a3,  Hairs; 

Hair-follicle;   b,   lobulated   gland;  c,  c,  sebaceous  glands;  d,  inner  root-sheath;  e, 

c,     tubular     gland;     d,     alveolar  outer  root-sheath;  /,  arrector  pili;  g,  connective 

gland  (Bauer).  tissue;  h,  sweat-gland  (X  3°)  (Rabl). 

upon  the  free  surface — vary  in  development,  and  are  somewhat  incon- 
stant, sparse,  or  numerous. 

Although  fundamentally  the  same  in  structure,  sebaceous  glands 
vary  considerably  in  size  and  form.  The  simplest  is  a  mere  small  pouch- 
like  body,  and  various  forms  from  this  up  to  one  distinctly  multilobular 
and  racemose  are  to  be  seen,  as  shown  in  the  accompanying  cuts. 

The  gland-structure  consists  of  a  secretory  portion  and  duct,  the 
latter  emptying  between  the  surface  of  the  hair  and  the  inner  root- 
sheath  of  the  latter.  The  hyaline  basement  membrane  of  the  gland 
is  surrounded  by  dense  connective  tissue  arising  from  the  hair-follicle 
or  from  the  corium,  and  containing  blood-vessels,  nerves,  and  lym- 
phatics. Upon  the  basement  membrane  are  seated  several  layers  of 
epithelial  cells,  the  outermost  resembling  those  of  the  rete.  In  this 
layer  the  cells  are  cylindric  and  columnar;  towrard  the  inner  portion 


THE  HAIR  37 

they  become  larger  and  more  or  less  cuboid  or  polyhedral,  and  con- 
tain fat-globules,  the  fatty  degeneration  of  the  cells  taking  place  in 
the  center  of  the  cells;  this  is  most  noticeable  in  the  cells  of  the  inner- 
most layer.  The  various  lobules  or  acini  empty  into  a  common  gland 
cavity,  which  is  observed  to  contain  fat-globules,  fat  crystals,  and 
epithelial  debris,  and  this  finds  final  exit  through  the  excretory  duct, 
which  is  also  lined  with  epithelial  cells,  into  the  hair-follicle,  or,  where 
there  are  lanugo  hairs,  often  more  or  less  directly  upon  the  free  surface 
of  the  skin.  The  glandular  product,  together  with  the  epithelial  debris 
from  the  excretory  duct,  constitutes  what  is  known  as  sebum  or  sebaceous 
matter.  The  so-called  smegma,  formed  about  the  glans  penis  and  inner 
side  of  the  prepuce,  is  not  at  present  believed  to  be  the  product  of  the 
sebaceous  glands,  but  to  be  due  chiefly  to  an  exfoliation  of  the  horny 
layer  of  the  epidermis.  It  is  not  improbable,  however,  that  both  may 
be  factors  in  its  production.  Not  uncommonly  a  parasitic  mite,  the 
acarus,  or  demodex  folliculorum,  generally  considered  to  be  harmless,  is 
found  in  the  sebaceous  gland,  especially  its  duct,  with  its  head  usually 
toward  the  gland. 

The  first  sign  of  the  development  of  the  sebaceous  glands  is  usually 
noticed  in  the  third  or  the  fourth  month  of  fetal  life,  and  appears  as  a 
budding  from  the  external  root-sheath  of  the  hair-follicle;  primarily 
they  consist  of  epithelial  cells  that,  by  multiplication  and  further  pro- 
jection downward,  form  the  gland.  They  have  a  rich  vascular  supply, 
and  are  surrounded  by  a  network  of  capillaries.  Like  the  hairs,  they 
appear  first  in  the  skin  of  the  eyebrows  and  forehead,  and  spread  over 
the  trunk  to  reach  the  extremities  last  (Macleod). 

THE  HAIR 

Hairs  are  short  or  long,  rounded  or  cylindric,  horny  formations 
derived  from  the  epidermis,  having  their  seat  in  obliquely  directed 
pouch-like  depressions  in  the  corium,  commonly  known  as  the  hair- 
follicles  or  hair-sacs.  As  a  rule,  but  one  hair  is  implanted  in  each  follicle, 
but  exceptionally  two  and  even  three  hairs  have  been  observed. 

The  hair  varies  considerably  in  different  individuals,  and  especially  in 
those  of  distinct  nationality  or  type,  the  differences  being  due  mainly 
to  the  degree  of  straightness  or  curl,  caliber,  length,  and  color  (Duhr- 
ing).  The  negro  hair-follicle  and  its  contained  portion  of  the  hair-shaft, 
according  to  the  studies  of  Browne,  C.  Stewart,  and  Anderson  Stuart, 
are  much  longer  than  in  the  white,  and  are  remarkably  curved,  this 
latter  feature,  Anderson  Stuart  suggests,  accounting  for  the  curl  in  the 
projecting  shaft.  The  hairs  are  very  abundant,  but  their  number  varies 
considerably.  On  the  scalp  of  average  growth  there  are  about  1000  to 
the  square  inch,  approximately  120,000  to  the  entire  region  (E.  Wilson). 
The  hair  of  lightest  color  always  shows  the  greatest  number  (140,000), 
whereas  red  hair  is  least  abundant  (90,000),  the  brown  (109,000),  and 
the  black  (108,000)  occupying  a  middle  position  between  these  two 
extremes  (Duhring).  Owing  to  the  direction  of  the  obliquely  set  fol- 
licles, which  bears  some  relation  to  the  various  planes  of  the  surface,  the 


B 


38 

hair-growth  has  various  centers,  and,  as  Eschricht  has  shown,  exhibits 
in  the  arrangement  of  both  the  short  and  long  hairs,  curves  and 

whorls. 

Hairs  are  found  in  all  regions  except  the  palms,  soles,  backs  of  the 
last  phalanges  of  the  fingers  and  toes,  lips,  glans  penis,  and  inner  surface 
of  the  prepuce.  They  may  be  divided  into  three  forms:  (i)  Lanugo, 
or  fleecy  or  downy  hairs,  which  are  short,  soft,  and  extremely  fine,  as 
with  those  usually  seen  upon  the  face,  trunk,  buttocks,  and  limbs;  (2) 
short,  strong,  or  bristly  hairs,  somewhat  thick,  such  as  the  eyelashes, 
the  eyebrows,  and  those  in  the  nares  and  in  the  outer  auditory  canal; 
(3)  long  hairs,  of  variable  length  from  a  few  inches  upward,  and  exempli- 
fied by  the  hairs  of  the  scalp,  beard,  axillae,  and  genital  region. 

Two  parts  of  a  hair  are  usually  distinguished — the  hair-shaft,  or 
that  portion  exterior  to  the  skin,  and  the  hair-root,  or  that  contained 
within  the  follicle.  The  hair-root  is  thicker  than  the  shaft  proper, 
and  becomes  more  markedly  so  at  its  lower  part,  where  it  expands 
into  a  bulb-shaped  body,  known  as  the  hair-bulb,  which  is  seated  upon 

and  grasps  the  hair  papilla.  Both  in 
its  shaft  and  root  a  hair  consists  of  an 
outer  thin  covering  or  cuticle,  a  cortical 
mass,  and  usually  a  medullary  portion, 
or  medulla. 

The  cuticle  is  a  transparent  mem- 
brane enveloping  the  whole  hair,  and 
composed  of  thin,  non-nucleated  imbri- 
cated lamellae  arranged  in  an  overlap- 
ping fish-scale  and  shingle-like  manner, 
with  the  free  or  outer  portion,  slightly 
elevated  and  pointing  toward  the  distal 
end  of  the  hair,  giving  it  a  serrated  or 
reticulated  appearance.  The  cortical 
substance  or  mass,  or  main  body  of  the 
hair,  is  made  up  of  delicate  flat,  fusi- 
form, nucleated,  firmly  attached  epi- 
dermal scales,  which  are  so  closely  fused 
or  agglutinated  as  to  form  narrow, 
elongated,  spindle-shaped  bundles  of 

fibers;  they  show  longitudinal  striations,  are  more  or  less  uniformly 
colored,  and  often  contain,  both  within  and  between  the  scales,  a  vary- 
ing amount  of  pigment-granules  and  diffuse  pigment.  The  medulla,  or 
medullary  portion,  in  the  center  of  the  shaft,  is  not  present  in  all  hairs, 
being  usually  absent  in  lanugo,  and  most  clearly  shown,  as  a  rule,  in  thick, 
short,  and  strong  hairs.  It  extends  from  the  bulb  almost  to  the  free 
end,  often  uniformly  as  a  cord-like  structure;  sometimes,  however,  it  is 
somewhat  irregular  or  broken.  It  consists  of  epidermal  elements,  often 
pigmented,  and  frequently  showing  granules  that  were  formerly  thought 
to  be  pigment-granules  and  fat,  but  that,  according  to  recent  investiga- 
tions, are  now  believed  to  be,  in  great  part  at  least,  air-vesicles. 

The  hair-root,  or  the  part  of  the  hair  implanted  in  the  skin,  or  within 


Fig.  17. — A,  Human  hair:  the 
upper  half  of  the  figure  represents 
the  superficial  horny  cells  (h)  con- 
stituting the  cuticle;  the  lower  half 
(s) ,  the  fibrous  structure  of  the  cor- 
tical substance  and  m,  the  medulla. 
B,  isolated  elements  of  the  hair:  a, 
Cuticular  scales;  b,  thin  fiber-cells 
of  cortical  substance  (Piersol). 


THE  HAIR  39 

the  hair-follicle,  is,  in  its  upper  part,  structurally  the  same  as  the  out- 
lying shaft.  Toward  the  lower  portion,  or  hair-bulb,  however,  the 
fiber-like  character  gradually  disappears,  the  lamellae  becoming  softer, 
and  changing  into  spindle-shaped  nucleated  cells.  Further  down  they 
are  polyhedral  in  shape,  and  the  lowermost,  those  about  the  hair  papilla, 
are  cylindric.  These  cells  resemble  closely  those  of  the  rete,  and  often 
contain  pigment-granules — so  many,  in  some  instances,  as  to  constitute 
true  pigment-cells. 

In  the  deepest  portion  of  the  hair-bulb  are  found  a  variable  number 
of  stellate  pigment-cells  that  are,  presumably,  as  believed  by  Kolliker, 
Aeby,  and  Riehl  (cited  by  Duhring),  wandering  connective-tissue  cells 
from  the  hair  papilla,  and  of  importance  in  the  function  of  pigment- 
formation. 

The  hair-bulb  lies  within  either  the  corium  or  upper  subcutaneous 
tissue,  the  lower  part,  in  the  stronger  hairs,  not  infrequently  extending 
into  the  latter.  It  is  a  club-shaped  expansion,  seated  upon  and  embrac- 
ing the  hair  papilla.  It  is  surrounded  by  the  inner  root-sheath,  or  root- 
sheath  proper,  of  the  hair-follicle,  which  extends  upward  to  the  duct  of 
the  sebaceous  gland.  In  transverse  section  the  hair  is  of  rounded  or  ellip- 
tic form,  the  latter  being  most  pronounced  in  markedly  curly  hair,  and 
least  so  in  straight  hair. 

The  color  of  the  hair  is  due  mainly  to  the  varying  amount  of  pigment- 
granules  and  diffuse  pigment  present  in  the  cortex,  or  body  of  the  hair, 
and  the  medullary  portion.  The  presence  of  air,  usually  as  air-vesicles, 
is  also,  doubtless,  an  important  factor,  especially  in  contributing  toward 
light  blonde,  white,  or  gray  hair.  Indeed,  according  to  Pincus,  the 
presence  of  air  in  the  cortical  substance  or  in  its  outer  portion  may  give 
the  hair  a  whitish  or  grayish  color,  even  though  the  central  part  be 
distinctly  dark.  It  is  presumably  owing  to  a  rapid  evolution  of  air- 
vesicles  that  "sudden  graying  of  the  hair"  (q.  v.)  is  produced. 

The  first  sign  of  the  development  of  the  hair  is  observed  usually 
at  the  end  of  the  third  fetal  month,  and  consists  of  a  downward,  cone- 
like  or  club-shaped  projection  of  the  rete,  covered  with  the  horny  layer. 
According  to  Unna,  this  is  first  observed  on  the  face,  and  not  until 
toward  the  seventh  or  the  eighth  month  on  other  parts.  Macleod  states 
that  the  earliest  development  is  noted  on  the  forehead  and  eyebrows,  be- 
tween the  second  and  the  third  month,  and  on  the  back,  breast,  and 
abdomen,  about  the  fourth  month,  reaching  the  dorsal  aspects  of  the 
hands  and  feet  between  the  sixth  and  the  seventh  month.  This  rudi- 
mentary formation  is  gradually  surrounded  by  connective-tissue  cells, 
extends  more  deeply,  expands  at  its  lower  end,  and  grasps  the  papilla, 
which,  in  the  mean  time,  has  arisen  from  the  corium.  The  young  hair 
continues  to  grow,  and  after  a  time — about  the  end  of  the  fifth  month- 
its  pointed  tip  perforates  the  cone,  through  the  horny  layer,  and  the  hair 
becomes  exposed.  The  embryonal  or  early  hairs  are  always  of  the 
lanugo  type,  and  devoid  of  medullary  substance,  having  a  small  and 
short  follicle,  and  usually  a  relatively  large  sebaceous  gland.  When  a 
hair  has  reached  its  full  term  of  existence  it  falls,  and  is  replaced  by  a 
new  hair  formed  around  the  old  papilla,  and  whose  growth  has  frequently 


4o 


ANATOMY  AND   PHYSIOLOGY  OF  Th'E   SKIN 


started  before  the  old  hair  has  been  entirely  cast  off,  the  latter  often 
being  pushed  out  by  the  new  growing  hair. 

The  term  bed-hairs,  so  named  by  Unna,  are  those  early  or 
embryonal  hairs,  unprovided  with  papilla,  that  push  out  from  the 
sides  of  shallow  follicles  from  epithelial  offshoots,  and  that  fall  out 
and  are  supplanted  by  young  papillary  hairs,  usually  near  the  end 
of  intra-uterine  life  or  shortly  after  birth. 

The  embryonal  hairs  are  shed  in  utero,  beginning  with  the  seventh 
or  the  eighth  month,  their  place  being  taken  by  new  hairs  growing 
in  the  same  follicle;  and  if  this  hair-shedding,  or  normal  hair  change, 
is  not  finished  at  birth,  it  completes  itself  in  the  first  few  months  after- 
ward. The  long  black  hairs  on  the  scalp  sometimes  observed  at  birth 

are  in  reality  embryonal  or 
lanugo  hairs,  the  shedding  of 
which  has  merely  been  post- 
poned until  after  birth. 

There  is  some  difference  of 
opinion  as  to  the  manner  of 
hair  growth.  C.  Heitzmann 
believes — and  his  view  is  shared 
by  Professor  Duhring — that  the 
new  growth  takes  place  within 
the  province  of  the  root-sheath 
proper  exclusively,  being  a  pro- 
duct of  the  latter,  the  young 
hairs,  as  showrn  by  Kolliker 
and  Lang,  forming  around  the 
old  papilla. 

Hair-follicle.— The  hair- 
follicle  or  sac  is  the  root-bed 
of  the  hair,  and  consists  of  an 
obliquely  directed,  pouch-like 
depression  in  the  skin,  into  the 


Fig.  1 8. — Section  of  skin  of  fetal  kitten 
exhibiting  hairs  in  various  stages  of .  devel- 
opment: a,  Superficial  layers  of  epidermis; 
b,  rete  mucosum,  from  which  rudimentary 
hair-follicles  extend  into  connective  tissue 
(c)  of  the  primitive  corium;  d,d,e,f,f,  hairs 
in  different  stages  of  development;  g,  seba- 
ceous glands  growing  from  young  hair-folli- 
cle (Piersol). 


central  part  of  the  base  of 
which  projects  the  hair-papilla. 
The  follicle  proper  is  usually  considered  to  include,  in  its  strictest  limi- 
tation, all  that  part  of  the  sac  below  the  point  of  entrance  of  the  seba- 
ceous duct,  which  is  the  narrowest  part,  or  neck  of  the  follicle ;  the  outlet 
above  this,  or  the  mouth  of  the  follicle,  is  funnel  shaped,  and  the  part 
below  expands  somewhat  broadly  down  to  the  base.  The  sheaths  of  the 
follicle,  which  is  essentially  a  depression  from  the  surface,  practically 
correspond  to  the  epidermis  and  corium,  the  former  representing  the 
inner  coat  and  the  latter  the  outer  coat  (C.  Heitzmann).  The  accom- 
panying longitudinal  and  transverse  sections  of  the  follicle  and  inclosed 
hair  show  the  construction  and  the  different  layers  of  both  of  these 
structures. 

The  dermic  or  external  coat,  which  gives  substantial  and  firm  form 
to  the  follicle,  consists  of  bundles  of  connective-tissue  fibers  running 
parallel  to  the  follicle,  with  some  elastic  fibers,  occasional  muscular 


THE  HAIR 


fibers  from  the  arrector  piii,  circularly  disposed,  and  scanty  fat-cells. 
The  outermost  part  (external  layer)  is  richly  supplied  with  blood- 
vessels and  some  medullated  nerve-fibers;  the  middle  layer  showing 


The  hair 


Stratum  Malpighii  of  outer  root-sheath. 

-Cuticle  of  hair. 

-Cuticle. 


—  Huxley's  layer. 
-Henle's  layer. 


-Glassy  layer. 

Basal  cells  of 
—  the  outer  root- 
sheath. 


Medulla  of  hair. 


Cortical  sub- 
, stance  of  hair. 


Inner 
root- 
sheath. 


_Glassy  layer  of 
hair-bulb. 

Connective  tis- 

'<? sue    of    the 

cutis. 


Fig.  19. — Longitudinal  section  of  human  hair  and  its  follicle  (X  about  300)  (Bohm 

and  Davidoff). 

some  capillaries,  in  the  main  transversely  disposed,  extends  into  the 
papilla,  and  bears  some  resemblance  to  muscular  tissue — so  much  so 
that  there  is  a  difference  of  opinion  regarding  this  point.  The  inner 


42  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

layer  (internal  layer)  of  the  dermic  coat,  also  known  as  the  hyaline, 
or  vitreous  membrane  or  glassy  layer,  is  of  homogeneous  structure,  thin 
at  the  upper  portion  of  the  follicle,  becoming  thicker  as  it  approaches 
the  base,  and  thinning  again  as  it  nears  the  papilla. 

The  epidermic  or  inner  coat,  more  generally  known  as  the  outer  or 
external  root-sheath  (Professor  Duhring  designates  this  the  epidermis 
of  the  hair-follicle,  and  Unna,  the  "prickle-cell  layer  of  the  hair-follicle11), 
consists  essentially  of  a  turning  inward  of  the  rete,  which,  contiguous 
to  the  inner  or  vitreous  membrane  of  the  dermic  coat,  dips  downward, 
lining  the  whole  follicle,  thinning  at  the  base  and  into  the  neck  of  the 
hair  papilla  as  one  or  two  rows  of  cells,  and  merging  with  those  of  other 
layers.  From  this  sheath  the  epithelial  budding  or  pouch  is  produced, 
which  develops  into  the  sebaceous  gland.  It  is  thickest  at  the  middle 
of  the  follicle,  and  is  several  times  thicker  than  the  root-sheath  proper. 


Fig.  20. — Cross-section  of  human  hair  with  its  follicle  (X  about  300)  (Bohm  and 

Davidoff). 


The  root-sheath  proper  of  the  hair  (Unna  and  Kolliker), 
more  generally  known  as  the  inner  or  internal  root-sheath,  has  two 
layers — an  outer,  or  sheath  of  Henle,  and  an  inner,  or  sheath  of  Huxley. 
It  arises  from  the  cylindric  cells  covering  the  hair-papilla  (Robinson). 
As  Macleod  states,  these  layers  are  "only  parts  of  a  single  layer,  so 
modified  by  differences  in  tension  and  pressure,  and  by  the  presence  of 
more  or  less  keratohyalin  in  their  cells,  as  to  suggest  that  they  have 
had  a  different  origin."  The  former  consists  of  pale  and  finely  granular 
polyhedral,  somewhat  elongated,  non-nucleated  epithelia,  or  with  in- 
distinct nuclei.  In  the  inner  sheath  the  cells  are  coarsely  granular  and 
nucleated.  At  the  base  of  the  follicle  the  sheath  doubles  on  itself  and 


THE  NAILS  43 

surrounds  the  papilla;  the  cells  are  soft,  broader,  polygonal,  and  rounded, 
contain  granules  of  keratohyalin,  and  fuse  with  contiguous  layers  of  the 
hair,  forming  a  broadened  knob — the  hair-bulb. 

The  root-sheath  proper  is  covered  with  a  closely  adherent  cuticular 
membrane,  with  overlapping,  shingle-like  cells  directed  downward 
(Ebner,  cited  by  Duhring),  the  reverse  of  those  of  the  hair  cuticle,  so 
that  the  scales  of  these  two  contiguous  layers  interlock.  As  has  been 
stated  previously,  the  hair  is  believed  to  be  a  solid  elongation  of  this 
root-sheath. 

The  Hair-papilla. — This  is  a  club-shaped  or  spheric  formation, 
arising  from  the  corium  as  a  narrow  neck-like  projection  or  pedicle,  and 
expanding  upward  into  the  hair-bulb,  by  which  it  is  surrounded.  It  is 
about  twice  as  long  as  it  is  broad,  its  breadth,  according  to  Robinson, 
being  in  direct  proportion  to  the  length  of  the  hair.  It  is  composed  of  a 
delicate  fibrous  or  myxomatous  connective  tissue,  devoid  of  fibrillae 
and  elastic  fibers,  freely  supplied  with  colorless  or  pigmented  connective- 
tissue  corpuscles,  and  containing  a  number  of  blood-vessels,  with  a 
loop  in  its  apex  similar  to  that  of  the  papilla  of  the  corium.  Knowledge 
as  to  the  nerve-supply  of  the  hair-papilla  is  somewhat  indefinite.  Robin- 
son states  that  non-medullated  nerve-fibers  are  to  be  found  within  its 
structure;  and  according  to  Merkel,  Ranvier,  and  Bonnet,  nerves  and 
nerve-endings  are  observed  in  abundance  close  by  in  connection  with  the 
follicle  and  its  membranes. 

THE  NAILS 

The  nails  are  horny,  elastic,  transparent,  shield-shaped,  plate-like 
formations,  derived  from  the  epidermis,  embedded  in  the  corium  on 
the  dorsal  aspect  of  the  distal  phalanges  of  the  fingers  and  toes.  They 
are  moderately  curved  downward  from  side  to  side,  and  less  decidedly 
from  the  root,  or  posterior  part,  to  the  anterior  or  free  edge. 

In  substance  a  nail  proper  corresponds  to  the  horny  layer  of  the 
epidermis,  and  differs  from  it  only  in  being  harder  and  firmer,  with  a 
soft  layer  beneath,  corresponding  to  the  rete,  constituting  in  reality  a 
part  of  the  nail-bed.  According  to  Bowen,  it  is  a  modification  of  the 
stratum  lucidum.  It  is  made  up  of  separate  strata,  composed  of  poly- 
gonal cells,  or  little  plates,  of  which  the  lower  ones  exhibit  indistinct 
nuclei,  the  outermost  resembling  epidermal  scales.  Sometimes,  in  the 
intercellular  spaces,  and  also  in  the  interior  of  the  plates,  small  or  large 
air-vesicles  occur,  and  produce  by  reflected  light  the  so-called  "white- 
spots,"  "gift  spots,"  etc. 

Various  names  are  used  to  designate  different  portions  of  its  sub- 
stance, and  the  couch  or  surface  upon  which  it  grows  and  rests. 

The  nail  (unguis)  is  divided  into  two  parts — the  uncovered  part,  or 
nail  body,  and  the  embedded  portion,  or  nail-root.  The  former  is  usually 
spoken  of  as  the  nail  proper. 

The  top  surface  of  the  nail  is  smooth,  horny,  and  glossy;  the  under 
surface  shows  a  number  of  longitudinal  ridges,  which,  with  the  postero- 
anterior  papillary  ridges  of  the  underlying  corium,  form  an  interlocking, 


44 


ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 


giving  the  nail  a  much  firmer  seat  than  if  the  under  surface  were  smooth 
and  even.  The  nail  is  embedded  posteriorly,  and  to  some  extent  laterally, 
into  a  depression  between  the  matrix  and  overlapping  skin,  known  as  the 
nail-groove,  which  also  extends  on  upward  along  the  free  side;  the  over- 
lapping portion  of  skin  is  known  as  the  nail-fold,  or  nail-wall,  and  the 
thin,  film-like  layer  of  cuticle  extending  forward  from  the  fold  over  the 
body  of  the  nail  posteriorly  for  a  short  distance  is  the  eponychium, 
or  nail-skin,  whereas  the  epidermis  bordering  the  whole  nail  is  called  the 
perionychium,  and  that  underlying  the  body  of  the  nail  upon  which  it 
rests,  the  hyponychium. 

The  term  nail-bed  is  usually  employed  to  designate  that  part  upon 
which  the  uncovered  portion  of  the  nail  rests,  although  in  reality  it 
signifies  the  whole  nail  couch;  that  part,  however,  beneath  the  nail- 
root,  or  embedded  portion  of  the  nail,  is  known  as  the  matrix.  These 
two  parts  of  the  nail-couch  are  separated  by  the  lunula,  a  more  or  less 


Fig.  2i.— Nail  Qongitudinal  section)  (X  100):  H,  Nail-plate  corresponding  to 
horny  layers;  R,  R,  rete  mucosum;  P,  P,  papillary  layer;  B.  bed  of  nail;  £,  epidermis; 
D,  derma  with  injected  blood-vessels;  N.  S,  nail-skin;  N.  F,  nail-fold;  N.  G,  nail-groove 
(L.  Heitzmann). 

convex  line  or  half-moon-shaped  area  at  the  base  of  the  uncovered  por- 
tion, and  that  is  most  distinct  on  the  thumb,  although  usually  well 
defined  on  the  other  fingers;  it  is  often  ill  defined  or  absent  on  the  toes, 
although  in  many  instances  it  becomes  visible  after  the  nail-fold  has 
been  pushed  back.  There  is  some  difference  of  opinion  concerning  its 
formation.  According  to  Hebra,  it  corresponds  to  a  part  of  the  matrix 
or  nail-couch  devoid  of  papillae.  Ranvier,  Toldt,  Duhring,  Bowen,  and 
others  ascribe  it  to  opacity  or  decreased  transparency  of  the  nail-tissue 
at  this  place.  The  latter  seems  to  be  the  correct  view;  the  opaque  ele- 
ments are,  according  to  Henle,  Duhring,  and  others,  transitional  cells 
thickly  covered  with  points  that  by  reflected  light  appear  whiter  than  the 
granular  cells.  Macleod  thinks  it  is  probably  due  to  the  presence  of  re- 
fractive keratohyalin  granules  in  the  transitional  cells. 

The  nail-bed  is  formed  of  the  rete,  corium,  and  subcutaneous  tissue, 
and,  in  the  region  of  the  root  of  the  nail,  at  the  matrix,  there  is  a  gradual 


THE  NAILS 


45 


transformation  from  the  epithelial  cells  of  the  rete  into  those  of  horny 
character,  resulting  in  the  production  of  the  hard-nail  substance  itself. 
The  rete  layer  of  the  epidermis  constitutes  the  germ-layer  of  the  nail  or 
the  matrix,  and  this  is  the  only  part  of  the  nail-couch  that  is  concerned 
in  generating  the  nail.  The  subjacent  papillary  layer  of  the  corium  is 
highly  developed,  especially  the  papilla?  of  the  matrix.  The  papillae 
are  shorter,  broader,  and  more  closely  set  in  the  matrix  than  anteriorly, 
and  in  the  former  region  project  forward;  they  are  arranged  in  parallel 
rows  longitudinally  disposed,  forming  comb-like  ridges  that  tend  to 
converge  symmetrically  in  their  posterior  division. 

The  subcutaneous  tissue  underlying  the  corium  contains  no  fat. 
The  ascending  connective-tissue  fibers  arise  from  the  periosteum  of 
the  last  phalanges,  and  extend  in  a  brush-like  manner  toward  the  nail- 
root,  constituting  the  retinacula  unguium  of  Kb'lliker.  The  nail-bed  is 
highly  vascular,  being  well  provided  with  blood-vessels,  especially  the 
papillae  of  the  matrix.  The  nerve  supply  is  not  so  abundant  as  that  of 
the  surrounding  skin. 

The  development  of  the  nail  begins  in  the  third  fetal  month  as  a 
fold  in  the  epidermis.  Before  the  end  of  the  fourth  month  the  entire 


Fig.  22. — Section  through  dorsal  portion  of  ungual  phalanx  of  four-months'-old 
fetus:  c,  Nail-bed;  m,  mucous  layer;  e,  upper  strata  of  mucous  layers,  showing  cells 
with  eleidin-like  granules;  n,  nail  lamellae,  ep,  eponychium  (Kolliker). 

fingers  and  toes  are  covered  with  a  continuous  layer  of  "granular  and 
bladder  cells,"  representing,  in  the  region  of  the  nails,  a  persistent  and 
thickened  portion  of  the  epitrichial  layer  of  the  young  embryos,  and  in 
which  region  Unna  has  designated  it  the  eponychium ;  beneath  this  the 
nail  makes  its  appearance,  formed  from  peculiar  cells  in  the  upper  part 
of  the  rete  containing  deeply  stained  granules  of  keratohyalin  (Bowen). 
During  the  fifth  month,  Bowen  further  states,  the  epitrichial  covering 
of  the  nail,  or  the  eponychium,  is  cast  off  from  the  body  of  the  nail, 
and  the  free  surface  exposed;  whereas,  at  the  edges  the  bladder  and 
granular  cells  are  heaped  up  in  great  numbers  in  a  ridge-like  manner,  and, 
undergoing  a  process  of  keratosis,  form  a  part  of  the  normal  stratum 
corneum. 

Nail-growth  varies  somewhat  in  different  individuals  and  in  different 
nails;  it  is  more  rapid  in  the  young  and  during  the  summer,  and  slower 
in  the  nails  of  the  toes  than  in  those  of  the  hands.  Exposure  of  the 
latter  to  light  and  air  has  probably  a  determining  influence.  According 


46  ANATOMY  AND  PHYSIOLOGY  OF  THE   SKIN 

to  Moleschott,  the  difference  of  rapidity  in  summer  is  much  more 
noticeable  in  the  nails  bf  the  right  hand.  Berthold  states  that  the  growth 
from  the  lunula  to  the  free  edge  of  the  fingers  requires  an  average  of 
about  four  months,  and  Dufour's  observations  practically  agree  with  this. 
Quain  gives  a  growth  of  -^  inch  in  a  week.  Moleschott  found,  from 
observations  on  his  own  person,  that  the  nails  of  the  hands  and  feet  to- 
gether produce  about  9.2  milligrams  of  nail  substance  in  a  day,  equiva- 
lent to  about  3^  grams  a  year. 


PHYSIOLOGY1 

THE  skin  is  to  be  viewed  as  a  complex  organ  with  complex  func- 
tions. It  is  one  of  the  four  emunctories  of  the  body,  and  probably  in 
this  function  not  unimportant,  although  it  is  generally  so  considered. 

To  some  extent  a  partial  suppression  of  the  excretory  action  of  one 
of  these  four — intestinal  tract,  kidneys,  lungs,  and  skin — is  made  up 
by  compensating  activity  of  the  other  three.  An  absolute  suppression 
of  the  functions  of  the  skin  might,  however,  lead  to  untoward  or  grave 
results,  although  the  experiments  made  from  time  to  time  by  Socoloff, 
Ellenberger,  Senator,  and  others,  cited  by  Ziemssen,  of  varnishing  the 
cutaneous  surface  or  covering  it  with  some  impermeable  substance, 
are  somewhat  conflicting,  and  yet  too  scanty  to  warrant  definite  con- 
clusions. In  rabbits,  varnishing  the  surface  after  removing  the  hair 
is  sooner  or  later  followed  by  death,  preceded  by  symptoms  of  acute 
febrile  disease,  with  subsequent  diminution  in  temperature;  nor  is  it 
necessary  that  the  entire  surface  be  covered,  but  the  more  completely 
it  is  covered,  the  more  rapid  is  the  issue.  In  other  larger  animals  the 
effects  are  apparently  less  marked  and  slower;  and  the  experiments  of 
Senator  seem  to  show  that  man  is  still  less  affected  than  the  latter,  the 
effects  in  his  experiments  on  adults  being  practically  nil. 

The  well-known  instance  of  the  fatal  result  quickly  following  the 
gilding  of  a  boy  at  the  installation  of  Leo  X.  is  often  quoted,  and  ap- 
parently proves  the  contrary;  but  both  Senator  and  Ziemssen  are 
inclined  to  doubt  the  relationship  of  cause  and  effect  in  this  case,  from 
the  fact  that  death  followed  so  rapidly,  whereas  in  most  animal  experi- 
ments the  result  has  been  observed  to  be  slow. 

The  physiologic  functions  of  the  skin  are  to  be  considered  chiefly 
from  the  standpoints  of  its  offices  as  a  protective,  sensory,  respiratory, 
heat-regulating,  and  secretory  organ. 

Protective  Function — The  several  layers,— epidermis,  corium, 
and  subcutaneous  tissue, — together  with  the  nerves,  glands,  and  ap- 
pendages, act  not  only  as  an  elastic  incasement  of  the  body,  but  also  as  a 
guard  against  injuries  of  various  kinds  from  without,  and  a  barrier  to 
too  rapid  loss  of  liquids  and  heat  from  wyithin.  The  corium  and  subcu- 
taneous tissue,  especially  the  former,  owing  to  its  firmness,  high  elas- 
ticity, and  flexibility,  and  the  latter  to  its  loosely  meshed  character  and 
adipose  layer,  are  well  adapted  for  protecting  the  underlying  structures, 
muscles,  nerves,  and  blood-vessels  from  external  pressure,  blows,  and 
other  possible  damaging  traumatic  agencies. 

1  In  addition  to  the  several  valuable  sources  of  information  consulted,  mentioned 
on  page  19,  I  also  desire  to  acknowledge  my  indebtedness  to  Ziemssen's  paper  on 
Physiology,  in  the  Handbook  of  Skin  Diseases,  edited  by  him.  A  recent  exhaustive 
serial  paper  of  value  and  interest  on  "The  Functions  of  the  Skin"  is  that  by  Pembrey, 
Brit.  Jour.  Derm,  for  1910,  covering  the  whole  subject. 

47 


48  ANATOMY  AND  PHYSIOLOGY  OF  THE   SKIN 

The  epidermis,  on  account  of  its  thickness  and  the  great  imper- 
meability and  insensibility  of  its  corneous  layer,  serves  as  a  protection 
to  the  injurious  effects  of  high  and  of  low  temperature  and  of  the  action 
and  absorption  of  many  caustic  and  poisonous  liquids  and  other  dele- 
terious substances.  The  oily  coating  furnished  by  the  glands  is  also  an 
important  aid  to  this  end,  and  this  oily  coating  and  the  horny  layer  to- 
gether are  chiefly  concerned  in  the  prevention  of  too  great  evaporation 
of  water  from  within.  The  hair  of  the  head  is  an  additional  protection  to 
this  important  part,  guarding  the  brain  from  the  effect  of  extremes  of 
temperature  and  from  mechanical  injury. 

Sensory  Function. — The  surface  of  the  skin  is  extremely  sen- 
sitive both  as  to  touch  and  general  sensation,  due  to  its  abundant 
nerve  supply.  As  shown  by  the  studies  of  Landois,  Goldschneider, 
Weber,  Couty,  and  others,  the  sensory  function  is  not  uniform  on  all 
parts  of  the  body,  nor  to  all  influences  or  agencies  on  the  same  part. 
The  temperature  or  thermal  sense  especially  varies  in  acuteness  in 
different  localities,  and  is  responsible  for  illusions,  according  to  Landois, 
as  to  other  properties  of  material  substances — as,  for  example,  a  warm 
object  seeming  lighter  than  a  cold  one  of  equal  weight. 

According  to  the  experiments  of  Blix  and  Goldschneider,  following 
the  theories  of  Miiller  and  Helmholtz,  affirming  the  specific  energy  of 
the  sensory  nerves,  the  skin  has  a  separate  nerve  apparatus  for  heat, 
for  cold,  and  for  pressure;  their  experiments,  made  independently  of  one 
another,  showing  that  sensation  does  not  seem  to  depend  upon  the  kind 
of  irritation,  but  on  the  specific  property  of  the  nerve-endings  or  the 
nerve-fibers  themselves.  Their  investigations  indicate,  therefore,  that 
the  points  on  the  skin  sensitive  to  pressure,  heat,  and  cold  are  severally 
distinct. 

The  tactile  sensibility,  or  the  sense  of  touch,  through  which  are 
made  known  the  size,  form,  and  other  characters  of  bodies,  varies  greatly 
in  intensity  in  different  parts;  it  is  most  highly  developed  in  the 
finger-tips,  where  the  tactile  corpuscles  and  sensory  nerves  are  most 
numerous — and  these  are  most  abundant  where  the  papillae  are  found 
in  greatest  numbers.  It  is  dullest  in  the  middle  of  the  limbs.  As  acutely 
developed  as  it  naturally  is,  it  is  capable  of  much  higher  cultivation  in 
the  line  of  its  most  frequent  employment,  as  when  it  is  called  upon  to  aid 
in  replacing  the  sense  of  sight,  as  in  the  blind.  Goldschneider  has  shown 
that  the  tactile  sense  has*  two  kinds  of  sensitive  nerves,  and  that  the 
tactile  corpuscles,  which  are  usually  considered  to  be  of  paramount 
importance  in  this  function,  are  to  be  looked  upon  mainly  as  a  protec- 
tive organ  to  the  nerve-endings.  Landois  also  holds  the  opinion  that  two 
kinds  of  nerve-fibers,  functionally  distinct,  are  found  in  the  sensory  nerves 
— pain,  or  sensitive  fibers,  and  tactile,  or  touch-fibers. 

The  vasomotor  nerves,  although  not  involved  in  the  sensory  func- 
tion, may  here  be  briefly  referred  to.  The  non-striped  muscles  of  the 
arterial  system  are  well  supplied  with  these  vasoconstrictor  nerves,  and 
as  these  are  concerned  in  the  constriction  and  dilatation  of  the  cutaneous 
vessels,  must  have  an  important  bearing  in  many  pathologic  conditions, 
not  only  owing  to  the  diminished  or  increased  blood  supply,  but  also  from 


PHYSIOLOGY  49 

the  effect  of  this  latter  upon  the  temperature  of  the  part.  They  are 
brought  into  action  in  two  ways:  either  from  a  stimulation  or  depression 
of  the  governing  centers  in  the  medulla  oblongata,  and  possibly  in  the 
cord,  or  from  some  action  exerted  through  the  circulatory  fluid  upon  the 
peripheral  endings. 

Although  we  often  refer  to  an  affection  of  the  skin  as  being  a  tro- 
pohoneurosis,  we  know  little  about  the  existence  and  mode  of  action  of 
the  so-called  trophic  nerves;  the  nutrition  of  most  of  the  peripheral 
parts,  as  shown  by  Charcot  and  others,  is  governed  or  influenced  by 
the  spinal  cord  (Duhring). 

Respiratory  Function — The  respiratory  function  of  the  skin, 
as  compared  to  the  lungs,  is,  of  course,  insignificant.  It  is  similar  to 
the  latter,  however,  in  the  exhalation  of  water  and  carbonic  acid,  and 
the  inhalation  or  absorption  of  oxygen,  although  the  amount  of  car- 
bonic acid  and  oxygen  respectively  given  off  and  taken  in  is  doubtless 
small.  Seguin  states  that  the  amount  of  loss  taking  place  through 
the  skin  daily  is  one-sixty-seventh  of  the  body-weight.  According  to 
Scherling,  10  grams  of  carbonic  acid  are  given  off  in  twenty-four  hours, 
whereas  Aubert  makes  the  quantity  much  smaller — 3.9  grams.  Com- 
pared to  the  lungs,  quoting  from  Kaposi,  carbonic  acid  exhalation  is 
•5-|-T,  and  oxygen  inhalation  Tl¥.  Gerlach  gives  the  latter  a  slightly 
larger  proportion — TiT.  Water  is,  however,  given  off  in  large  quantities. 
There  is  considerable  doubt  as  to  exhalation  of  nitrogen  and  ammonia, 
even  as  to  small  amounts.  The  mode  of  egress  is  probably  through  the 
sweat-glands;  however,  it  is  not  impossible  that  direct  transpiration 
of  carbonic  acid  and  water  from  the  capillaries  of  the  papillae  also  takes 
place,  although  it  is  known  that  the  horny  layer  is  scarcely  penetrable 
by  fluids,  and  the  exhalation  could  hardly  be  appreciable,  unless,  as 
Kaposi  suggests,  it  might  occur  between  the  crevices  of  the  epidermic 
cells,  which  are  connected  with  the  lymph-spaces  of  the  rete  cells. 

Absorption  by  the  skin  can  be  considered  in  connection  with  the 
respiratory  function.  As  previously  stated,  the  epidermis  forms  prac- 
tically an  impermeable  barrier  to  the  absorption  of  liquids  and  also  to 
solid  substances,  but  is  less  resistant  to  gaseous  and  volatile  bodies. 
The  natural  oily  coating  of  the  skin  is  also  an  additional  obstacle  to 
penetrability.  Sources  of  error  in  the  investigation  of  these  matters  are 
so  readily  possible  that  there  is  still  much  to  learn  before  positive  and 
definite  conclusions  can  be  formulated.  It  is  known,  however,  that 
water,  and  substances  dissolved  in  water,  are  not  absorbed  by  the  epi- 
dermis. The  same  may  be  stated,  but  probably  somewhat  less  strongly, 
as  to  some  substances,  of  alcoholic  solutions.  The  evidence  as  to  alco- 
holic and  watery  solutions  applied  as  sprays  is  somewhat  conflicting, 
although,  as  a  rule,  unless  the  contained  substance  is  gaseous  or  volatile, 
no  absorption  takes  place.  Occasional  exceptions  have  been  noted  as 
to  substances  in  solution  and  to  a  few  solids  or  semisolids,  but  what 
the  favorable  conditions  are  is  unknown.  A  defective  epidermis,  or  a 
skin  freed  of  its  oily  coating  and  outer  hardened  horny  cells  by  washing 
with  soap  and  water,  would  lessen  the  natural  protection  against  the 
absorption  of  such  solutions,  and  it  is  not  improbable  that  the  various 
4 


5O  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

exceptional  substances  which  have  been  noted  to  be  absorbed,  first 
change  the  character,  and  modify  or  damage  the  upper  corneous  cells,  as 
Ritter's  researches  seem  to  indicate.  Certainly  tar,  iodin,  arsenic,  sul- 
phur, and  a  few  other  substances  are  capable  of  being  taken  up,  even 
though  not  applied  in  ointment  or  oily  form.  Many  volatile  materials,  as 
already  intimated,  are  readily  absorbed  to  a  variable  degree,  and  Rohrig, 
cited  by  Duhring,  has  remarked  that  such  volatile  substances  are  those 
that  act  upon  and  destroy  the  continuity  of  the  epidermis. 

The  matter  is  somewhat  different,  however,  with  substances  dis- 
solved or  suspended  in  oils  or  fats;  some  substances,  when  so  applied, 
are  taken  up,  but  for  the  most  part,  only  when  well  rubbed  in.  All 
substances  are  apparently  not  absorbable,  certainly  not  equally  so, 
even  when  applied  in  this  manner,  although  Lassar's  experiments 
upon  rabbits  show,  in  general,  a  ready  absorbability  when  so  applied. 
The  most  readily  absorbed  is  mercury  in  the  form  of  mercurial  oint- 
ment; some  of  its  salts  incorporated  in  fat  are  likewise  readily  taken 
up,  although,  as  a  rule,  not  so  freely.  The  ready  absorbability  of  this 
drug  is  thought  by  some  to  be  due  to  the  fact  that  it  may  undergo  vapor- 
ization, gaseous  or  vaporized  substances,  as  already  stated,  usually 
being  more  readily  absorbed.  Substances  applied  by  means  of  vapor 
baths  are  likewise  more  readily  taken  up,  but  with  these  also  there  is  a 
good  deal  of  variation,  and  absorption  will  be  much  prompter  and  more 
decided  if  the  skin  had  been  previously  washed  with  soap  and  water,  for 
reasons  just  given. 

It  is  believed,  however,  that  absorption  usually  takes  place  through 
the  gland-ducts,  most  experiments  bearing  upon  this  point  naturally 
having  been  made  with  substances  dissolved  or  suspended  in  oils  or 
fats,  and  for  the  most  part  with  mercury.  The  investigations  of  Neu- 
mann, Auspitz,  and  others  bear  out  this  view,  in  which  Duhring,  Robin- 
son, and  many  others  concur,  although  Rindfleisch,  Fleischer,  Voit,  and 
others  contend  that  the  particles  pass  through  the  epidermis.  The  former 
is  doubtless  the  correct  explanation,  and  this  is  in  accord  with  Ehr- 
mann's observations  as  to  the  introduction  of  dissolved  substances  by 
means  of  cataphoresis.  According  to  Wasmuth's  experiments  with 
different  bacteria,  quoted  by  Louis  Heitzmann,  the  port  of  entrance, 
for  micro-organisms  at  least,  appears  to  be  between  the  hair-shaft  and 
the  sheaths,  and  not  by  way  of  the  sebaceous  and  sweat-glands.  In 
furuncles,  etc.,  the  organisms  probably  enter  in  this  manner,  aided 
usually  by  friction,  as  on  the  back  of  the  neck,  from  the  collar-band. 
In  fact,  the  mechanical  element  of  rubbing  is  an  important  factor  in 
promoting  absorption  by  the  skin,  as  it  is  believed  with  mercury  that  the 
minute  portions  or  globules  of  the  substance  are  thus  forced  into  the 
ducts,  where  absorption  is  favored  or  where  it  first  undergoes  chemic 
change,  rendering  it  more  easily  absorbable. 

Heat-regulating  Function.— The  skin  has  an  important  func- 
tion in  regulating  the  amount  of  heat  given  out  by  the  body  through 
evaporation,  radiation,  and  conduction,  and  thus  exercises  a  control- 
ling influence  in  maintaining  an  equable  heat  of  the  blood.  In  this 
function  the  epidermis,  more  particularly  the  horny  layer,  plays  an 


PHYSIOLOGY  51 

important  role.  It  is  a  bad  conductor  of  heat,  and  limits,  by  this  prop- 
erty, too  great  a  loss  of  heat  from  the  superficial  blood-vessels,  and  by 
its  firm,  unyielding  character  a  certain  amount  of  pressure  is  directed 
against  the  underlying  capillaries,  preventing  overfilling  and  conse- 
quent heat-loss.  The  vasomotor  nerves  also  have  an  active  and  promi- 
nent part  in  this  function,  acting  as  a  regulator  of  the  cutaneous  blood 
supply  by  reflex  impressions  from  without,  and  probably  also  in  response 
to  excessive  or  reducing  heat-producing  processes  within.  A  cold  at- 
mosphere without  acts  upon  the  cutaneous  fibers,  and  these  sentinels, 
thus  apprised,  bring  about,  through  the  agency  of  the  muscular  fibers  of 
the  blood-vessels,  a  contraction  of  the  capillaries,  in  this  manner  directly 
reducing  heat-loss  by  lessening  the  volume  of  surface  blood,  and  indi- 
rectly by  diminishing  the  supply  to  the  sweat-glands,  with  the  conse- 
quent reduction  or  temporary  suppression  of  this  secretion,  thus  pre- 
venting or  lessening  the  chilling  that  results  from  its  evaporation.  On 
the  other  hand,  the  reverse  takes  place  when  there  is  an  external  warm 
or  hot  atmosphere  or  an  overproduction  of  heat  within — the  vessels 
relax,  the  integument  becomes  full-blooded,  the  sweat-glands  secrete 
freely,  and  there  results,  in  consequence,  a  compensating  loss  of  heat 
by  radiation,  conduction,  and  evaporation,  and  in  this  manner  chiefly 
an  equilibrium  is  maintained.  But  the  changes  and  vicissitudes  of 
climate  are  so  variable  that  animals  exposed  are  still  further  protected 
by  a  hairy  coating  of  sufficient  growth  for  the  season,  whereas  man,  for  the 
same  reason,  is  obliged  to  supplement  the  natural  principle  of  heat-regula- 
tion by  wearing  apparel  of  different  thicknesses. 

The  Secretory  Function.— The  sweat-  and  sebaceous  glands 
are  secretory  glands  of  the  skin,  and  are  of  functional  importance  to 
this  organ,  keeping  it  lubricated  and  soft,  and  playing  an  important  part 
in  the  regulation  of  an  equable  heat  of  the  blood.  In  addition  to  this 
office,  however,  they  have  also  another  function,  that  of  excretion, 
removing  some  of  the  deleterious  or  used-up  products  from  the  body. 
In  the  latter  function  the  sebaceous  glands  probably  have  an  insignifi- 
cant or  minor  role. 

Sweat  Secretion. — Sweat  is  secreted  in  the  coil  or  gland  proper, 
finding  its  way  to  the  surface  through  the  duct.  It  is  also  not  impos- 
sible, as  Ziemssen  states,  that  some  sweat  is  secreted  from  the  lymph- 
spaces  directly  through  the  sudoriferous  ducts.  While  more  or  less 
constant,  ordinarily  it  escapes  by  evaporation  as  rapidly  as  it  is  pro- 
duced, so  that  its  presence  is  not  perceived — insensible  perspiration; 
if,  for  any  reason,  however,  their  function  is  increased,  as  the  result 
of  exercise,  work,  or  heat,  the  secretion  is  formed  much  more  rapidly 
than  it  vaporizes,  and  collects  on  the  surface  of  the  body  in  the  form 
of  drops  or  a  continuous  layer — sensible  perspiration.  In  some  parts 
of  the  body  the  secretion  is  more  profuse  than  in  others,  due  usually 
to  the  presence  of  larger  and  more  numerous  glands,  or  to  increased 
heat  of  the  part;  this  freer  secretion  is  especially  noticed  on  the 
palms,  soles,  face,  neck,  axillae,  and  genitocrural  region.  The  amount 
normally  excreted  in  the  twenty-four  hours  varies  somewhat,  depend- 
ing upon  the  surrounding  temperature,  the  average  being  about  2 


52  ANATOMY  AND  PHYSIOLOGY  OF  THE   SA'/,\ 

pounds — according  to  Seguin  i|  to  2  pounds,  and  according  to 
Rohrig,  i  pound  9  ounces  troy.  The  amount  can,  however,  be  enor- 
mously increased  if  desired,  as,  for  example,  by  active  exercise,  the 
drinking  freely  of  liquids,  by  hot  baths,  and  by  taking  certain  dia- 
phoretics, particularly  pilocarpin — with  the  last  much  more  markedly 
when  the  individual  is  kept  thickly  covered  with  clothing,  blankets,  or 
similar  material,  and  is  given  warm  liquids.  On  the  other  hand,  inac- 
tivity, scanty  covering,  abstention  from  drinking  freely  of  water  or  other 
fluids,  and  certain  drugs,  especially  atropin,  materially  limit  the  amount. 
The  effect  of  external  heat  or  cold,  either  of  natural  or  intentional  pro- 
duction by  scanty  or  overthick  clothing,  etc.,  is  also  shown  by  inter- 
changeable activity  of  the  sweat-glands  and  kidneys.  In  summer  or 
during  warm  weather  the  skin  normally  acts  freely,  and  the  kidney 
elimination  is  relatively  reduced,  whereas  in  cold  winter  weather,  when 
the  general  surface  is  chilled  or  cool,  the  perspiratory  glands  are  inactive, 
and  there  is  a  compensatory  increase  in  the  amount  of  urine  passed. 
The  nervous  system  is  also  an  important  factor — the  so-called  "cold 
sweat"  from  fright  is  a  familiar  example  of  this  influence;  in  fact,  the 
sweat  secretion  is  especially  dependent  upon  the  influence  of  the  nerves, 
the  centers  of  which  are  situated  in  the  spinal  cord  as  far  up  as  the 
medulla  oblongata,  which  latter,  according  to  Luchsinger,  contains  a 
general  center. 

Increased  activity  is,  as  with  all  glands,  usually  accompanied  by 
dilatation  of  the  capillary  blood-vessels,  but  although  there  is  a  close 
connection  between  the  nerve-fibers  that  control  sweating  and  vaso- 
motor  fibers — which  Landois  believes  are  together  in  the  same  nerve- 
trunks — the  former  may  act  independently  of  the  latter,  as  shown  in  the 
instances  where  there  is  increased  sweating,  even  though  the  skin  is  pale 
and  the  circulation  depressed. 

The  composition  of  sweat  is  somewhat  complex,  although  water 
forms  about  99  per  cent,  of  the  whole  secretion.  It  contains  sodium 
chlorid,  urea,  volatile  fatty  acids, — acetic,  formic,  butyric,  propionic, 
caproic,  and  caprylic,  in  variable  quantity, — and  small  amounts  of  neutral 
fats,  palmitin  and  stearin,  and  cholesterin.  There  is  also  a  trace  of  earthy 
phosphates  and  sodium  phosphate. 

Ordinarily,  sweat  is  a  clear,  watery  liquid  of  saltish  taste,  with  a 
variable  odor,  substantially  the  same  in  some  individuals,  but  slightly 
or  markedly  different  in  many  others;  the  odor  varies  also  in  different 
regions  of  the  same  person.  It  has  an  acid  or  an  alkaline  reaction, 
according  to  circumstances;  it  is  generally  considered  to  be  normally 
acid,  but,  according  to  the  observations  of  Luchsinger  and  Triimpy, 
the  acidity  would  seem  to  be  due  to  the  admixture  of  sebaceous  matter, 
as  they  found  that  in  the  palms  of  the  hands,  where  there  are  no  seba- 
ceous glands,  it  is  alkaline;  and  also  of  this  reaction  on  other  parts  after 
the  skin  is  carefully  freed  of  sebaceous  secretion.  This  appears  to  be 
further  corroborated  by  Heuss,  who  found  that  as  the  sweat  becomes 
profuse  by  the  administration  of  diaphoretics  the  reaction  is  neutral 
and  alkaline;  this  was  also  noted  by  Luchsinger  and  Triimpy  in  profuse 
sweating  from  natural  causes— in  short,  the  acidity  due  to  the  sebaceous 


PHYSIOLOGY  53 

admixture  is  neutralized  or  overcome  by  the  alkalinity  of  the  increased 
sweat  secretion,  although  Heuss  does  not  put  this  construction  upon  his 
observations,  and  considers  the  sweat  normally  acid  in  individuals  when 
at  rest. 

The  belief  foreshadowed  by  the  observations  of  Simon,  Krause, 
and  Kolliker  that,  in  addition  to  the  secretion  of  sweat  as  ordinarily 
understood,  the  coil-glands  also  secrete  fat  for  the  lubrication  of  the 
skin,  has  been  substantiated  through  the  careful  observations  and  in- 
vestigations of  Meissner  and  Unna,  and  this  view  is  now  generally  ac- 
cepted. This  is  readily  recognizable  in  the  palms  of  the  hand,  the  in- 
tegument here  being  kept  soft  and  supple  by  oily  lubrication  produced 
by  the  coil-glands. 

Sebaceous  Secretion. — This,  the  product  of  the  sebaceous  glands, 
known  as  sebum,  or  sebaceous  matter,  is,  in  its  purest  or  normal  physio- 
logic state,  a  fluid  or  semifluid  fat,  especially  within  the  glands,  which, 
becoming  somewhat  firmer  in  the  ducts,  passes  out  insensibly,  lubricates 
the  hairs  and  epidermis,  without  giving  a  perceptible  oiliness  to  these 
structures.  In  addition  to  this  function,  which  keeps  the  hairs  oiled 
and  the  skin  soft  and  pliable,  the  imperceptible  oily  coating  of  the 
skin  serves  to  prevent  too  great  evaporation  from  the  surface,  and  to 
guard  against  the  effects  of  long-continued  action  of  moisture,  as  well 
as  probably  to  aid  in  protecting  against  external  infection.  As  ordinarily 
observed,  it  consists  of  cast-off  nucleated  granular  epithelial  cells,  fat- 
globules,  fatty  matter,  debris,  and  cholesterin  crystals;  and,  chemically, 
of  water,  palmitin,  olein,  palmitic  and  oleic  acid,  saponified  fats,  choles- 
terin, a  casein-like  albuminoid,  and  inorganic  salts,  such  as  phosphates 
and  chlorids.  In  sebaceous  matter  is  frequently  found  the  microscopic 
mite,  the  acarus,  or  demodex  folliculorum,  usually  considered  harmless. 
There  are,  however,  in  the  amount  and  consistence  of  the  secretion, 
many  variations  within  the  limits  of  apparent  health.  To  some  extent, 
too,  it  varies  according  to  the  individual  and  also  on  different  parts  of 
the  body.  It  is  usually  more  abundant  where  the  glands  are  largest  and 
most  numerous.  Sometimes,  especially  where  the  glands  are  large 
and  probably  only  in  what  must  be  considered  as  a  pathologic  state, 
the  secretion  collects  in  the  glandular  orifices  as  a  tallow-like  mass, 
taking  a  worm-like  form  when  pressed  out;  or  it  may  be  produced  in 
considerable  quantity  and  be  of  somewhat  thick,  mush-like  consistence, 
exuding  on  the  surface  as  a  distinct  oily  or  greasy  coating.  In  these  con- 
ditions, observed  usually  about  the  nose,  there  is  generally  associated  a 
perceptible  gaping  or  patulousness  of  the  duct  outlets.  Such  abnormal  or 
excessive  secretion  is  most  commonly  noted  between  the  ages  of  fifteen,  or 
puberty,  and  twenty-five,  when  the  sebaceous  glands  are  especially 
active. 

On  the  scalp,  even  in  physiologic  states,  if  the  secretion  is  allowed  to 
collect  indefinitely,  the  parts  being  washed  only  at  long  intervals,  and 
only  carelessly  brushed  and  combed,  it  tends  to  collect  in  minute,  thin, 
greasy  scales,  producing  a  slight  pseudoseborrheic  aspect.  In  fact, 
in  the  seborrheic  secretion  the  difference  between  a  physiologic  and  a 
pathologic  process,  as  Professor  Duhring  states,  is  often  ill  defined. 


• 
54  ANATOMY  AND   PHYSIOLOGY  OF  THE   SKIN 

The  exact  mechanism  of  the  sebaceous  gland  secretion  is  not  fully 
understood,  and  the  part  that  the  nerves  play,  if  they  play  any,  is  not 
known,  although  this  observer  (Duhring)  believes  this  secretion,  as  in 
the  case  of  that  of  the  sweat,  to  be  under  the  control  of  the  nervous 
system,  and  subject  to  variations.  It  is  probable,  as  Bowen  suggests,  that 
it  is  increased  by  dilatation  of  the  blood-vessels  and  by  an  increase  in  the 
temperature  of  the  skin.  A  warm  external  temperature  perceptibly  in- 
creases the  oiliness  of  the  skin,  but  whether  this  increase  is  a  product 
of  heightened  action  of  the  sebaceous  glands  or  of  the  sweat-glands,  or  of 
both,  is  not  definitely  known.  The  secretion  is,  however,  doubtless  a 
continuous  one,  though  probably  somewhat  fluctuating.  It  is  generally 
accepted  as  consisting  of  a  fatty  degeneration  of  the  epithelial  cells, 
filling  them  with  fat,  and  the  subsequent  rupture  of  the  cell-wall  and  es- 
cape of  the  oily  matter  to  the  surface,  the  evacuation  being  principally, 
if  not  wholly,  due  to  the  contracting  action  of  the  arrectores  pili  muscles, 
which  skirt  one  side  of  the  gland  structure. 


GENERAL  SYMPTOMATOLOGY 

A  DISEASE  of  the  skin  is  made  known  by  integumentary  structural 
lesions  visible  to  the  eye  and  usually  appreciable  to  the  touch,  and 
by  certain  sensations  emanating  in  its  tissues,  recognizable  only  by 
the  patient,  and  having  no  outward  sign.  The  former  are  known  as 
objective  symptoms,  and  are  to  be  found  with  but  few  exceptions  in  all 
cutaneous  affections;  the  latter,  as  subjective  symptoms,  which  are 
usually  associated  with  structural  lesions,  but  which  also,  like  the  former, 
may  exceptionally,  as  in  pruritus,  constitute  the  sole  symptomatology 
of  the  disease. 

Objective  symptoms  speak  for  themselves,  and  constitute,  there- 
fore, the  foundation  upon  which  our  knowledge  of  diagnosis  must  be 
built — in  some  instances,  conjointly  with  an  examination  into  the  his- 
tologic  features,  history  of  the  disease,  and  other  factors.  Subjective 
symptoms,  while  sometimes  of  valuable  aid,  are  often  unreliable,  owing 
to  the  fact  that  they  are  only  under  the  cognizance  of  the  patient,  and 
therefore  subject  to  exaggeration,  undervaluation,  and  misinterpreta- 
tion, according  to  the  temperament,  nervous  susceptibility,  intelligence, 
and  honesty  of  the  individual. 

While  these  two  classes  of  symptoms  alone  constitute  the  semei- 
ology  in  most  dermatologic  cases,  in  a  small  minority  the  symptoms  are 
not  limited  to  the  integument  itself;  in  some  instances  an  affection  of  the 
liver,  kidneys,  stomach,  or  nervous  system  is  present,  but  in  the  majority 
of  such  cases  the  eruption  is  merely  an  accidental  consequence  of  such, 
and  not  an  associated  symptom  of  some  general  underlying  pathologic 
process.  Such  diseases,  it  is  true,  may  bear  an  etiologic  relationship,  al- 
though it  may  not  be  a  direct  one. 

The  constitutional  symptoms  usually  observed  in  connection  with 
some  cases  do  not  possess  any  distinct  characteristics,  and  even  in 
those  diseases  in  which  they  may  occasionally  be  observed,  as  in  ery- 
thema multiforme,  they  are  extremely  variable  as  to  degree.  In  other 
instances,  as  in  the  later  stages  of  granuloma  fungoides,  leprosy,  and  the 
like,  the  ensuing  systemic  symptoms  are  not  so  much  a  part  of  the  disease 
itself  as  a  consequence  of  the  resulting  septic  infection  which  commonly 
occurs. 

Subjective  Symptoms.— Subjective  symptoms  consist  of  a  feel- 
ing of  heat  or  burning,  tingling,  prickling,  stinging,  formication,  itch- 
ing, and  pain.  Disturbed  sensation,  such  as  diminished  and  height- 
ened sensibility,  designated  respectively  anesthesia  and  hyperesthesia, 
also  to  be  considered  in  this  class,  are  occasionally  noted.  Pain  is  a 
rare,  or  at  least  an  uncommon,  symptom,  but  is  met  with  in  such  affec- 
tions as  boils,  carbuncles,  in  some  ulcerations,  especially  of  the  deeper 
kind,  and  may  be  of  a  burning,  aching,  boring,  or  shooting  character. 


56  GENERAL   SYMPTOMATOLOGY 

The  neuralgic  pain  frequently  associated  with  the  development  of  zoster 
is  an  example  of  the  last  named.  Shooting  and  darting  pains  are  also  of 
common  occurrence  in  some  stages  of  leprosy.  In  many  skin  affections, 
however,  subjective  symptoms  are  wholly  wanting. 

Itching,  or  pruritus,  is,  however,  the  most  frequent  symptom  com- 
plained of,  and  is  present  in  a  variable  degree  in  many  diseases  of  the 
skin.  It  is  a  particularly  troublesome  one,  as  a  rule,  in  eczema,  and 
especially  in  the  papular  and  vesicular  types,  although  present  in  all 
varieties— sometimes  slight,  at  other  times  severe,  almost  constant  or 
paroxysmal.  In  urticaria,  dermatitis  herpetiformis,  scabies,  pediculo- 
sis, and  some  cases  of  psoriasis  it  is  also  present  usually  to  a  disturbing 
degree.  In  occasional  instances  it  exists  independently  of  any  visible 
lesional  symptoms,  constituting  the  malady  known  as  "pruritus," 
in  which  it  is  often  intense.  Itching  varies  in  character,  as  well  as  in 
degree,  sometimes  being  more  of  the  nature  of  pricking  sensations, 
tingling,  and  biting.  In  other  cases  it  may  consist  of  the  sensation 
as  if  insects  were  crawling  in  the  skin — formication.  It  is  probably  due 
to  various  causes  acting  upon  the  peripheral  nerves,  such  as  an  irritant 
operating  or  gaining  entrance  from  without,  as  in  certain  of  the  parasitic 
diseases,  an  irritation  from  some  general  toxic  substance  from  within, 
as  in  jaundice  and  some  instances  of  uric  acid  saturation,  and  also  from 
the  direct  action  of  local  inflammatory  processes,  either  through  pressure 
on  the  nerve  filaments  or  through  their  irritant  products. 

Objective  Symptoms.— The  varied  nature  of  the  pathologic 
processes  which  take  place  in  the  skin,  with  the  modifications  influ- 
enced by  the  peculiar  character  of  its  anatomic  structure,  gives  rise, 
as  might  be  supposed,  to  various  and  diverse  structural  alterations 
which  produce  the  cutaneous  symptoms  known  as  the  elementary  or 
primary  lesions.  Each  variety  of  lesion  has  characteristics  that  serve 
to  distinguish  it  from  the  others,  although  there  be  much  diversity  as 
to  size,  shape,  color,  and  other  features,  and  some  may  show  a  transi- 
tion stage  verging  into  another  form,  as  a  papule  into  a  vesicle,  a  vesicle 
into  a  pustule,  and  so  on.  These  elementary  or  primary  lesions,  as  the 
qualifying  term  signifies,  are  the  objective  lesions  with  which  cutaneous 
diseases  begin.  Even  if  the  eruption,  as  a  whole,  has  undergone  changes, 
the  component  individual  lesions  losing  their  elementary  characters 
in  the  coalescence  or  massing  that  often  ensues,  still,  here  and  there,  as 
a  rule,  may  be  found  some  that  throw  light  upon  the  initial  features  and 
materially  aid  in  diagnosis. 

The  elementary  lesions  may  continue  as  such,  or  may,  as  stated, 
undergo  modification,  either  from  accidental  or  natural  change  or 
from  extraneous  causes,  and  pass  into  what  are  known  as  the  con- 
secutive or  secondary  lesions.  These  are  the  two  divisions  into  which 
the  objective  symptoms  can  be  conveniently  and  naturally  placed, 
and  the  various  kinds  of  lesions  of  which  these  two  clasess  are  composed 
must  be  clearly  understood,  as  a  knowledge  of  their  appearance  and 
nature  is  of  essential  importance  for  the  intelligent  study  and  compre- 
hension of  the  various  cutaneous  diseases.  A  few  lesions  not  readily 
classifiable  under  the  subdivisions  usually  made,  such  as  horns,  some 


ELEMENTARY  OR  PRIMARY  LESIONS  57 

warts,  the  "burrow,"  or  "cuniculus,"  produced  by  the  itch-mite,  etc., 
will  receive  sufficient  attention  in  considering  the  diseases  which  they 
represent  or  of  which  they  may  form  a  part. 

ELEMENTARY  OR  PRIMARY  LESIONS 

Macules. — Synonyms. — Spots;  Erythematous  spots;  Maculae;  Fr., 
Taches;  Ger.,  Flecke. 

Macules  are  variously  sized,  shaped,  and  tinted  spots  and  discolora- 
tions,  or  circumscribed  alterations  in  the  color  of  the  skin,  without,  as  a 
rule,  appreciable  elevation  or  depression. 

They  may  constitute  a  part  or  the  whole  of  the  eruption,  or  may 
simply  be  an  early  stage  or  an  associated  symptom  in  mixed  cases. 
They  may  also  be  congenital  or  acquired,  evanescent  or  permanent, 
scanty  or  abundant,  and  may  or  may  not  disappear  under  pressure. 
Depending  upon  the  character  and  origin  of  the  lesions,  there  may  or 
may  not  be  associated  itchiness.  In  size  they  vary  from  that  of  a  pin- 
point to  that  of  the  palm  or  larger,  and  while  commonly,  especially 
the  small  macules,  more  or  less  rounded  or  oval,  they  are  not  infre- 
quently somewhat  irregular  in  outline;  they  may  have  a  sharp  defini- 
tion or  be  ill  defined.  The  color  may  be  of  any  tint  or  shade,  depend- 
ing upon  the  disease  of  which  it  may  be  a  part  or  symptom.  The  lesion 
is  the  result  of  numerous  pathologic  processes.  It  may  be  produced  by 
simple  hyperemia  or  congestion,  the  most  familiar  example  of  which  is  the 
pinkish  or  reddish  spots  and  patches  of  erythema,  in  erythema  hyperae- 
micum,  and  which  may  also,  by  coalescence  and  profusion,  form  an 
eruption  more  or  less  diffused  over  the  surface.  The  pinkish  or  reddish 
macules  of  the  various  exanthemata,  of  typhoid  fever  (rose-spots), 
and  of  copaiba  and  other  drug  rashes,  are  also  examples  of  the  hyperemic 
type.  The  ring  or  zone  of  hyperemia  sometimes  found  surrounding  other 
lesions,  known  as  the  areola  or  halo,  might  also  be  considered  as  an  annu- 
lar erythematous  spot  or  macule;  it  is  usually,  however,  distinctly  in- 
flammatory. The  hyperemic  macule  has  sometimes  a  trifling  degree  of 
underlying  accompanying  inflammatory  action,  but  rarely  sufficient  to 
give  perceptible  elevation.  When  there  is  a  slight  escape  of  the  coloring- 
matter  of  the  blood,  the  hyperemic  color  is  soon  mellowed  by  a  yellowish 
or  yellowish-white  tinge.  Sometimes,  in  such  macules,  there  may  be  ex- 
tremely slight,  scarcely  perceptible,  branny  scaliness;  this  is  also  observed 
in  the  spots  or  macules  of  tinea  versicolor. 

Occasionally  the  erythematous  spots  tend  to  merge  or  develop 
into  slight  elevations, — a  midway  lesion  between  macules  and  papules, — 
known  as  maculopapules  or  erythematopapules,  and,  when  this  charac- 
teristic is  predominant,  the  eruption  is  described  by  the  qualifying  term 
erythemato papular  or  maculo papular. 

Other  macules  may  be  the  direct  consequence  of  hemorrhage  into 
the  skin,  without  preceding  or  accompanying  hyperemia  or  inflamma- 
tion, as  the  spots  of  purpura,  which  are  usually  first  bright  red,  un- 
affected by  pressure,  and  change  to  a  dull  red,  yellowish,  and  finally 
fade  away.  Long-continued  inflammatory  action  with  deposit  of  the 


5g  GENERAL   SYMPTOMATOLOGY 

coloring-matter  of  the  blood  or  the  deposition  of  pigment,  as  in  lichen 
planus  syphilis,  and  some  other  diseases,  especially  when  on  dependent 
parts  leaves  behind  dark-red  or  brownish  colored  macules  or  stains  of 
more' or  less  persistence.  Other  examples  of  pigmentary  macules  are 
freckles,  chloasma  spots  and  patches,  and  naevus  pigmentosus,  which 
are  due'to  excessive  pigment  deposit,  and  may  be  of  different  degrees  of 
shade  from  light  yellow  to  almost  black.  When  such  deposit  is  diffused, 
involving  large  areas  and  of  more  or  less  uniform  distribution,  it  is  com- 
monly designated  a  discoloration. 

Small  circumscribed  discolored  spots  sometimes  are  of  artificial 
origin,  resulting  from  the  forced  introduction  of  pigment-matter  in  or 
beneath  the  skin,  as  in  tattoo-marks  and  powder-stains.  The  skin 
may  also  be  discolored  temporarily  by  certain  chemicals  or  dyes.  In 
contradistinction  to  the  dark  macules  are  the  white  spots  of  vitiligo, 
and  those  associated  with  other  atrophic  changes  of  the  skin,  as  in 
leprosy  and  other  disorders.  Casual  mention  may  also  be  made  of 
the  reddish  spots  or  macules  due  to  capillary  dilatation  or  new  growths, 
as  in  the  acquired  blemish  designated  telangiectasis,  and  in  the  con- 
genital formation  known  as  vascular  nevus. 

Wheals.—  Synonyms— Pomphi;  Urticae;  Fr.,  Plaques  ortiees; 
Ger.,  Quaddeln. 

Wheals  are  variously  sized  and  shaped,  whitish,  pinkish,  or  red- 
dish edematous  elevations,  of  an  evanescent  character. 

Their  common  and  most  typical  expression  is  as  the  lesion  of  urti- 
caria, although  they  can  also  be  produced  by  the  bite  of  a  mosquito  or 
by  the  sting  of  the  common  nettle.  They  are  closely  related  to  ery- 
thema, and  can  almost  be  considered  as  erythematous  spots  or  macules 
with  underlying  edema.  The  peripheral  portion  of  a  typical  wheal  is 
usually  pinkish  or  reddish,  the  central  and  main  portions  whitish  or 
pinkish  white,  and  they  not  infrequently  have  a  shining  aspect.  Some- 
times they  are,  however,  almost  wholly  white,  and  in  others  pink  or  red, 
with  a  mellowing  toward  a  white  color  centrally.  In  shape  they  are 
most  commonly  rounded  or  ovoid,  pea-  to  bean-sized,  and  considerably 
elevated;  if  numerous  and  close  together,  from  enlargement  and  the 
arising  of  new  efflorescences  in  the  interspaces,  solid  plaques  result, 
usually  in  their  main  aspect  appearing  to  be  white,  edematous,  elevated, 
flattened  infiltrations,  with  or  without  pinkish  shading  here  and  there, 
and  generally  with  a  pink  or  red  edge  or  areola.  In  other  instances, 
mixed  in  with  the  ordinary  rounded  forms,  there  may  be  linear  wheals, 
from  a  fractional  part  of  an  inch  to  several  inches  or  more  in  length,  and, 
if  not  arising  spontaneously,  such  forms  can  commonly  be  brought  out 
by  rubbing  or  scratching.  By  a  coalescence  of  ordinary  wheals,  linear 
forms,  etc.,  gyrate  or  ring-like  plaques  of  irregular  configuration  some- 
times result.  In  some  cases,  and  also  in  occasional  individuals  free  from 
ordinary  attacks  of  urticaria,  signs,  letters,  and  various  characters  can 
be  produced  by  firmly  drawing  the  finger  or  the  blunt  end  of  a  pencil 
over  the  parts — a  condition  known  as  "dermatographism"  (q.  v.). 
Exceptionally,  wheals  are  much  smaller  than  are  commonly  seen, 


ELEMENTARY  OR  PRIMARY  LESIONS  59 

especially  in  young  children,  in  whom  some  or  all  of  them  may  be  more 
of  the  nature  of  conic  or  acuminate  papules,  often  capped  with  a  minute 
vesicular  point — the  so-called  urticaria  papulosa.  In  some  cases,  too,  in 
adults,  as  well  as  in  those  younger,  the  edematous  exudation  is  so  rapid 
and  profuse  that  the  epidermis  is  lifted  up,  and  a  bleb,  or  bulla,  produced 
— urticaria  bullosum. 

Wheals  are  always  attended  with  more  or  less  burning,  a  feeling 
of  heat,  and  itching,  and  these  subjective  symptoms,  especially  the 
itching,  often  exist  to  an  intense  and  annoying  degree;  the  scratching 
and  rubbing  thus  induced  lead  to  aggravation  of  the  lesions  present 
and  the  development  of  new  ones.  The  lesion  is  of  rapid  formation, 
usually  fully  developed  in  a  few  seconds  or  a  few  minutes;  it  is  evan- 
escent and  capricious,  often  coming  and  going  quickly  and  in  the  most 
erratic  manner,  without  any  subsequent  scaliness  or  exfoliation.  It  is 
angioneurotic  in  character,  due  to  some  irritation  from  within  or  without, 
and  has  its  seat  in  the  papillary  layer  or  in  the  body  of  the  corium.  There 
is,  first,  a  dilatation  of  the  vessels,  then  a  sudden  exudation  of  serum 
takes  place,  followed  by  a  contraction  of  the  vessels,  which  prevents 
absorption;  as  soon  as  the  spasm  of  the  vessels  abates,  absorption  gradu- 
ally or  quickly  takes  place,  and  the  wheal  disappears. 

Papules. — Synonyms. — Pimples;  Papulae;  Fr.,  Papules;  Ger., 
Knotchen. 

Papules  are  small,  usually  superficially  seated,  pin-head  to  pea- 
sized,  circumscribed  solid  elevations. 

They  show  considerable  variation  in  size,  shape,  and  color,  and 
are  of  diverse  character  and  origin,  and  therefore  are  due  to  many 
different  pathologic  processes,  and  have  their  seat  in  different  structures 
of  the  skin.  They  may  be  white  or  whitish,  as  in  milium,  which  pro- 
duces a  papular  elevation;  yellow,  as  in  xanthoma;  bright  red,  as  in 
eczema;  dark  or  coppery,  as  in  syphilis;  violaceous,  as  in  lichen  planus; 
and  almost  black,  as  in  some  of  the  papular  infiltrations  of  some  varieties 
of  sarcoma. 

The  papule,  or  beginning  solid  pimple  of  acne,  and  the  red  pin- 
point to  pin-head-sized  papule  of  eczema  are  its  most  familiar  exam- 
ples. In  both  of  these  the  lesion  is  usually  rounded  at  the  base,  and 
conic  or  pointed  in  shape,  whereas  the  papule  in  lichen  planus  is  usually 
irregular  at  the  base  and  flat  or  umbilicated  in  form.  The  papules  of  the 
papular  type  of  erythema  multiforme  are  also  generally  somewhat 
flattened,  and  sometimes,  and  exceptionally  also  in  lichen  planus,  with  a 
tendency  to  slight  central  depression  or  partial  absorption  and  simul- 
taneous peripheral  extension,  the  papules  then  being  faintly  or  distinctly 
circinate  or  annular.  In  other  lesions,  instead  of  being  acuminate  or 
flat,  the  top  may  be  convex  or  bluntly  rounded.  In  addition  to  the 
various  examples  of  papules  already  referred  to,  may  be  mentioned  those 
which  are  formed  by  epidermic  collections  about  the  hair-follicle  outlets, 
as  in  keratosis  pilaris,  and  which  are  harsh,  rough,  and  grayish,  with, 
sometimes,  a  reddish  base.  The  same  may  be  said  of  the  follicular 
papules  observed  in  pityriasis  rubra  pilaris  and  in  ichthyosis.  It  will 


6o  GENERAL   SYMPTOMATOLOGY 

thus  be  seen  that  this  lesion  may  be  inflammatory  or  plastic  in  origin,  as 
in  eczema;  due  to  duct  obstruction  or  obliteration,  as  in  acne  and  milium; 
to  cellular  or  new-growth  infiltration,  as  in  xanthoma  and  lupus;  to  hy- 
pertrophy of  the  epidermic  layer  or  scale  accumulation,  as  in  keratosis 
pilaris;  or  of  the  papillary  layer — the  papillae — as  in  ichthyosis  and 
warts.  They  sometimes  arise  from  erythematous  spots,  and  may 
not  become  fully  developed  papules,  being  erythemato papular  or  macula- 
papular.  As  a  rule,  inflammatory  papules  are  itchy,  sometimes  markedly 
so,  as  in  papular  eczema  and  lichen  planus;  other  papular  formations  are 
rarely  attended  with  active  subjective  symptoms. 

Papular  lesions  persist  as  such,  or  in  some  diseases  at  times  change 
into  vesicles,  as  in  eczema,  or  into  pustules,  as  in  acne  and  some  syphilitic 
papules.  Some  are,  as  already  described,  essentially  squamous;  others 
may  become  so,  as  with  lichen  planus  and  the  papular  syphiloderm, 
constituting  the  squamous  papule;  the  eruption  in  which  such  feature  is 
predominant  is  designated  papulosquamous.  Sometimes  the  transforma- 
tion into  a  vesicle  or  pustule  is  incomplete  or  partial,  the  lesion  remaining 
comparatively  solid,  and  thus  arise  the  lesions  known  as  papulovesicles 
or  vesicopapules  and  papula  pustules;  and  when  this  is  displayed  in  a 
greater  number  of  the  lesions  the  eruption  is  described  as  vesico papular 
or  papulovesicular  and  papula  pustular.  The  duration  of  papular  lesions 
is  variable,  depending  upon  their  nature,  origin,  and  management. 

The  term  lichen  is  sometimes  erroneously  used  to  designate  a  papular 
eruption  as  a  whole,  and  the  word  lichenoid,  as  synonymous  with  the 
term  papular,  but  the  former,  especially,  is  a  misleading  and  more  or  less 
obsolete  term,  unless  used  with  a  qualifying  adjective — as,  for  example, 
lichen  planus  and  lichen  scrofulosus.  Lichenification  is  a  term  that  the 
French  apply  to  a  condition  of  the  skin  usually  observed  about  the 
joints,  characterized  by  some  thickening,  dryness,  and  often  slight  rough- 
ness and  sometimes  trifling  scaliness,  with  accentuation  of  the  lines  of 
the  skin;  and  with,  in  most  instances,  closely  crowded  or  coalescing, 
slight,  flat,  dull-reddish,  papular  elevations.  They  believe  this  condi- 
tion results  from  chronic  inflammatory  processes,  others  are  inclined  to 
consider  it  as  an  expression  of  lichen  planus  or  chronic  eczema,  the 
peculiar  added  lichenification  features  being  due  to  the  consequent 
rubbing,  friction,  scratching,  and  possibly  to  some  extent  to  local 
medication. 

Tubercles. — Synonyms. — Nodules;  Small  tumors;  Tuberc'ila; 
/*>.,  Tubercules;  Ger.,  Knoten. 

Tubercles  are  solid,  usually  clearly  circumscribed,  rounded,  pea- 
sized,  somewhat  deep-seated,  elevations,  generally  of  a  persistent  char- 
acter. 

Clinically,  there  is  a  close  analogy  between  papules  and  tubercles, 
and  the  latter  might  almost  be  described  as  or  named  an  exaggerated 
papule;  it  is  not  always  an  easy  matter  to  classify  them.  It  can  be 
considered  as  an  intermediate  or  merging  lesion  between  a  papule  and  a 
small  tumor.  The  tubercle  commonly  consists  of  a  cellular  infiltration, 
is  usually  neoplastic,  as  in  the  tubercles  of  leprosy,  lupus,  syphilis,  etc., 


ELEMENTARY  OR  PRIMARY  LESIONS  6l 

\ 

although  it  may  also  be  hypertrophic  and  inflammatory.  The  deep- 
seated  character,  its  more  intimate  association  with  the  corium  or  sub- 
cutaneous tissue,  and  its  commonly  convex  or  bluntly  rounded  pro- 
jecting portion  are  the  features  that  distinguish  it  from  its  near  affinity, 
the  larger-sized  papules.  These  latter  are  more  of  the  nature  of  surface 
lesions,  with  but  slight  tendency  to  downward  growth ;  in  short,  a  papule 
may  be  said  to  be  a  solid  lesion  extending  upward;  a  tubercle,  a  solid 
lesion  projecting  both  upward  and  downward. 

Some  confusion  has  been  added  to  the  term  tubercle,  so  long  used 
in  dermatologic  description  to  designate  this  primary  lesion  variety,  by 
its  more  recent  application  to  a  product  of  tuberculosis.  In  dermatology 
it  refers  solely  to  the  form  and  general  characters  of  the  lesion,  and  not  to 
its  nature. 

While  generally  circumscribed  and  rounded,  tubercles  may  also  be 
conic  and  somewhat  flat  or  irregular  in  outline.  They  are  of  gradual 
growth,  and  when  close,  together,  coalesce  and  form  solid  infiltrated 
areas,  with  sometimes  an  entire  disappearance  of  their  original  nodular 
character.  Usually,  howrever,  more  or  less  distinct  characteristic  tuber- 
cles are  to  be  recognized  at  the  peripheral  portion,  or  outlying  close  to  the 
border.  In  color  a  tubercle  is  usually  dull  reddish,  but  in  xanthoma 
they  are  yellow,  in  fibroma  normal  or  pinkish,  in  molluscum  conta- 
giosum  pinkish  and  waxy,  and  in  some  cases  of  sarcoma  and  carcinoma 
purplish  red  or  blackish. 

Tubercles  are  not  only  of  slow  formation,  as  a  rule,  but  sluggishly 
persist,  and  are  extremely  slow  in  disappearing.  Some  persist  indefinitely, 
with  no  tendency  to  involution,  as  in  fibroma.  In  others,  after  some 
weeks,  months,  or  at  times  even  years,  involutionary  changes  set  in, 
and  they  disappear  by  absorption  without  trace,  or  with  some  remaining 
atrophy  and  discoloration;  or  they  undergo  degenerative  and  destruc- 
tive changes  and  ulcerate,  as  often  observed  in  the  tubercles  of  syphilis, 
lupus,  leprosy,  etc.,  and  are  followed  by  scar- formation. 

Tumors. — Synonyms. — Tumores;  Phymata;  Fr.,  Tumeurs;  Ger., 
Knollen;  Geschwulste. 

Tumors  are  soft  or  firm,  usually  more  or  less  circumscribed,  though 
variously  sized  and  shaped,  elevations,  having  their  seat  in  the  corium 
and  subcutaneous  tissue.  They  are  generally  large  and  prominent 
formations,  the  smallest  size  commonly  accepted  under  the  term — a 
somewhat  vague  one — being  that  of  a  large  pea  or  a  large  tubercle,  the 
dividing-line  from  the  latter  being  more  or  less  arbitrary,  as  tubercles 
are  often  spoken  of  as  small  tumors.  More  commonly,  however,  it  im- 
plies a  growth  of  dimensions  exceeding  those  of  a  cherry.  They  are  fre- 
quently walnut-  to  egg-sized  or  larger.  Their  color  is  usually  that  of  the 
skin,  but  the  latter  is  sometimes  put  upon  the  stretch,  and  may  look 
thinned,  glistening,  and  often  pinkish  or  reddish. 

They  are  generally  semiglobular  in  shape,  originate,  as  a  rule,  deeply, 
either  in  the  subcutaneous  tissue  or  conjointly  in  this  and  the  corium,  and 
gradually  develop  to  their  normal  size  or  to  indefinite  proportions — 
to  a  slight  extent  spreading  out  into  the  deeper  structure,  to  a  greater 


62  GENERAL   SYMPTOMATOLOGY 

degree  laterally,  and  in  many  instances  probably  most  upward  where 
there  is  less  resistance,  finally  resulting  in  variously  sized,  shaped,  and 
constituted  firm  or  soft  prominences,  sharply  or  fairly  well  circumscribed, 
or  intimately  associated  or  blended  with  the  adjacent  tissues,  or  forming 
pendulous  tumors.  In  those  of  markedly  inflammatory  or  active  origin, 
as  in  carbuncles,  gummata,  and  similar  growths,  there  is  a  good  deal  of 
lateral  extension,  the  mass  becomes  suppurative  and  necrotic,  the  skin 
dark  to  purplish  red,  with  its  gradual  destruction  in  totality  or  at  points. 
The  tumors  of  granuloma  fungoides,  sarcoma,  carcinoma,  leprosy,  and 
like  malignant  affections  also  usually  undergo  final  destructive  changes, 
terminating  in  small  or  large  ulcerating  masses  or  open  ulcers.  On  the 
other  hand,  the  sebaceous  cyst,  ordinary  fibroma,  angioma,  keloidal 
growths,  lipoma,  myoma,  lymphangioma,  etc.,  are  benign,  or  relatively 
so,  usually  maintaining  their  integrity  throughout.  Tumors  are,  there- 
fore, as  is  to  be  inferred  from  the  various  cited  examples,  of  different 
constitution,  character,  growth,  and  termination,  according  to  the  seat 
of  origin  and  the  nature  of  the  pathologic  process,  influenced  probably 
by  accidental  or  extraneous  factors  or  conditions. 

Vesicles. — Synonyms. — Little  blisters;  Vesiculae;  Fr.,  Vesicules; 
Ger.,  Blaschen. 

Vesicles  are  pin-point  to  small  pea-sized,  whitish,  yellowish,  or  red- 
dish, circumscribed  epidermal  elevations,  containing  clear  or  opaque 
fluid.  They  arise  as  vesicles  or  are  formed  from  pre-existing  papules. 
They  may  be  acuminate,  conic,  or  rounded,  sometimes  slightly  flattened. 
Their  color  depends  upon  their  contents  and  the  degree  of  the  accom- 
panying inflammatory  action.  The  contents  may  be,  as  usually  always 
at  first,  perfectly  clear  and  watery,  consisting  of  pure  serum,  which  may 
subsequently,  and  in  some  instances  almost  from  the  start,  show  a  slight 
cloudiness;  later  some  lesions  become  seropurulent,  and  in  others  there 
is  a  slight  admixture  of  blood.  Thickness  of  the  epidermal  covering  is 
also  an  influencing  factor  in  the  coloring,  as  shown  in  the  sago-grain-like 
vesicle  of  pompholyx.  For  the  most  part  inflammatory  vesicles  are  well 
distended  and  conic  or  acuminate.  Those  of  eczema  are  usually  minute, 
pin-point  to  pin-head  in  size,  or  sometimes  slightly  larger,  yellowish  and 
glistening,  aggregated  or  crowded  together,  superficially  seated,  with  thin 
walls,  and  generally  tending  to  spontaneous  rupture.  The  lesions  may 
be  so  close  together  as  to  coalesce,  sometimes  almost  before  completely 
formed,  and  undermine  the  horny  layer  of  the  epidermis.  The  tendency 
to  the  appearance  in  groups,  aggregations,  or  closely  packed  masses 
seems  to  be  more  or  less  characteristic  of  the  lesion,  although  in  some 
diseases  they  may  be  scanty,  isolated,  or  discrete,  even  if  generally 
disseminated.  The  former  is  shown  in  eczema,  herpes  simplex,  herpes 
zoster,  and  dermatitis  herpetif ormis ;  the  latter  in  miliaria,  sudamen, 
hydrocystoma,  and  varicella. 

While  ordinarily  rounded,  conic,  or  acuminate,  they  may  be  oblong 
or  somewhat  linear,  as  frequently  seen  in  some  lesions  in  scabies,  or 
oblong,  irregular,  or  angular,  both  at  the  base  and  in  their  body,  as  in 
dermatitis  herpetiformis  and  some  cases  of  herpes.  In  these  latter 


ELEMENTARY  OR  PRIMARY  LESIONS  63 

two  diseases,  as  well  as  in  others,  sometimes  instead  of  being  distended 
and  tense,  they  are  only  partly  full  and  flaccid.  Exceptionally  in  the 
larger  vesicles  a  tendency  to  umbilication  is  exhibited.  Some  display 
but  little,  if  any,  tendency  to  spontaneous  rupture,  as  in  herpes  simplexr 
herpes  zoster,  hydrocystoma,  etc.  This  latter  feature  depends  upon 
their  point  of  origin,  whether  superficial  or  deep,  and  the  thickness  of  the 
stratum  corneum.  Some  simply  have  the  upper  corneous  layers  as  the 
epidermal  covering,  others  the  entire  horny  stratum,  while  still  others 
are  still  farther  down,  beneath  the  granular  layer.  In  the  palms  and 
soles,  owing  to  the  thickness  of  the  horny  layers,  their  covering  is  com- 
monly thick  and  tough;  in  this  region,  too,  owing  to  this  fact,  under- 
mining sometimes  results.  They  are  usually  the  result  of  exudation  from 
the  vessels  of  the  papillae;  sometimes  they  are  due  to  sweat  retention, 
generally  in  some  part  of  the  gland-duct.  They  may  be  one-celled  or 
simple,  having  but  a  single  chamber  or  cavity,  as  in  the  vesicles  of  eczema 
and  sudamen,  or  multilocular  or  compound,  having  two  or  more  cavities 
or  chambers,  as  in  the  vesicles  of  variola,  herpes,  and  varicella. 

Vesicles  are  rarely  persistent  as  such,  but  break  spontaneously 
and  crust  over,  as  in  eczema;  dry  up  and  desiccate  into  a  thin  crust, 
as  usually  in  herpes  simplex  and  herpes  zoster;  the  contents  are  in  part 
or  completely  absorbed  or  evaporated,  the  covering  wall  exfoliating  as 
a  thin  scale,  as  in  sudamen;  develop  into  blebs  through  either  coales- 
cence or  enlargement,  as  sometimes  in  herpes  zoster,  and  frequently  in 
dermatitis  herpetiformis;  or  they  become  pustules,  as  in  variola,  and 
sometimes  in  eczema.  In  this  last,  however,  as  in  some  other  diseases, 
the  lesions  often  do  not  become  strictly  purulent,  but  are  of  a  sero- 
purulent  character,  forming  vesicopustules,  and  when  such  a  feature  is  a 
predominant  one,  the  eruption  is  usually  designated  vesicopustular  or 
pustulovesicular.  In  exceptional  instances  the  vesicles  undergo  con- 
siderable enlargement,  approaching  to  or  almost  merging  into  blebs,  or 
they  may  be  originally  of  fairly  large  size,  and  in  such  the  eruption  is 
often  temed  vesicobullous,  although  this  same  designation  is  also  some- 
times applied  to  mixed  vesicular  and  bullous  eruptions.  As  a  rule, 
vesicular  eruptions  are  attended  by  a  good  deal  of  burning  and  itching, 
although  in  some  instances,  as  in  sudamen  and  hydrocystoma,  sub- 
jective symptoms  are  entirely  absent. 

Blebs.— Synonyms.— Blisters;  Bullae;  Fr.,  Bulles;  Ger.,  Blasen. 

Blebs  are  rounded  or  irregularly  shaped,  tense  or  flaccid,  pea-  to 
egg-sized  or  larger,  epidermic  elevations  with  serous  or  seropurulent 
contents;  they  are,  in  brief,  similar  to  vesicles  except  as  to  dimensions. 
While  commonly  rounded  or  oval,  they  may  be,  as  with  vesicles,  some- 
what irregular  in  shape.  They  sometimes  arise  from  vesicles,  either  by 
direct  extension  or  growth,  or  from  the  coalescence  of  several  lesions. 
In  their  most  typical,  although  probably  not  most  common,  expression, 
as  in  pemphigus,  they  frequently  spring  from  a  seemingly  healthy  or 
non-inflammatory  surface,  so  that  they  may  or  may  not  have  a  mildly 
inflammatory  or  hyperemic  areola.  They  arise  in  dermatitis  herpeti- 
formis either  as  blebs  or  by  coalescence  of  vesicles  from  an  apparently 


64  GENERAL   SYMPTOMATOLOGY 

normal  or  reddened  skin,  or  develop  upon  pre-existing  erythemato- 
papular  lesions.  As  accidental  lesions,  they  may  develop  upon  urticarial 
efflorescences,  as  in  urticaria;  upon  an  erythematous  or  erythemato- 
papular  base,  as  in  erythema  multif orme ;  or  arise  in  erysipelas,  leprosy, 
and  some  other  diseases.  They  are  not  an  uncommon  feature  of  rhus- 
poisoning  and  other  forms  of  dermatitis.  In  their  earliest  formation 
bullae  are,  as  a  rule,  clear  or  pale  yellowish,  their  contents  being  serous 
and  of  a  neutral  or  alkaline  reaction;  later  they  usually  become  some- 
what clouded  or  turbid,  and  whitish  or  yellowish  in  color;  if  containing 
blood,  uniformly  mixed,  the  color  is  reddish  or  brownish;  if  this  ad- 
mixture is  not  evenly  distributed  through  the  bleb,  the  appearance  is 
whitish  or  yellowish,  with  an  intermingling  of  reddish  or  brownish  streaks 
or  flakes.  Sometimes  they  are  seropurulent  from  the  beginning. 

At  first  they  are  usually  tense  and  distended,  but  unless  sponta- 
neously or  accidentally  ruptured  the  walls  become  flaccid;  in  some 
instances  the  latter  character  is  noted  throughout.  They  are  unilocular 
or  one-chambered,  have,  as  a  rule,  somewhat  tough  walls,  which  do  not 
readily  burst.  In  some  cases,  however,  their  covering  is  thinner  than 
ordinarily,  ruptures  early  either  spontaneously  or  as  the  result  of  trifling 
external  accidental  agencies,  the  broken  walls  remaining  temporarily 
attached  to  the  skin  as  thin,  irregular  shreds.  In  pemphigus  foliaceus 
this  is  especially  noticed,  the  thin  walls  breaking  rapidly,  scarcely  before 
there  is  much  observable  exudation,  and  new  exudation  frequently 
taking  place  before  the  corneous  layer  has  been  fully  replaced,  and  as 
soon  as  slightly  lifted  up  breaks  again,  and  so  the  process  continues; 
frequently  in  these  cases  the  lesions  are  so  closely  contiguous  that  they 
coalesce,  the  exudation  producing  essentially  a  more  or  less  general 
undermining.  The  base  of  the  broken-  blebs  varies  somewhat  in  appear- 
ance and  character,  ordinarily  being  simply  the  red  rete  or  corium,  ap- 
pearing as  a  red  superficial  abrasion,  which  soon  heals  over.  At  other 
times  it  is  a  decided  erosion,  dotted  or  streaked  over  with  seropurulent 
or  purulent  matter  or  blood,  and  continuing  to  secrete  actively  for  a 
variable  time;  occasionally  the  surface  shows  a  vegetating  or  papillo- 
matous  tendency. 

The  course  of  bullae  is  essentially  the  same,  therefore,  as  with  vesi- 
cles, and  they  terminate  in  the  same  way  by  suppuration,  by  partial 
absorption,  desiccation,  and  crusting,  and  by  rupture  and  thin  crusting; 
those  becoming  purulent  finally  ending  in  like  manner  as  those  which 
remain  serous  or  seropurulent — by  rupture,  desiccation,  and  crusting, 
the  latter  being  thicker  and  sometimes  quite  bulky. 

Blebs  are,  as  remarked,  usually  unilocular  or  one-chambered,  and, 
as  with  vesicles,  have  their  seat  in  the  epidermis,  either  in  the  superficial 
or  deeper  layers;  in  some  instances  the  entire  epidermis  is  lifted  up.  As 
a  rule,  they  are  rarely  accompanied  by  active  subjective  symptoms, 
although  often  a  sensation  of  tension  and  slight  burning  attend  their 
development.  Their  presence  is  usually  to  be  considered  either  an  acci- 
dental one,  as  in  urticaria,  erythema,  etc.,  due  to  the  intensity  and 
rapidity  of  the  inflammatory  action  and  effusion;  or  an  expression  of 
some  general  nerve  disturbance  or  depression,  chronic  auto-intoxication, 


ELEMENTARY  OR  PRIMARY  LESIONS  65 

septicemia,  a  depraved  or  cachectic  state  of  the  health,  and  the  like,  as 
in  dermatitis  herpetiformis,  pemphigus,  and  syphilis. 

Pustules — Synonyms.— Pustulae;  Fr.,  Pustules;  Ger.,  Pusteln. 

Pustules  are  pin-point  to  finger-nail-sized  circumscribed  epidermic 
elevations  containing  pus.  They  are,  in  brief,  similar  to  vesicles  and 
to  the  smaller  blebs  having  an  inflammatory  areola,  except  that  the 
contents  are  purulent  instead  of  serous  or  seropurulent,  as  in  these 
lesions.  They  originate  as  pustules  or  arise  from  vesicles,  and,  if  from 
the  latter,  sometimes  may  become  only  incompletely  purulent,  con- 
stituting vesicopustules.  They  may  also  develop  from  a  papule,  and  here 
likewise  the  transition  in  some  lesions  or  cases  may  be  incomplete,  the 
papular  basis  being  maintained,  the  suppurative  change  taking  place 
at  the  central  apex  portion,  resulting  in  the  lesions  known  as  papula- 
pustules.  In  many  instances,  however,  when  arising  from  vesicles  or 
papules,  the  pustular  metamorphosis  may  be  so  rapid  that  the  vesicular 
or  papular  origin  can  scarcely  be  recognized.  As  a  rule,  however,  in 
such  instances  there  is  an  intermingling  of  the  primary  formations, 
which  have  continued  as  such,  or  undergone  only  slight  transformation; 
in  fact,  it  is  usual  to  find  lesions  in  all  stages  of  transition. 

In  color  pustules  are  usually  yellowish,  unless  they  contain  an 
admixture  of  blood,  when  they  are  reddish  or  brownish  yellow.  In 
shape  they  are  acuminate,  as  often  in  eczema  and  sycosis;  conic  or 
rounded,  as  usually  in  acne,  furuncle,  and  an  occasional  type  of  im- 
petigo (Duhring's  impetigo  simplex) ;  or  flat  or  flattened,  as  in  most  cases 
of  impetigo,  in  ecthyma,  flat  pustular  syphiloderm,  etc. ;  in  some  diseases 
with  central  depression  or  umbilication,  as  in  variola  and  the  varioliform 
syphiloderm;  and  occasionally  oblong  or  somewhat  linear,  as  some- 
times in  scabies.  In  size  they  vary  from  a  pin-point,  as  in  the  smallest 
pustules  of  eczema,  to  that  of  a  finger-nail,  as  in  the  lesions  of  impetigo 
and  ecthyma.  They  may  be  superficially  seated,  as  in  eczema  and  im- 
petigo pustules;  or  moderately  deep,  as  in  some  lesions  of  the  latter 
disease  and  of  sycosis;  or  deep  seated,  as  in  most  pustules  of  the  last- 
named  affection,  in  acne,  and  in  furuncle.  They  are,  therefore,  as 
regards  the  point  of  origin,  somewhat  variable,  that  of  eczema,  impetigo, 
and  ecthyma  usually  or  chiefly  in  the  mucous  layer,  that  of  sycosis  around 
the  hair-follicle,  that  of  acne  in  or  about  the  sebaceous  gland,  and  that 
of  boils  deep  in  the  corium.  The  hair-follicle  plays  an  important  part 
in  most  pustular  lesions,  either  as  the  sole  or  conjoint  seat  of  the  suppu- 
rative process  or  as  the  port  of  entrance  for  pyogenic  cocci.  As  a  rule, 
pustules  form  rapidly  and  are  generally  attended  by  a  good  deal  of 
inflammatory  action,  sometimes  with  considerable  burning,  pain,  and 
tenderness,  but  itching,  except  in  those  of  eczema,  is  rarely  complained 
of.  Exceptionally  their  formation  is  slow,  as  occasionally  in  the  pus- 
tules of  impetigo,  ecthyma,  and  syphilis;  this  usually  results  in  a  flatten- 
ing and  a  tendency  to  central  depression,  or  in  stratification  of  the  crust, 
as  particularly  shown  in  the  condition  known  as  rupia.  In  this  latter  the 
covering  and  upper  portion  of  the  contents  of  the  pustule  or  small 
purulent  bleb  dry  to  a  crust  that  is  lifted  up  by  the  gradually  forming 


66  GENERAL    SYMPTOMATOLOGY 

and  extending  purulent  collection  beneath;  this  in  turn  dries  to  a  crust, 
while  the  base  of  the  lesion  is  still  enlarging  and  secreting,  and  in  this 
manner  it  may  continue  for  a  variable  period.  When  fully  formed,  the 
entire  overlying  crust  is  thick  and  stratified,  with  that  of  small  diameter 
at  the  top  and  the  largest  at  the  under  part,  presenting  an  oyster-shell- 
like  arrangement.  In  impetigo  and  ecthyma  the  central  part  some- 
times dries  and  becomes  firmly  attached  to  the  underlying  part,  while  the 
purulent  collection  to  a  slight  degree  extends  peripherally  as  a  spreading 
purulent  wall. 

Upon  the  whole,  pustules  usually,  like  vesicles  and  blebs,  tend  to 
rapid  development,  course,  and  termination,  varying  somewhat  accord- 
ing to  their  cause,  nature,  and  seat.  As  with  vesicles,  they  may  be 
unilocular  or  have  but  one  cavity,  or  multilocular,  with  several  or  more 
chambers.  They  generally  end  by  rupture  and  discharge,  with  subse- 
quent slight  crust-formation  and  repair;  or  they  may  break  imperfectly, 
with  but  little  escape  of  fluid,  and  gradually  dry  into  a  rather  thick,  firm 
crust  that  finally  drops  off;  or  they  may  dry  up  without  rupture.  The 
color  of  the  crust  varies  from  a  yellowish  or  yellowish  brown,  as  in 
eczema,  to  reddish  or  dark  brown,  in  syphilis,  and  may  be  thin,  thick, 
friable,  or  firm,  depending  upon  the  character  of  the  morbid  process  and 
other  circumstances.  The  processes  involving  the  corium  may  be  fol- 
lowed by  scar-formation,  as  in  variola,  syphilis,  acne,  ecthyma,  and  the 
like. 

CONSECUTIVE  OR  SECONDARY  LESIONS 

Hxcoriations. — Synonyms. — Excoriationes ;  Abrasions;  Erosions; 
Scratch-marks;  Fr.,  Excoriations;  Ger.,  Hautabschiirfungen;  Excoria- 
tionen. 

Excoriations  are  variously  sized  and  shaped,  but  usually  small, 
irregular,  or  linear,  solutions  of  continuity,  generally  of  a  superficial 
character,  and  the  result  of  traumatic  or  mechanical  causes. 

The  most  familiar  and  chief  examples  are  the  red  denuded  points, 
small  abrasions,  jags,  and  lines  or  shallow  furrows  produced  by  the 
finger-nails  in  the  act  of  scratching,  in  efforts  to  gain  relief  from  the 
troublesome  itching  in  certain  diseases,  notably  eczema,  pruritus, 
scabies,  and  pediculosis.  Not  infrequently  they  are,  especially  the  points 
and  small  areas,  more  or  less  irregularly  covered  with  thin  crusts  com- 
posed of  blood  and  the  exuded  serum.  As  a  rule,  they  involve  the  epi- 
dermis only,  rarely  extending  more  than  superficially  into  the  papillary 
layer  of  the  corium.  The  epidermis  being  denuded,  the  rete  or  corium 
is  laid  bare,  and  the  lesions  thus  resulting  are  slightly  depressed,  although 
scarcely  perceptibly,  and  are  usually  bright  or  dark  red  in  color,  with 
sometimes  a  yellowish  or  mellowed  tinge,  due  to  a  thin  coating  of  desic- 
cated exuded  serum;  or  they  may  be  of  a  brownish  or  almost  blackish 
color,  owing  to  the  presence  or  admixture  of  dried  blood.  They  may  be 
bordered  by  a  narrow  band  or  areola,  with  sometimes  slight  inflamma- 
tory elevation.  At  times  the  excoriations  are  somewhat  elevated,  due 
to  the  fact  that  the  lesions  scratched  are  papules,  as  in  papular  eczema, 
the  summits  alone  getting  the  brunt  of  the  injury.  The  extent  and 


CONSECUTIVE    OR   SECONDARY  LESIONS  67 

depth  of  the  excoriations  depend  upon  the  force  employed  in  scratching 
and  the  resisting  power  or  susceptibility  of  the  skin ;  the  latter  may  be  an 
inherent  peculiarity  of  the  individual  or  be  due  to  the  cutaneous  disease, 
as  is  frequently  observed  in  eczema.  The  great  difference  in  the  char- 
acter, amount,  and  depth  of  the  excoriations  in  cases  in  which  the  dis- 
ease is  apparently  of  similar  extent,  the  itching  as  intense,  and  the 
scratching  as  vigorous,  is  not  an  uncommon  clinical  observation. 

The  nails  are  not  the  only  agents  by  which  excoriations  are  pro- 
duced, although  the  usual  and  common  one;  they  may  be  the  result 
of  slight  traumatisms  of  other  kinds.  Pricks  and  scratches  caused  by 
pins,  needles,  and  other  familiar  articles  are  often  responsible  for  isolated 
lesions;  "skinning  the  finger,"  "barking  the  shin,"  giving  rise  to  an 
abraded  or  "raw"  condition  of  the  skin,  can  also  be  cited.  The  simple 
act  of  rubbing,  and  even  the  friction  of  the  clothing  itself,  will,  in  vesicu- 
lar lesions  and  vesicopapules,  often  remove  the  surface  and  give  rise  to 
superficial  punctate  tears  or  abrasions.  Persistent  and  repeated  scratch- 
ing in  eczematous  and  other  inflammatory  processes  often  leads  to 
greater  infiltration  and  inflammatory  activity;  and  in  diseases  in  which 
itching  occurs  independently  of  any  exciting  structural  changes,  as  in 
pruritus  and  pediculosis,  a  mild  or  moderate  degree  of  dermatitis  or 
eczematous  inflammation  is  sometimes  thus  provoked.  Long-con- 
tinued scratching  and  rubbing  of  a  part,  as  in  a  long-continued  pediculo- 
sis, pruritus,  eczema,  and  other  diseases,  will  also,  in  addition  to  the 
induced  inflammatory  infiltration  and  thickening,  sometimes  produce 
more  or  less  pigmentation;  this  is  especially  observed  in  those  who  have 
for  a  long  time  been  the  subjects  of  pediculosis,  producing  a  pigmenta- 
tion so  extensive  and  dark  colored  as  even  to  suggest  Addison's  disease. 

As  a  rule,  excoriations  being  of  superficial  character,  are  rarely 
followed  by  scarring,  but  in  some  instances,  where  they  are  deep,  in- 
volving the  corium,  slight  atrophic  whitish  spots  are  to  be  seen,  and 
these  especially  about  the  upper  back  in  the  chronic  affection  last 
mentioned.  Excoriations  are  often  accompanied  by  small  and  large 
pustules,  the  opened  points  and  abrasions  giving  ready  opportunity 
for  local  integumentary  infection  by  pyogenic  cocci;  in  such  instances, 
as  well  as  occasionally  in  others  where  distinct  pustular  lesions  are  not 
formed  or  conspicuously  present,  there  is  sometimes  noted  a  swelling  of 
the  neighboring  lymphatic  glands. 

These  lesions  are  frequently  an  important  feature  in  many  skin 
affections,  and  their  character  and  distribution  often  alone  suffice  to 
the  formation  of  a  correct  diagnostic  conclusion,  as  illustrated  espe- 
cially in  pediculosis  and  scabies.  Their  presence,  too,  is  always  signif- 
icant of  itching,  and  in  the  differentiation  this  factor  bars  out  a  number 
of  diseases  that  may  have  other  symptoms  in  common. 

Fissures.— Synonyms.— Cracks;  Rents;  Clefts;  Rhagades;  Rimae; 
Fr.,  Fissures;  Ger.,  Hautschrunden ;  Rhagaden;  Einrisse;  Fissuren. 

Fissures  are  linear  cracks  or  wounds  involving  the  epidermis  or 
epidermis  and  corium,  and  the  result  of  disease  or  injury. 

They  are  most  commonly  met  with  where  the  epidermis  is  thick- 


68  GENERAL   SYMPTOMATOLOGY 

ened  and  infiltrated,  when  due  to  cutaneous  disease,  which  impairs  the 
local  nutrition  and  renders  the  parts  inelastic;  and  especially  if  upon 
regions  where  there  is  a  great  deal  of  natural  active  or  frequent  move- 
ment. They  are,  therefore,  most  frequently  observed  about  the  palms, 
ringers,  soles  and  toes,  and  joints,  especially  the  flexures;  also  at  the  angles 
of  the  mouth  and  lips,  and  about  the  nares  and  the  anus.  They  are  also 
not  infrequent  back  of  the  ear.  More  commonly,  but  by  no  means  al- 
wa.ys,  they  occur  in  the  natural  lines  and  furrows.  They  are  usually 
seen  in  eczema,  not  infrequently  also  in  other  chronic  inflammatory  in- 
filtrated diseases,  especially  those  of  a  dry  character,  as  in  ichthyosis, 
scleroderma,  psoriasis,  lichen  planus,  dermatitis,  and  similar  affections. 
In  such  diseases  their  production  is  often  induced,  aggravated,  or  in- 
creased by  applications  that  cause  dryness,  especially  the  free  use  of  soap. 
Indirectly  the  tendency  is  added  to,  moreover,  as  in  eczema  of  the 
hands  and  fingers,  by  the  frequent  use  of  water  and  contact  with  irri- 
tating substances,  as  with  cooks,  laundresses,  polishers,  pasters,  etc.,  the 
underlying  disease  or  tissue  weakness  being  thus  increased.  In  those  of 
sensitive  and  especially  naturally  dry  skin,  exposure  to  cold  and  wind 
will  suffice  to  bring  about  a  variable  fissuring  of  the  lips  and  hands — 
so-called  "chaps"  or  "chapping."  Fissures  are  also  frequently  noted 
at  the  angles  of  the  mouth  and  about  the  anus  in  congenital  syphilis. 

They  may  be  of  various  lengths,  widths,  and  depths,  the  margins 
usually  being  abrupt  and  sharply  defined;  although  generally  straight, 
they  may  be  curved  or  crooked.  They  may  be  dry  or  moist,  and  reddish 
in  color,  more  particularly  toward  the  base,  and  if  they  are  at  all  numer- 
ous and  deep,  impair  the  free  movement  of  the  part  through  fear  of  the 
accompanying  pain  and  the  possible  deeper  opening  of  the  cracks  and  the 
production  of  new  breaks. 

Scales. — Synonyms. — Exfoliating  epidermis;  Epidermal  exfolia- 
tions; Squamae;  Fr.,  Squames;  Ger.,  Schuppen;  Hornplattchen. 

Scales  may  be  defined  as  dry,  usually  laminated,  epidermal  exfolia- 
tions or  desquamations ;  or  as  collections,  on  the  surface,  of  loose,  dry 
epidermis,  resulting  from  some  underlying  morbid  process. 

A  mild  degree  of  ordinarily  invisible  or  scarcely  perceptible  exfolia- 
tion in  the  form  of  minute,  thin  epidermic  particles  is  physiologically 
taking  place  constantly,  which,  if  its  removal  is  not  facilitated  by  baths 
and  soap-and-water  washings,  may  accumulate  sufficiently  to  be,  on  close 
inspection,  noticeable  as  a  branny  roughness,  as  not  infrequently  ob- 
served in  those  of  the  dispensary  class.  It  is  more  pronounced  or  more 
quickly  noted  after  discontinuance  of  ablutions  in  those  of  a  naturally 
dry  skin.  Pathologic  scaliness,  however,  with  which  we  are  concerned, 
is  due  to  the  rapidity  of  epidermic  cell-formation  or  to  an  interference 
with  the  process  of  normal  horny  transformation,  and  is  the  result  of 
various  morbid  processes.  It  presents  itself  from  that  of  scaliness  of  a 
scarcely  greater  degree  than  that  of  the  physiologic  exfoliation  already 
mentioned,  to  that  of  thick,  circumscribed,  or  more  or  less  generalized, 
imbricated,  horny,  epidermal  accumulations,  produced  slowly  and  in 
slight  or  moderate  quantity,  or  rapidly  and  in  great  abundance.  As 


CONSECUTIVE    OR   SECONDARY  LESIONS  69 

illustrating  the  extremes  and  the  intermediate  degree  may  be  men- 
tioned the  insignificant  branny  or  flour-like  scaliness,  or,  as  commonly 
designated,  furfuraceous  scales,  of  tinea  versicolor;  the  scarcely  greater 
of  so-called  pityriasis  capitis;  the  slightly  more  emphasized  in  some 
cases  of  erythematous  eczema;  moderate  or  fairly  abundant  in  squa- 
mous  eczema,  seborrhea,  the  milder  types  of  ichthyosis,  lichen  planus, 
etc.;  and  the  usually  profuse  in  psoriasis,  the  severer  grades  of  ichthy- 
osis, some  types  of  dermatitis  exfoliativa,  and  pityriasis  rubra  pilaris. 
Sometimes  the  exfoliation  is  of  the  nature  of  thin,  variously  sized  flakes, 
or  lamella,  as  frequently  in  eczema,  the  milder  varieties  of  dermatitis 
exfoliativa,  erythema  scarlatinoides,  scarlatina,  etc.;  in  the  last  two, 
usually  taking  place,  especially  about  the  extremities,  as  thin,  parchment- 
like  or  sheet-like  more  or  less  extensive  films;  in  others,  in  the  form  of 
thicker  imbricated  masses,  as  especially  well  shown  in  psoriasis  in  ad- 
vanced stages  of  pityriasis  rubra  pilaris,  and  severe  cases  of  ichthyosis — 
in  the  last  named  occurring  usually  as  thick,  plate-like  masses.  They 
are  generally  loosely  attached  to  the  underlying  epidermis,  but  ex- 
ceptionally, as  in  lupus  erythematosus,  they  adhere  somewhat  firmly. 

In  character  scales  are  dry,  harsh,  horny,  brittle,  with  a  disposi- 
tion to  break  up  into  thin  flakes  or  minute  particles;  occasionally,  how- 
ever, from  the  admixture  of  oily  secretion,  as  in  some  seborrheic  scales, 
or  of  dried  serous  or  seropurulent  exudation,  as  is  observed  in  some 
scaly  masses  in  eczema,  the  accumulations  are  seen  to  be  more  closely 
agglutinated,  less  brittle,  and  sometimes  slightly  oily  or  gummy,  forming, 
in  reality,  a  mixture  of  scale  and  crust — crustce  lamellosa — which,  when 
thin,  can  be  well  designated  crusty  scales,  and  when  thick,  scaly  crusts, 
although  these  terms  are  commonly  used  interchangeably.  These 
latter  scaly  masses  are  usually  dull  yellowish,  dirty  yellowish,  some- 
times with  a  brownish  cast  or  deeper  hue;  whereas  ordinarily  scales  are 
white  or  grayish,  and  either  lusterless  or,  as  in  some  instances,  as  often 
seen  in  psoriasis,  in  some  cases  of  eczema,  lichen  planus,  etc.,  with  a 
glistening,  micaceous  aspect. 

Crusts — Synonyms.— Crustae;  Scabs;  Fr.,  Croutes;  Ger.,  Krusten; 
Borken. 

Crusts  are  dried  effete  masses  of  exudation,  usually  with  an  admix- 
ture of  more  or  less  epithelial  debris.  They  vary  greatly  in  thickness, 
color,  size,  form,  and  in  other  features.  They  are  thin,  flattened,  and 
yellowish,  as  in  impetigo  contagiosa  and  in  some  cases  of  eczema;  flat 
and  thick  and  dark  yellow  to  reddish  brown  in  ecthyma  and  in  some  of 
the  pustules  of  syphilis  and  pustular  eczema;  and  thick,  irregular,  and 
of  a  brownish,  dark-red,  or  blackish  color,  in  some  ulcerations,  especially 
those  of  syphilis.  In  the  last-named  disease  some  of  the  pustules,  bullous 
lesions,  or  ulcerations  become  covered  over  with  oyster-shell-shaped 
crusts,— rupia,— as  referred  to  in  describing  pustules.  The  crusts  of 
syphilis,  and  also  less  frequently  those  in  other  purulent  processes,  are 
sometimes  of  a  greenish  hue.  Crusts  are,  at  times,  somewhat  soft  and 
friable,  frequently  but  lightly  attached,  as  commonly  observed  in  those 
of  eczema  and  impetigo  contagiosa,  those  of  the  latter  often  looking  as  if 


7O  GENERAL   SYMPTOMATOLOGY 

"stuck  on"  or  imperfectly  pasted  on.    Others  are  firmer,  tougher,  and 
more  adherent  to  the  subjacent  tissues,  as  in  ecthyma  and  syphilis. 

These  several  characters  depend  chiefly  upon  the  nature  of  the 
secretion,  the  crusts  being  variously  composed  of  serum,  pus,  blood, 
and  extraneous  matter;  sometimes  exclusively  of  serum,  as  the  com- 
mon yellowish  or  candied-looking  crusts  of  vesicular  eczema;  often  of 
serum  and  pus,  as  the  dirty,  dark  yellow,  or  greenish  yellow  of  sero- 
purulent  eczema  and  impetigo;  and  frequently  with  a  varying  quantity 
of  blood,  giving  the  crust  a  reddish  or  blackish  appearance.  They 
usually  contain  also  more  or  less  epithelial  debris.  The  thickness  de- 
pends upon  the  amount  of  the  discharge,  more  especially  when  the 
latter  is  dense  and  tenacious;  to  their  firmer  adherence  to  the  under- 
lying part,  together  with  the  duration.  The  crusts  or  "scabs"  covering 
ulcerations  are  usually  thickest  and  the  most  bulky;  if  removed,  and  the 
subjacent  ulcerations  still  remain,  the  part  soon  scabs  or  crusts  over 
again.  More  or  less  surface  destruction  underlies  those  of  ecthyma, 
lupus,  epithelioma,  syphilis,  etc.,  and  in  the  last  two  especially  it  may  be 
quite  deeply  seated. 

Crusts  other  than  those  named  possess  some  peculiarities.  Those 
of  seborrhea  and  of  mixed  seborrheic  and  eczematous  processes  are 
usually  more  or  less  unctuous  to  the  touch,  light  or  dirty  yellowish, 
at  times  darker,  somewhat  lamellated,  and  adherent,  possessing  features 
of  both  crusts  and  scales, — crusty  scales,  scaly  crusts,  crustae  lamellosae, — 
as  referred  to  in  describing  scales.  The  crusts  of  favus,  when  more  or  less 
isolated  and  circumscribed,  consist  of  somewhat  thick  yellow  concavo- 
convex  discs,  friable  and  granular,  with  the  convex  side  pressed  down  on 
or  in  the  skin;  but  if  the  disease  has  been  long  continued,  these  crusts 
may  be  so  closely  set  and  continuous  as  to  lose  this  peculiar  shape,  and 
form  thick,  confluent,  yellowish,  mortar-like  masses;  it  is  made  up 
chiefly  of  the  vegetable  fungus,  to  which  the  disease  is  due,  together  with 
epithelial  cells  and  debris.  The  crusts  observed  in  certain  forms  of 
eruption  due  to  the  ingestion  of  bromids  are  sometimes  thick  and 
brownish  or  brownish  yellow;  they  cover  the  part  and  dip  down  between 
the  papillomatous  projections  usually  present,  forming  an  interlocking 
that  gives  them  a  firm  setting,  these  crusts  being  noted  especially  for  their 
persistence  and  tenacious  attachment.  The  same  characters,  but,  as  a 
rule,  much  less  pronounced,  are  also  seen  in  some  forms  of  iodid  eruption. 

Ulcerations — Synonyms.— Ulcers;  Ulcera;  Fr.,  Ulceres;  Ger., 
Geschwiire. 

Ulcerations  are  rounded  or  irregularly  shaped  and  sized  losses  of 
cutaneous  tissues,  sometimes  extending  into  the  subcutaneous  struc- 
tures, resulting  from  disease. 

Excluding  those  arising  from  traumatic  influences,  and  the  ordinary 
simple  leg  ulcers  with  which  dermatologists  are  rarely  concerned,  these 
excavations  are  the  result — of  impaired  nutrition  of  the  part,  as  in  the 
ulcers  on  the  lower  part  of  the  legs  associated  with  varicosities  and 
eczema;  of  suppurative  inflammations,  as  in  boils  and  ecthyma;  of 
cell-growth  combined  with  suppuration,  with  subsequent  cell  and  tissue 


CONSECUTIVE    OR   SECONDARY  LESIONS  71 

destruction,  as  in  gummata  and  erythema  induratum;  and  of  cell- 
growth  or  infiltration,  with  retrograde  metamorphosis,  as  in  neoplastic 
formations,  such  as  lupus  and  other  forms  of  cutaneous  tuberculosis, 
tubercular  syphiloderm,  leprosy,  sarcoma,  carcinoma,  etc.  By  far  the 
largest  number  of  cases  of  ulcerations  encountered  are  due  to  syphilis, 
and  commonly  to  the  tubercular  and  gummatous  syphilodermata. 

Ulcerations  may  be  small  or  large;  some  are  scarcely  larger  than  a 
pin-head,  and  from  this  intermediate  sizes  up  to  those  covering  a  good 
deal  of  surface  occur.  In  shape,  they  vary  considerably:  they  may  be 
rounded,  oval,  or  irregular,  and  often,  as  in  syphilis,  and  less  frequently  in 
lupus,  crescentic,  kidney-shaped,  or  segmental;  when  several  of  the 
latter  are  close  together,  they  form  a  more  or  less  wavy,  irregular,  and 
serpiginous  tract.  As  dermatologically  met  with,  ulcerations  are,  as  a 
rule,  superficial  and  shallow,  as  in  many  cases  of  lupus  and  tubercular 
syphiloderm,  but  in  occasional  cases  of  lupus,  in  some  cases  of  the 
tubercular  syphiloderm,  in  syphilitic  gummatous  lesions,  in  erythema 
induratum,  in  many  cases  of  epithelioma,  and  in  other  neoplastic  affec- 
tions they  may  extend  considerably  into  the  subcutaneous  structures. 
The  character  of  the  edges,  which  are  usually  clearly  defined,  sometimes 
with  bordering  inflammation  and  infiltration,  differs  materially — abrupt, 
almost  as  if  the  ulcer  were  punched  out,  sloping,  everted,  or  under- 
mined. Their  bases  are  smooth  or  uneven,  sometimes  clean,  others 
covered  with  a  slough,  and  occasionally  exhibiting  a  papillomatous  or 
vegetating  tendency,  and  discharging  a  scanty  or  abundant,  offensive  or 
inoffensive,  serous,  seropurulent,  or  purulent  secretion. 

Syphilitic  ulcers,  which  may  be  either  shallow  or  deeply  seated,  in 
addition  to  showing,  usually,  crescentic  or  segmental  shapes,  generally 
have  perpendicular,  sometimes  undermined,  edges,  uneven  floor,  with 
a  free  purulent  discharge,  and  ordinarily  but  little  surrounding  infiltra- 
tion; if  there  is  crusting,  it  is  generally  thick  and  dark  colored  or  green- 
ish. Lupus  ulcerations  are,  as  a  rule,  shallow,  small,  rounded  sloping 
excavations  often  close  together,  running  into  each  other,  usually  with 
but  little,  if  any,  surrounding  infiltration,  and  having  generally  but  a 
scanty  discharge  of  a  serous  or  seropurulent  character;  the  crust,  if 
present,  is  usually  thin  and  yellow  or  yellowish-brown.  The  ulceration 
of  superficial  epithelioma  is  shallow,  usually  single,  with  sloping  walls 
and  surrounding  slight  infiltration,  often  with  an  elevated,  roll-like, 
pearly,  or  waxy-looking  border,  and  having  generally  but  a  scanty 
serous  or  viscid  discharge,  occasionally  with  a  trifling  blood  admixture, 
and  with  or  without  a  thin  to  slightly  thickened  brownish  or  reddish- 
brown  crust.  The  deeper  type  of  epithelioma  shows  greater  excavation, 
more  infiltration,  somewhat  inflammatory  borders,  the  discharge  similar 
to  that  of  the  superficial  type,  or  more  abundant,  and  sometimes  more 
purulent,  frequently  with  blood  streaks  or  flakes;  and  often  with  a 
tendency  to  thick  brownish  or  reddish-brown  crust-formation. 

Ulcerations  may  occur  upon  any  part,  but  are  common  upon  the 
leg,  here  usually  of  a  simple  inflammatory  character,  frequently  in  asso- 
ciation, as  previously  stated,  with  varicosities  and  eczema.  Those  of 
lupus  are  most  frequent  upon  the  face,  especially  about  the  nose.  Those 


j2  GENERAL   SYMPTOMATOLOGY 

due  to  syphilis  are  also  common  in  the  facial  region,  although  likewise 
seen  frequently  upon  other  parts.  Ulcerations  may  or  may  not  be  pain- 
ful and  tender.  They  may  be  stationary,  progressive,  or,  except  in 
malignant  forms,  undergo  healing,  always  with  the  formation  of  cicatri- 
cial  tissue. 

Scars. — Synonyms. — Cicatrices;  Fr.,  Cicatrices;  Ger.,  Narben. 

A  scar  or  cicatrix  is  a  connective-tissue  new  formation  replacing 
loss  of  substance  which  had  involved  the  corium  or  the  tissues  more 
deeply. 

Scars  may,  therefore,  be  small,  large,  rounded,  oval,  or  irregularly 
shaped,  depending  upon  the  size  and  other  characters  of  the  preceding 
ulcer  or  ulceration  or  the  morbid  processes  that  have  led  to  their  forma- 
tion. Scars  are  not  always,  however,  evidence  that  active  or  necrotic 
destruction  has  preceded,  as  is  instanced  by  those  of  lupus  erythemato- 
sus,  scleroderma,  favus,  atrophy  of  the  skin,  and  some  cases  of  lupus 
vulgaris  and  syphilis.  In  some  of  these  diseases  the  cutaneous  struc- 
tures are  the  seat  of  cell  infiltration,  which,  in  undergoing  absorption  or 
retrogressive,  but  non-ulcerative,  changes,  lead  to  superficial  scar-for- 
mation, as  in  both  varieties  of  lupus  and  syphilis.  In  the  several  other 
affections  named  the  tissues  undergo  direct  atrophy  from  distention,  as 
in  linea  albicantes  and  other  forms  of  atrophia  cutis,  or  from  pressure, 
as  that  in  favus;  or  they  may  result  from  neoplastic  overgrowth  of  the 
fibrous  elements,  as  in  keloid.  Generally  speaking,  however,  the  pres- 
ence of  a  scar  points  to  a  previous  ulcerative  process  or  loss  of  tissue 
from  traumatism,  and  their  shape  naturally  is  determined  by  the  form 
of  the  previous  ulceration  or  destruction.  When,  in  certain  diseases, 
this  has  been  at  all  peculiar  or  characteristic,  as  in  the  crescentic,  kidney- 
shaped,  and  serpiginous  ulcers  of  syphilis,  the  forms  of  the  resulting  scars 
have  a  diagnostic  value  in  passing  judgment  as  to  the  causative  disease 
and  also  as  to  ulcerative  processes  that  may  still  be  present  nearby  or 
elsewhere  on  the  surface.  Soft  thin  scars,  especially  when  showing  on 
their  surface  somewhat  deeper,  small,  pea-sized  depressions;  small, 
rounded,  thin  scars  arranged  in  segmental  groups  or  in  a  serpentine 
manner;  and  scars  with  scallop-like  edges — are  all  also  suggestive,  and 
usually  conclusive,  of  syphilis.  Thin  scars  on  the  face,  with  a  somewhat 
glistening  and  stretched  appearance,  studded  with  minute  depressions, 
corresponding  to  the  gland-duct  outlets,  are  characteristic  of  lupus 
erythema tosus.  Thickish,  tough,  and  fibrous  scars,  sometimes  of  a 
slightly  corded  character,  are  frequent  in  lupus  vulgaris,  and  when 
about  the  face,  where  this  disease  is  most  common,  are  an  almost  inva- 
riably conclusive  factor  in  the  diagnosis  between  this  affection  and  the 
tubercular  syphiloderm  that  it  resembles.  A  fibrous,  stringy,  or  cord 
or  ribbon-like  thickening,  frequently  with  a  general  keloidal  tendency, 
commonly  suggests  burns  as  its  origin,  and  almost  conclusively  so  if  at 
all  extensive.  The  significance  of  the  numerous,  scattered,  small,  pea- 
sized,  white,  depressed  scars,  especially  marked  and  abundant  on  the 
face,  as  pointing  to  a  previous  attack  of  small-pox,  is  well  known. 
Numerous  minute,  pin-head-sized  scars,  disseminated  over  the  general 


LESIONAL    CONFIGURATION  AND  DISTRIBUTION  ?$ 

surface,  with  a  tendency  to  groups  or  aggregations,  but  commonly  scanty 
or  with  no  special  predominance  on  the  face,  usually  is  clearly  indica- 
tive of  a  pre-existing  secondary  miliary  papulopustular  or  pustular  syph- 
iloderm.  If  somewhat  larger  and  irregularly  disseminated,  they  are 
significant  of  the  small  or  varioliform  pustular  syphiloderm ;  and  if 
finger-nail  to  bean-sized,  flat,  slightly  depressed,  generally  distributed, 
but  not  necessarily  numerous,  the  large  flat  pustular  syphiloderm 
has  usually  gone  before.  The  scar,  therefore,  is  not  only  valuable 
as  indicating  the  disease  that  has  caused  it,  but  its  presence,  especially 
if  indicative  of  syphilis,  may  often  afford  valuable  aid  in  determining 
the  nature  of  obscure  associated  skin-lesions  as  well  as  the  nature  of  some 
obscure  organic  or  general  disease.  Recent  scars  are  pinkish  or  reddish; 
the  color  is  gradually  lost,  and  gives  place  to  a  glistening  or  dead  white ; 
exceptionally,  however,  they  are  pigmented  to  a  variable  degree,  which 
is  commonly  most  pronounced  at  the  margin  or  limited  to  this  portion. 
Occasionally  the  redness  is  more  or  less  persistent,  even  acquiring  a 
purplish  tinge. 

Scars  are  usually  smooth,  soft,  and  more  or  less  pliable,  but  occa- 
sionally, as  just  referred  to,  may  be  uneven,  thick,  tough,  stringy, 
puckered,  or  distinctly  keloidal  or  hypertrophic.  They  consist  of  new 
formations  of  connective  tissue,  containing  blood-vessels,  lymphatics, 
and  nerves,  but  unless  extremely  superficial,  no  hairs  or  glandular  struc- 
tures. From  their  very  nature  they  are  persistent  formations,  some- 
times, however,  becoming,  in  the  course  of  years,  less  conspicuous,  and 
coming  up  almost  to  a  level  with  the  surface.  On  the  other  hand,  ex- 
ceptionally, they  may  undergo  hypertrophic  change,  growing  thicker 
and  elevated,  tough,  stringy,  corded,  and  uneven,  but  remaining  limited 
to  the  original  destroyed  or  ulcerated  area,  constituting  the  so-called 
hypertrophic  scar;  less  frequently  still  the  hypertrophic  scar-tissue  growth 
extends,  projecting  into  the  bordering  healthy  skin,  more  or  less  uni- 
formly or  in  the  form  of  irregularly  disposed  or  claw-like  processes,  thus 
developing  into  keloid.  As  a  rule,  scars  are  painless  formations,  but  in 
occasional  instances  they  may  be  the  seat  of  some  itching  or  pain,  rarely 
constantly,  but  usually  intermittently  or  of  a  paroxysmal  character. 

LESIONAL  CONFIGURATION,  DISTRIBUTION,  AND 
OTHER  FEATURES 

The  varying  size  of  the  lesions  of  different  kinds,  as  well  as  of  those 
of  the  same  variety,  has  already  been  considered,  and  some  of  the 
terms  usually  employed  were  named  incidentally.  Several  others  may 
be  here  briefly  referred  to. 

A  single  group  or  aggregation  of  lesions  or  area  of  disease  consti- 
tutes a  patch,  and  this,  alone  or  with  other  lesions,  groups,  areas,  or 
patches,  considered  as  a  whole,  is  known  as  an  eruption.  When  the 
eruption  is  made  up  of  the  same  type  of  lesion  it  is  said  to  be  uniform; 
if  of  several  or  mixed  types,  multiform,  polymorphous.  The  lesions, 
patches,  or  areas  of  disease,  which  are  also  sometimes  designated  as 
efflorescences,  may  be  distinctly  separated— discrete;  if  the  component 


74 


GENERAL    S YMPTOMA  TOL  OGY 


lesions  tend  to  form  groups  or  bunches  of  several  or  more,  as  in  herpes 
simplex,  herpes  zoster,  etc.,  the  eruption  is  said  to  be  herpetiform; 
or  they  may  be  close  together  or  crowded — aggregated;  or  they  may  be 
fused,  forming  solid  patches  or  sheets — confluent;  or  they  may  be  seated 
only  in  one  or  two  regions — limited  or  localized;  more  or  less  uniformly 
distributed  over  most  of  the  entire  surface — diffused,  general,  or  general- 
ized; involving  the  whole  surface — universal;  irregularly  scattered — 
disseminated. 

When  a  patch  or  area  of  disease  is  sharply  defined,  it  is  said  to  be 
circumscribed;  if  rounded  and  of  sharp  contour — orbicular  or  discoid. 
The  term  circinate  is  applied  to  those  of  circular  outline,  but  its  most 
usual  application  is  to  circular  patches  with  clearing  center,  as  in  tinea 
circinata,  whereas  an  annular  or  ring-like  patch  is  a  round  or  circular 
patch  made  up  of  a  free  or  clear  center  and  an  enclosing  ring  or  band ;  to  a 
rounded  area  composed  of  several  concentric  rings,  usually  of  different 
duration  and  stage,  and,  therefore,  somewhat  variegated  as  to  coloring, 
the  term  iris  is  added,  as  in  erythema  iris  and  herpes  iris. 

The  term  gyrate  refers  to  an  irregular  or  festoon-like  configuration, 
usually  resulting  from  the  coalescence  of  several  contiguous  rings,  the 
eruption  disappearing  at  the  points  of  contact,  as  in  some  cases  of  pso- 
riasis; and  serpiginous  when  the  eruption  spreads  in  a  creeping-like 
manner  at  the  border,  clearing  up  at  the  older  part,  as  in  the  tubercular 
syphiloderm.  An  area  of  disease  is  said  to  be  marginate  when  it  is  ab- 
ruptly defined  against  the  healthy  skin,  as  in  eczema  marginatum  and 
erythema  marginatum. 

The  regional  localization  is  sometimes  added  to  the  name  of  the 
disease,  or,  as  for  example,  herpes  facialis,  seborrhea  capitis,  etc. ;  and 
occasionally  the  lesional  origin  or  anatomic  involvement,  as  keratosis 
pilaris;  and  sometimes  the  age  or  life  period  is  indicated,  as  pemphigus 
neonatorum,  pruritus  senilis. 

Additional  names  and  terms  other  than  those  already  given  will  be 
found  in  the  course  of  the  text,  and,  as  with  the  foregoing,  are  mostly 
those  with  which  students  of  anatomy  and  medicine  in  general  have 
already  been  made  acquainted,  and  which  are,  moreover,  as  a  rule,  self- 
explanatory. 


GENERAL   ETIOLOGY 

DISEASES  of  the  skin  are  symptomatic  or  idiopathic.  The  most 
typical  examples  of  the  symptomatic  class  are  the  eruptive  fevers, 
such  as  scarlet  fever,  measles,  rotheln,  chicken-pox,  small-pox,  and 
the  eruptions  of  typhus  and  typhoid  fever;  likewise  the  cutaneous 
outbreaks  due  to  other  constitutional  diseases,  infections,  or  other 
internal  systemic  provocation,  as  syphilis,  leprosy,  scurvy,  purpura, 
erythema  multiforme,  urticaria,  medicinal  rashes,  and  the  like.  These 
are  merely  symptomatic  of  some  known  or  unknown  constitutional 
infectious  agent,  bacterial,  chemical,  or  toxic,  and  the  eruptive  phe- 
nomena may  be  simply  one  of  the  direct  symptoms  of  the  underlying 
general  cause  or  disturbance,  or  an  indirect  one  through  some  action 
on  the  nerves  or  nervous  system  or  the  vasomotor  apparatus.  On  the 
other  hand,  an  eruption  may  be  idiopathic,  have  no  relationship  to  the 
general  economy,  but  arise  in  the  cutaneous  tissues,  and  remain  limited 
to  these  structures,  as  in  most  of  the  atrophies  and  hypertrophies,  the 
local  parasitic  diseases,  and  the  various  affections  due  to  other  irritating 
causes,  as  those  of  dermatitis  venenata,  etc.  The  skin,  like  any  other 
organ  or  structure  of  the  body,  is  subject  to  disease  originating  in  and 
limited  to  its  own  tissues.  It  is  true,  however,  that  in  many  affections 
the  local  damaging  or  causative  factors  in  idiopathic  diseases  are  often 
influenced  or  even  made  operative  by  certain  constitutional  conditions 
or  organic  disturbances.  The  latter  may  also  serve  to  favor  continued 
action  of  the  former  and  make  the  malady  less  amenable  to  external 
treatment — this  not  by  any  direct  relationship,  but  indirectly  by  the 
general  enfeebled  condition  of  the  health  induced,  in  which  the  cuta- 
neous tissues  share  and  by  which  their  resisting  power  is  lessened. 

The  more  common  and  important  of  the  etiologic  influences  may  be 
here  discussed  briefly,  reserving  special  consideration  of  this  point  for  the 
diseases  in  which  one  or  the  other  may  be  more  specifically  concerned. 

Climate. — Common  observations  show  that  some  diseases  are 
practically  limited  to  certain  climates  or  regions;  others,  while  not  con- 
fined chiefly  to  such  limitation,  may  be  much  more  frequent  in  special 
countries.1  It  is  not  probable,  however,  that  the  climate  is  alone  re- 
sponsible, but  that  this,  together  with  the  character  of  the  food,  habits 
of  the  people,  their  mode  of  living,  and  allied  factors  constitute  an 

1  See  valuable  and  interesting  papers  by:  J.  C.  White,  "Variations  in  Type  and 
Prevalence  of  Diseases  of  the  Skin  in  Different  Countries  of  Equal  Civilization,"  Pro- 
ceedings  Internal.  Med.  Cong.,  Philadelphia,  1876;  also  "Immigrant  Dermatoses," 
Jour.  Cutan.  Dis.,  1890,  p.  369;  Hyde,  "Observations  Based  Upon  the  Statistics  of 
Cutaneous  Diseases  in  America,"  Trans.  Internal.  Cong.  Derm,  and  Syph.,  Paris,  1889. 
Crocker,  "Tropical  Diseases  of  the  Skin,"  Jour.  Cutan.  Dis.,  1908,  p.  49;  J.  M.  Elaine, 
"Dermatoses  and  Dry  Climate,"  Colorado  Medicine,  vol.  iii,  p.  239;  Chipman,  Cali- 
fornia State  Jour,  of  Med.,  Nov.,  1911  (noo  consecutive  skin  cases  in  San  Francisco). 

75 


76  GENERAL   ETIOLOGY 

ensemble  of  influences  to  which  this  difference  is  due.  Thus,  prurigo 
is  relatively  frequent  in  Austria,  and  comparatively  unknown  or  rare  in 
many  other  countries — as,  for  instance,  in  England  and  our  own  land, 
— whereas  urticaria,  inflammatory  glandular  diseases,  and  some  other 
maladies  are  relatively  more  common  with  us.  Leprosy,  as  is  well 
known,  is  not  uncommon  in  some  climates  or  countries,  and  is  rarely 
seen  in  others.  Lupus  is  an  every-day  affair  in  Vienna,  other  parts 
of  Austria,  as  well  as  in  other  European  lands,  but  with  us  one  or  two 
cases  a  month  at  our  clinics  of  ordinary  size  seem  to  be  a  fair  average. 
Favus  is  extremely  common  in  Italy,  and  also,  although  less  so,  in 
Scotland.  Pellagra  is  chiefly  limited  to  Italy,  and  especially  to  the 
northern  part;  and  the  greater  frequency  and  even  limitation  of  fram- 
besia  and  of  filarial  elephantiasis,  mycetoma,  ainhum,  Delhi  boil,  and 
others  to  one  or  several  regions,  mostly  tropical,  are  known. 

In  the  same  climate  or  region  the  effect  of  different  seasons  is 
also  noted,  some  diseases,  as  winter  pruritus  (pruritus  hiemalis),  as  the 
name  signifies,  occurring  in  the  cold  season;  and  at  this  time,  some  of 
the  chronic  inflammatory  diseases,  such  as  eczema  and  psoriasis,  are 
usually  much  worse,  and  not  infrequently  measurably  or  completely 
disappear  as  the  warm  season  approaches.  Miliaria,  or  prickly  heat,  on 
the  other  hand,  is  essentially  a  disease  of  the  hot  season,  while  erythema 
multiforme  is  relatively  more  common  in  the  spring  and  autumn  months. 

Not  only  the  climate,  region,  and  season  may  sometimes  be  instru- 
mental in  favoring  certain  diseases,  but  the  abode  or  habitation 
itself,  if  unhygienic,  improperly  ventilated,  damp,  deprived  of  the 
beneficent  and  health-giving  action  of  sunlight,  and  contaminated 
with  poisonous  emanations — as,  for  instance,  sewer-gas — will  have  so 
damaging  an  influence  upon  the  nutrition  and  vital  powers  that  the 
skin  becomes  a  more  ready  prey  to  morbid  action.  Furuncular  and 
phlegmonous  processes,  as  well  as  the  development  of  the  scrofulous 
diathesis,  with  its  consequent  tissue  weakness,  can  sometimes  be  traced 
to  such  agency. 

Heredity.1 — That  heredity  plays  an  important  part  in  disease 
can  scarcely  be  questioned,  although,  doubtless,  the  disease  itself, 
except  such  as  syphilis,  icthyosis,  and  a  few  others,  can  hardly  be  con- 
sidered transmissible.  It  is  rather  a  tissue  weakness,  or  predis- 
position, that  is  inherited;  other  and  favoring  circumstances  being 
necessary  to  produce  the  malady,  and  without  which  the  individual 
might  remain  entirely  free  from  its  development.  The  list  of  derma- 
toses  of  which  the  heredity  is  evident  is,  as  White  has  pointed  out, 
very  short.  In  addition  to  the  several  diseases  named,  the  tendency 
seems  to  be  displayed,  however,  in  many  cases  of  psoriasis,  eczema, 
xanthoma,  and  in  some  other  maladies. 

Certain  families  seem  peculiarly  prone  to  a  particular  class  of  dis- 
eases— family  diseases — some  chiefly  heart  affections,  others  pul- 
monary, others  zymotic,  others  again  showing  special  proclivity  to 
cutaneous  affections,  and  sometimes  without  associated  heredity.  This 

1  See  "Hereditary  Dermatoses,"  by  J.  C.  White,  Trans.  Internal.  Cong.  Derm,  and 
Syph.,  Paris,  1889,  p.  363. 


DIA  THESIS 


77 


hereditary  and  family  tendency  can  also  be  observed  in  the  greater 
families  or  nationalities  constituting  the  different  races.  The  tendency 
to  favus  seems  to  follow  the  Italian  and  Hungarian,  even  into  this 
country,  the  associated  American  born,  although  equally  exposed, 
showing  but  little  susceptibility.  Morison1  and  Howard  Fox2  have 
shown  that  the  negro  seems  to  be  more  liable  to  some  affections,  as 
keloid,  chilblain,  ainhum,  etc.,  and  that  acne,  lupus,  and  eruptive  dis- 
turbance or  irritation  due  to  animal  parasites  are  uncommon.  The 
rare  diseases,  xeroderma  pigmentosum  and  idiopathic  multiple  pig- 
mented  sarcoma,  appear  to  be  observed  more  frequently  in  those  of  the 
Hebrew  race. 

Sex — Age. — The  etiologic  influence  of  sex  is  often  noted.  Lupus 
erythematosus,  the  milder  types  of  acne  rosacea,  impetigo  herpeti- 
formis,  and  Paget's  disease  are  more  common  in  women,  and  the  last 
two  diseases  are  confined  almost  exclusively  to  this  sex;  whereas  men 
are  more  frequently  the  subjects  of  epithelioma,  the  severer  grades  of 
acne  rosacea,  and  the  various  occupation  dermatoses;  sycosis  is  ob- 
viously seen  only  in  this  sex.  The  influence  of  age  is  often  shown;  certain 
diseases  are  more  frequently  encountered  at  definite  periods  of  life;  some 
only  at  such  times.  Infancy,  youthful  development,  mature  growth,  and 
old  age  all  have  their  cutaneous  vulnerabilities.  In  the  first  months 
or  years  are  seen,  beginning  with  birth  or  shortly  afterward,  pemphigus 
neonatorum,  dermatitis  exfoliativa  neonatorum,  the  congenital  syphilo- 
dermata,  eczema,  especially  of  the  face  or  face  and  scalp,  chicken-pox, 
and  other  exanthemata,  impetigo  contagiosa,  ringworm  of  the  scalp, 
etc.  Lupus  more  commonly  develops  during  childhood,  and  likewise 
urticaria  and  the  erythemata  are  not  uncommon. 

During  the  age  of  puberty  and  maturing  manhood  acne  and  other 
diseases  of  the  sebaceous  glands,  as  seborrhea,  are  common,  as  at  this 
period  these  structures  are  unusually  active.  During  this  time  psoriasis 
usually  first  shows  itself,  and  eczematous  inflammation  of  the  hands  and 
forearms,  excited  by  irritating  substances  incidental  to  various  occupa- 
tions or  trades  (trade  eczema),  frequently  presents.  At  this  time  too,  or 
later,  sycosis  in  men  is  more  commonly  observed,  and  at  this  period  of 
life  lupus  erythematosus  likewise. 

Dentition  occurring  at  an  age  of  peculiar  susceptibility  is  often 
given  an  important  place  as  an  etiologic  factor,  but  while  a  disturb- 
ing element,  with  effects  upon  the  nervous  system,  digestion,  etc.,  and 
therefore  also  of  nutritional  and  neurotic  influence  upon  the  skin,  it 
is  usually  overrated. 

Diathesis.3  Organic  and  Constitutional  Disease.— The 
significance  of  the  word  diathesis  is  not  clear,  often  indicating  family 

1  Morison,  "Personal  Observations  on  Skin  Diseases  in  the  Negro,"  Trans.  Amer. 
Derm.  Assoc.  for  -1888;  Jour.  Cutan.  Dis.,  1888,  p.  429. 

2  Howard  Fox,  "Observations  on  Skin  Diseases  in  the  Negro,"  Jour.  Cutan.  Dis., 
1908,  pp.  67  and  109  (good  illustrations,  review  of  the  subject,  with  bibliography). 

3  Hutchinson,  The  Pedigree  of  Disease  (Temperament,  Idiosyncrasy,  and  Diathesis), 
London,  1804;  New  York,  1885.    In  an  interesting  paper  "On  Cutaneous  Affections  in 
Various  Diseases  with  Especial  Reference  to  Certain  Angio-neuroses,"   Brit.  Jour. 
Derm.,  1906,  pp.  305,  354,  387,  and  417,  Dore  reviews  the  etiologic  influence  of  these 
various  diseases  referred  to,  and  gives  a  full  bibliography. 


78  GENERAL    ETIOLOGY 

tendency  or  predisposition,  with  an  underlying,  acquired  or  hereditary, 
susceptibility  to  such  diseases  as  tuberculosis — tuberculous  or  scrofu- 
lous diathesis  or  strumous  diathesis;  or  gout  or  rheumatism — gouty 
diathesis,  rheumatic  diathesis,  uric  acid  diathesis,  or  arthritic  diathesis. 
Certain  diseases,  such  as  furuncular,  abscess-like,  and  atrophic  types 
of  acne,  and  some  cases  of  eczema  are  often  seen  in  individuals  who 
appear  to  possess  a  scrofulous  or  tuberculous  tendency  or  history,  and 
which  do  well  under  appropriate  remedies  directed  against  this.  The 
influence  of  the  variously  named  rheumatic  and  gouty  diatheses,  arthritic 
diathesis,  lithemia,  and  uric-acid  saturation  in  the  etiology  of  eczema, 
psoriasis,  pruritus,  etc.,  is  not,  I  am  sure,  an  unimportant  one,  and 
requires  attention  in  the  management  of  the  cutaneous  disease.  The 
frequent  and  well-known  association  of  rheumatic  symptoms,  especially 
with  erythema  multiforme,  erythema  nodosum,  purpura,  and  other 
affections,  is  suggestive  of  a  common  etiologic  cause  or  relationship. 
Other  conditions  shown  by  the  urinary  excretion,  such  as  oxaluria,  uric 
acid  excess,  diabetes,  albuminuria,  etc.,  are  sometimes  of  direct  or  indi- 
rect etiologic  influence  in  some  cutaneous  diseases.  Saccharine  diabetes 
is  seen  in  connection  with  xanthoma  diabeticorum,  and  improvement  or 
temporary  abeyance  in  the  sugar  loss  means  a  partial  or  complete  recov- 
ery from  the  skin-lesions.  The  association  of  diabetes  with  boils,  car- 
buncles, pruritus,  eczema,  dermatitis  herpetiformis,  and  some  other 
affections  has  been  not  infrequently  noted,  and  the  influence  of  the 
conditions  underlying  albuminuria  upon  cutaneous  processes,  as  eczema, 
pruritus,  chronic  urticaria,  and  the  like,  is  likewise  of  importance;  such 
relationship  has  received  particular  attention  by  Bulkley,1  Kaposi,2 
Thibierge,3  Gamberini,4  Winfield,5  Hartzell,6  Sherwell,7  and  others. 

Organic  and  functional  disturbances  of  the  uterus  and  utero-ovarian 
system8  are  sometimes  of  evident  import  in  the  erythemata,  acne,  acne 
rosacea,  chloasma,  and  other  disorders,  probably  through  their  direct  or 
indirect  influence  upon  the  nervous  and  vasomotor  system,  and  even  in 
the  male  urethral  irritation,  through  reflex  action,  has  been  thought  to 
play  an  occasional  part  in  erythema  multiforme,  and  is  even  suspected  of 
influence  in  some  cases  of  acne.9  The  erythemata  occasionally  seen  in  the 

1  Bulkley,  "The  Relations  of  the  Urine  to  Diseases  of  the  Skin,"  Arch.  Derm., 
1875-76,  p.  i. 

2  Kaposi,  "Ueber  besondere  Formen  von  Hauterkrankung  bei  Diabetikern,"  Wien. 
med.  Presse,  1883,  p.  1605. 

3  Thibierge,  "Des  Relations  des  Dermatoses  avec  les  affections  des  reins  et  1'albu- 
minurie,"  Annales,  1885,  pp.  424  and  511,  with  numerous  references. 

4  Gamberini,  "L'urina  in  rapporto  colle  dermopatie,"  Giorn.  Ital.,  1884,  H.  3, 
May- June;  brief  abstract  in  Monatshefte,  1884,  p.  313. 

5  Winfield,  "Glycosuria  in  Dermatitis  Herpetiformis,"  Jour.  Cutan.  Dis.,  1893,  p. 
447- 

6  Hartzell,  "Diseases  of  the  Skin  Associated  with  Glycosuria,"  Internal.  Clinics, 
Oct.,  1898;  and  "Cutaneous  Diseases  Accompanying  Diabetes,"  Jour.  Amer.  Med. 
Assoc.,  Jan.  26,  1901.     Other  references,  including  some  in  reference  to  gout  and  rheu- 
matism, will  be  found  in  connection  with  special  diseases. 

7  Sherwell,  "Cutaneous  Manifestations  in  Diabetes,"  Med.  News,  June  29,  1901. 

8  See  paper  by  Duhring  and  Hartzell,  in  Keating  and  Coe's  Clinical  Gynecology, 
1895,  P-  9?8;  and  by  Rohe,  "Diseases  of  the  Skin  Associated  with  Disorders  of  the 
Female  Sexual  Organs,"  in  Buffalo  Med.  and  Surg.  Jour.,  Feb.,  1889  (with  references). 

9  Sherwell,  Jour.  Cutan.  Dis.,  Nov.,  1884;  Denslow,  Med.  Record,  Nov.  7,  1885; 
Winfield,  Jour.  Cutan.  Dis.,  1891,  p.  93. 


DIA  THESIS  79 

course  of  gonorrhea,  independent  of  possible  drug  rashes,  are  possibly 
thus  to  be  explained;  or  they  may  be  attributable  to  absorption  of  the 
toxic  products  of  the  organisms. 

Both  sexual  excess  and  sexual  continence — directly  antagonistic 
conditions — have  been  blamed  for  acne  and  some  other  affections,  but 
with  questionable  evidence;  the  former  doubtless  by  its  disturbing  or 
depressing  influence  on  the  nervous  system  might  be  an  indirect  factor 
in  some  maladies. 

During  the  active  sexual  life  the  periods  of  pregnancy  and  lac- 
tation are  sometimes  contributory  factors,  and  outbreaks  of  eczema, 
psoriasis,  and  dermatitis  herpetiformis  are  of  relatively  frequent  occur- 
rence. At  the  menopause,  urticaria,  eczema,  and  other  cutaneous  dis- 
eases sometimes  develop  or  are  aggravated,  although  this  physiologic 
transition  period,  like  that  of  dentition,  is  often  undeservedly  blamed. 
In  advancing  years  and  old  age,  pruritus,  keratoses,  and  epithelioma  are 
most  usually  encountered. 

In  fact,  the  nervous  system,  as  clinically  observed  and  shown  by 
the  writings  of  Weir  Mitchell,1  Bulkley,2  Mayer,3  Leloir,4  Schwimmer,5 
Crocker.6  Winfield,7  Zeisler,8  Frick,9  and  others,10  is  probably  of  con- 
siderable import,  not  only  in  its  effect  upon  distribution  of  eruptions, 
but  also  in  its  causal  relationships.  While  we  use  the  term  "tropho- 
neurosis"  in  connection  with  various  diseases,  our  knowledge  con- 
cerning the  same,  and  the  chain  of  evidence  connecting  cause  and 
effect,  are  elementary  and  without  much  precise  information  or  demon- 
strable facts.  Doubtless,  eruptions  (scarlatinoid,  papular,  urticarial, 
etc.)  seen  sometimes  after  operations,  especially  after  abdominal  opera- 
tions,11 can  be  ascribed  largely  to  the  nervous  factor,  occasionally  to  toxic, 
and  possibly  to  drug,  influence.  Among  other  affections  in  which  the 
nervous  system  seems  to  be  operative  or  contributory  may  be  mentioned 
pruritusj  glossy  skin,  Raynaud's  disease,  hyperidrosis,  some  cases  of 
alopecia  areata,  scleroderma,  herpes  zoster,  dermatitis  herpetiformis, 

1  Weir  Mitchell,  Injuries  of  Nerves  and  Their  Consequences,  Philadelphia,  1872. 

2  Bulkley,  Arch.  Electrol.  and  Neurology,  Nov.,  1874;  May,  1875. 

3  Mayer,  De  ^influence  des  emotions  morales  sur  le  develop pement  des  affections  cuta- 
nees,  Paris,  1876. 

4  Leloir,  Recherches  diniques  et  anatomo-pathologiques  sur  les  affections  cutanees 
d'originie  nerveuse,  Paris,  1881. 

5  Schwimmer's  Die  neuropathischen  Dermatonosen,  Vienna,  1883. 

6  Crocker,  "Lesions  of   the  Nervous  System  Etiologically  Related  to  Cutaneous 
Disease,"  Brain,  1884,  p.  343  (with  numerous  references). 

7  Winfield,  "The  Influence  of  the  Nervous  System  in  Skin  Disease,"  Med.  News, 
1897,  vol.  Ixxi,  p.  174. 

8  Zeisler,  "Trophic  Neuroses  Following  Fractures,"  Jour.  Cutan.  Dis.,  1898,  p.  418. 

9  Frick,  "Influence  of  the  Nervous  System  in  the  Production  of  Skin  Diseases," 
Kansas  City  Med.  Index,  1896,  p.  386. 

10  Blaschko,  "La  topographic  des  nerfs  cutanes  et  sa  signification  au  point  de  vue 
dermato-pathologique,"  Revue  pratique,  1906,  pp.  131,  160,  and  198  (an  elaborate 
paper,  with  review  of  the  subject,  illustrated);  Leredde,  "Le  r61e  du  syst£me  nerveux 
dans  les  dermatoses,"  ibid.,  p.  5,  contends  that  the  role  of  the  nervous  system  is  over- 
rated, or  at  least  without  substantial  proof.    Blaschko  also  inclines  to  the  belief  that 
we  are  holding  too  much  to  this  factor.   J.  A.  Fordyce,  "The  Relation  of  the  Nervous 
System  to  Diseases  of  the  Skin,"  N.   ¥.  Med.  Jour.,  June  4,  1910. 

11  Shepherd,  "On  Some  Eruptions  Occurring  After  Abdominal  Operations,"  Jour. 
Cutan.  Dis.,  1909,  p.  293. 


80  GENERAL  ETIOLOGY 

and  pemphigus.  Circulatory  disturbances1  seem  at  times  of  some 
possible  bearing  in  certain  disorders,  especially  of  the  extremities. 

The  influence  of  the  sympathetic  system  in  diseases  of  the  integu- 
ment, the  study  of  which  is  yet  more  or  less  academic,  is  probably  a 
much  more  potent  one  than  is  commonly  supposed.  Some  diseases,  too, 
are  doubtless  influenced  or  caused  by  vascular  dilatation,  contraction,  or 
fluctuation,  due  to  irritation,  stimulation,  depression,  or  other  action 
upon  the  vasomotor  centers  or  nerves. 

To  the  various  morbid  states  of  etiologic  relationship  already  men- 
tioned should  be  added  malaria,  which  is,  as  pointed  out  by  Yandell2 
and  others,  sometimes  the  active  exciting  cause,  or  certainly  a  not 
infrequent  important  contributory  factor.  The  not  uncommon  associa- 
tion of  chlorosis  with  the  more  marked  types  of  seborrhea  and  with 
chloasma  is  suggestive  of  a  possible  predisposing  influence,  although  it 
may  be  that  they  are  simply  associated  manifestations  of  a  common 
underlying  cause. 

The  most  potent  conditions,  however,  in  many  cases,  exciting  or 
predisposing  in  character,  are  to  be  found  in  digestive  disturbance. 
This  acts  by  either  reflex  action  or  by,  in  some  manner,  interfering 
with  metabolism,  or  by  direct  influence  through  the  resulting  nutri- 
tional impairment,  or  by  the  probably  more  frequent  development  of 
ferments  or  toxins — auto-intoxication — to  which  last  Pick,3  Hallopeau,4 
and  others  have  directed  attention.  I  am  firmly  convinced  that  this 
last  is  one  of  the  most  important  causes,  and  probably  the  sole  cause,  in 
many  instances  of  erythema  multiforme,  urticaria,  and  similar  affec- 
tions— developing  spontaneously  in  the  gastro-intestinal  tract  or  as  the 
result  of  the  ingestion  of  food-products  which  had  previously,  or  sub- 
sequent to  their  ingestion,  undergone  putrefactive  or  other  change; 
and  in  the  production  of  which  constipation  is  often  an  important 
contributory  factor.  In  recent  years  there  has  been  also  a  growing 
belief — without  much  direct  evidence,  however — that  the  "internal 
secretions,"  from  deficiency  or  excess,  may  be  an  important  factor  in  the 
etiology  of  some  diseases;  especially  has  this  been  noted  in  connection 
with  the  thyroid  gland.  It  is,  moreover,  thought  possible  that  a  condi- 
tion of  anaphylaxis,  or  hypersensitiveness  to  such  various  and  diverse 
substances  or  toxins  may  be  thus  brought  about,  and  the  individual 
made  still  more  susceptible  to  their  influence.5 

1  Walsh,  "Chronic  and  Recurrent  Maladies  of  the  Skin  in  Relation  to  Heart 
Disease,"  Brit.  Med.  Jour.,  Aug.  10,  1910. 

2  Yandell,  "Malaria  and  Struma  in  Their  Relations  to  the  Etiology  of  Skin  Dis- 
eases," Amer.  Practitioner,  1878,  p.  18. 

3  A.  Pick,  "Ueber  die  Beziehungen  einziger  Hauterkrankungen  zur  Storungen  in 
Verdauungstracte,"  Wien.  Med.  Presse,  1893,  p.  1213.     Also  Johnston  and  Schwartz, 
"Studies  in  the  Metabolism  of  Certain  Skin  Disorders,"  N.  Y.  Med.  Jour.,  March  13, 
20,  and  27,  1909. 

4  Hallopeau,  "Des  toxines  en  dermatologie,"  Annales,  1897,  p.  854. 

5  See  interesting  series  of  papers:     "Symposium  on  the  Toxic  Dermatoses,"  by 
Hartzell    ("Toxic    Dermatoses;    Dermatitis    Herpetiformis,    Pemphigus,    and    Some 
Other  Bullous  Affections  of  Uncertain  Place");  Fordyce  ("The Influence  of  Anaphy- 
laxis in  Toxic  Dermatoses") ;  Johnston  ("Some  Toxic  Effects  in  the  Skin  of  Disorders  of 
Digestion  and  Metabolism") ;  Anthony  ("The  Toxic  Origin  of  Erythema  Multiforme") ; 
and  discussions  thereon,  Jour.  Cutan.  Dis.,  1912,  pp.  119-167,  with  pertinent  litera- 
ture references.     The  reader  interested  in  this  subject  of  anaphylaxis  is  further 


FOOD-DRUGS  8 1 

Food — Drugs. — An  improper  diet,  as  well  as  either  a  too  bounti- 
ful or  a  too  meager  supply,  is  a  variously  operative  factor  in  many 
diseases  of  the  skin,  but  whether  such  influence  is  direct  or  indirect 
it  is  difficult  to  say.  Spoilt  food  is,  as  has  just  been  intimated,  probably 
often  an  unsuspected  factor.  It  is  doubtless  owing  to  this  that  oysters, 
clams,  crabs,  lobsters,  fish,  and  pork  meats — foods  that  are  apt  to 
undergo  rapid  change  and  deterioration — occasionally  provoke  urticaria 
or  erythema  multiforme  in  individuals  who  can  usually  take  these 
articles  without  the  slightest  evidence  of  disagreement.  Often  it  is 
true  idiosyncrasy  to  these  or  other  foods,  as  strawberries,  buckwheat, 
etc.,  which  is  not  infrequently  observed,  that  is  the  explanation,  but  in 
such  cases  the  effect  is  constant  and  not  occasional,  as  in  the  instances 
to  which  I  have  alluded.  It  is  not  improbable,  however,  that  many  of 
the  opinions  regarding  the  harmfulness  of  certain  foods  in  diseases  of 
the  skin  so  firmly  held  by  the  laity,  and  also  by  members  of  the  pro- 
fession, are  based  upon  examples  of  idiosyncrasy  rather  than  upon 
a  sufficient  foundation  of  constantly  observed  facts.1  Thus,  oatmeal, 
as  well  as  other  foods,  is  commonly  believed  to  be  detrimental  in  dis- 
eases of  the  skin, — causative  or  instrumental  in  the  continuance  of  the 
eruption, — and  yet,  gauged  by  common  observation,  it  scarcely  deserves 
so  sweeping  a  judgment ;  idiosyncrasy  or  weakness  in  digestive  power  for 
starchy  foods  is  the  probable  explanation.  Foods  or  condiments  of 
difficult  digestion  or  that  are  too  stimulating,  such  as  cheese,  pastries, 
pork  meats,  veal,  spices,  mustard,  pepper,  pickles,  excessive  use  of  coffee 
or  tea,  etc.,  are  certainly  to  be  avoided,  if  for  no  other  reason  than  that 
they  are  disturbers  of  digestion,  with  the  resulting  consequences.  They 
are  to  be  considered  of  possible  etiologic  import  in  some,  and  doubtless 
in  many,  cases;  and,  moreover,  indigestion  means  frequently  the  more 
ready  development  of  stomachic  and  intestinal  toxins. 

The  causative  action  of  the  ingestion  of  certain  drugs  in  the  pro- 
duction of  various  cutaneous  efflorescences  and  even  suppurative  and 
more  serious  action  is  well  known,  as  a  glance  at  the  subject  of  "derma- 
titis medicamentosa"  will  readily  prove.  The  drugs  capable  of  such 
action  are  almost  innumerable,  among  which,  as  being  probably  best 
known,  may  be  mentioned  the  bromids,  iodids,  copaiba,  quinin,  to- 
gether with  many  others.  With  some  the  action  is  more  or  less  con- 
stant, with  others,  due  to  individual  idiosyncrasy.  Alcohol  often  ex- 
referred  to  the  following  papers:  Von  Pirquet,  "Allergy,"  Archiv.  Int.  Med.,  1911, 
vii,  p.  259;  Friedemann,  "Anaphylaxis,"  Jahres.  u.  d.  Ergebn.  d.  Immunitatsforschung, 
1911,  vi,  p.  31;  Schittenhelm,  "Ueber  Anaphylaxie  vom  Standpunkt  der  patholog- 
ischer  Physiologic  und  der  Klinik,"  ibid.,  p.  115;  Hektoen,  "Allergy  or  Anaphylaxis  in 
Experiment  and  Disease,"  Jour.  Amer.  Med.  Assoc.,  April  13,  1912,  p.  1081. 

1  See  interesting  papers  by  J.  C.  White,  "An  Introduction  to  the  Study  of  Influence 
of  Diet  in  the  Production  and  Treatment  of  Skin  Diseases,"  Jour.  Cutan.  Dis.,  1887,  pp. 
409  and  436;  also  by  the  same  author,  "What  Effect  Do  Diet  and  Alcohol  have  upon 
the  Causation  and  Course  of  the  Eczematous  Affections  and  Psoriasis?"  Trans.  Amer. 
Derm.  Assoc.,  1896;  and  by  Corlett,  "Diseases  of  the  Skin  Due  to  Defective  Alimen- 
tation," Med.  Record,  1888,  2,  p.  172;  also  Stelwagon,  "Diet  as  an  Etiological  Factor," 
Jour.  Cutan.  Dis.,  1907,  p.  147;  and  G.  H.  Fox,  "Diet  as  a  Therapeutic  Measure," 
ibid.,  p.  152,  and  discussion  of  these  last  two  papers,  ibid.,  pp.  157-163.  D.  W. 
Montgomery  and  Culver,  "The  Influence  of  Milk-fat  on  the  Skin,"  Jour.  Cutan. 
Dis.,  1912,  p.  319,  believe  butter  in  large  quantity  and  other  forms  of  milk-fat  are 
contributing  factors  in  acne,  the  seborrheids,  and  infections. 

6 


82  GENERAL   ETIOLOGY 

erts  a  detrimental  influence,  more  especially  if  indulged  in  to  any  great 
extent,  probably  through  its  dilating  action  upon  the  cutaneous  capil- 
laries. Doubtless 'in  its  abuse,  its  disturbing  influence  on  digestion, 
liver,  and  kidneys  is  partly  responsible  for  its  untoward  action  in  some 
dermatoses,  notably  those  of  an  inflammatory  type.1 

EXTERNAL  INFLUENCES 

It  is  not  unlikely  that  external  causes  constitute  important,  and 
often  unsuspected  and  unrecognized,  factors  in  many  diseases — in 
some  being  the  exclusive  factors,  in  others  exciting  or  contributing, 
and  supplementary  to  some  underlying  constitutional  or  integumentary 
condition  or  state.  They  will  be  considered  more  specifically  in  con- 
nection with  the  subjects  of  eczema  and  dermatitis,  as  well  as  with  other 
affections  in  which  they  may  play  a  part.  Climate,  season,  and  habita- 
tion, already  touched  upon,  may  be  considered,  in  a  measure,  as  ex- 
ternal causes,  but  the  effect  is  chiefly  due  to  their  action  or  influence  upon 
the  general  health,  vigor,  or  nutrition,  and  are  therefore  more  properly 
considered  among  the  general  etiologic  factors. 

Personal  Hygiene. — There  is  a  prevalent  belief  that  skin  dis- 
eases as  a  whole  are  indicative  of  filth  and  uncleanliness,  and  no  one 
can  gainsay  that  such  have  some  effect  as  contributing  factors  in  some 
of  the  cutaneous  eruptions  among  the  poor  and  uncared-for.  These 
factors  naturally  tend  to  make  the  distinctly  parasitic  affections  more 
numerous  with  such  classes.  They  are,  however,  more  than  set  off  by 
the  habits,  customs,  and  overfeeding — in  themselves  matters  of  hy- 
giene, which  have  already  been  considered — of  the  luxurious,  and  by  the 
active  life  and  tension  of  the  middle  and  upper  strata  of  society.  Com- 
pared to  the  number  of  affections  or  cases  due  to  mental  or  physical 
exhaustion,  occupation,  and  luxurious  indulgence,  those  in  which  filth 
and  uncleanliness  are  the  chief  agents  are  not  conspicuously  numerous. 
Extreme  cleanliness — the  too  free  or  injudicious  use  of  soap,  water, 
Turkish  baths,  etc. — is  also  sometimes  responsible  for  the  production  or 
aggravation  of  certain  integumental  diseases,  as  chafing,  miliaria, 
dermatitis,  eczema,  and  some  others.  On  the  other  hand,  scant  use  of 
such  measures,  not  necessarily  to  the  point  of  absolute  uncleanliness,  is 
sometimes  an  element  in  seborrhea,  acne,  keratosis  pilaris,  and  a  few 
others. 

Another  possible  cause  that  can  here  be  referred  to  is  the  clothing. 
"Too  much  clad,"  as  in  babies,  during  the  hot  weather,  is  often  re- 
sponsible for  miliaria  and  its  not  infrequent  associated  consequence, 
furuncles,  in  such  subjects.  And  this  alone,  or  together  with  the  rough 
or  coarse  flannel  usually  worn,  will  sometimes,  in  the  working-classes, 
result  in  the  production  of  a  mild  dermatitis,  pruritus,  or  an  eczema,  as 
well  as  favor  the  affections  just  mentioned.  This  is  especially  so  when 
the  garment  worn  next  the  skin  is  dyed,  owing  to  the  added  irritant 
properties  common  to  some  dye-stuffs;  some  individuals  are  much  more 

*  See  J.  C.  White's  paper,  loc.  cit.,  and  that  by  Janin,  De  ^influence  de  alcoolisme  sur 
le  develop pement  el  I 'evolution  des  affections  cutanees,  Paris,  1881. 


EXTERNAL   INFLUENCES  83 

susceptible  than  others.  Moreover,  the  sweat  saturation  with  the 
resulting  uncleanliness  of  the  garment  is  a  favoring  factor  in  seborrhea 
corporis,  and  its  near  ally,  dermatitis  seborrhoica,  as  well  as  in  tinea  versi- 
color.  Hutchinson,1  Foley,2  and  others  have  called  attention  to  several 
of  these  factors. 

Chemical  and  Mechanical  Irritants — These  embrace  a  large 
number  of  external  factors  that  are  often  of  etiologic  importance,  and 
which  will  be  again  more  or  less  specifically  mentioned  under  derma- 
titis. The  irritating  effect  of  different  plants  with  many  persons,  and  the 
irritating  action  of  many  drugs,  such  as  iodoform,  turpentine,  and 
others,  are  well  known.  The  action  of  dye-stuffs  in  connection  with 
wearing  apparel  has  already  been  mentioned;  their  irritating  effects  are 
also  frequently  seen  on  the  hands  and  forearms  in  workmen — dyers — 
who  have  to  do  with  such  employment.  Indeed,  the  effect  of  occupa- 
tion— occupation  dermatoses — is  frequently  observed  in  dermatologic 
practice.  The  dermatitis  or  eczema  due  to  such  causes,  as  observed  in 
polishers,  plasterers,  bakers,  grocers,  and  others  in  the  course  of  their 
work,  and  directly  attributable  to  the  irritating  action  of  the  materials 
with  which  they  are  engaged,  is  quite  common,  and  concerning  which 
many  writers — among  others,  Foley  and  Lassar3 — have  made  journal 
contributions.  The  latter  observer  particularly  called  attention  to 
surgical  eczema,  or  dermatitis  which  is  observed  in  surgeons  and  nurses 
as  the  result  of  the  constant  vigorous  soap-and-water  scrubbing  and  the 
free  use  of  antiseptics,  many  examples  of  which  have  come  under  my 
own  observation.  The  irritation  due  to  the  constant  use  of  strong  soap 
and  water  is  also  seen  in  the  washerwoman.  The  possibility  of  occupa- 
tion with  animal  products  giving  rise  to  greater  chance  of  poison  wounds, 
malignant  pustule,  and  such  affections  has  often  been  shown. 

Those  who  are  exposed  to  heat  and  cold  are  also  more  liable  to 
certain  affections,  especially  eczema,  pruritus,  etc.4  The  action  of  pro- 
longed exposure  to  the  actinic  rays  of  the  sun  upon  some  skins,  and 
the  action  of  heat  in  the  production  of  miliaria,  and  of  cold  and  wind 
in  causing  frost-bite,  favoring  eczematous  irritation  and  rosacea,  are 
well  known.  Prolonged  scratching,  as  in  pediculosis  corporis  and  in 
pruritus,  occasionally  gives  rise  to  a  dermatitis  or  an  eczema,  and  also 
opens  up  the  tissues  to  local  infections  by  pus-cocci,  etc.5 

Parasites. — At  the  present  day  one  need  scarcely  enlarge  upon 
the  etiologic  aspects  of  this  cause;  nor  is  it  necessary  to  enumerate  the 
large  number  of  diseases  that,  in  a  broad  sense,  might  be  placed  under 
this  etiologic  heading.  To  the  parasitic  affections  produced  by  the 
grosser  animal  and  vegetable  parasites,  such  as  scabies,  pediculosis, 
favus,  ringworm,  and  others,  could  be  added  numerous  others  due  to  the 

1  Hutchinson,  Arch,  of  Surgery,  vol.  ii,  1890-91,  plate  23  (from  dyed  undershirt). 

2  Foley,  "The  Influence  of  the  Clothing  on  the  Skin,"  Montreal  Med.  Jour.,  vol.  xix, 
1890-91,  p.  406. 

3  See  under  Dermatitis  and  Eczema  for  literature  references. 

4  See  valuable  contributions  on  this  subject  by  Hyde,  "On  Affections  of  the  Skin 
Induced  by  Temperature  Variations  in  Cold  Weather,"  Chicago  Med.  Jour,  and  Exam., 
March,  1885,  and  Feb.,  1886,  and  by  Corlett,  Jour.  Cutan.  Dis.,  1894,  p.  457. 

6  Klotz,  "The  Infected  Scratch  and  Its  Relations  to  Impetigo  and  Ecthyma,"  Jour. 
Cutan.  Dis.,  1896,  p.  46. 


84  GENERAL   ETIOLOGY 

lower  micro-organisms,1  such  as  impetigo,  furuncle,  tuberculosis  cutis, 
leprosy,  etc.  Absolute  and  conclusive  proof  as  to  the  alleged  cause  and 
effect  is  still  wanting  in  connection  with  the  by-far  larger  number  of  the 
diseases  presumably  due  to  micro-organisms,  but  no  one  can  deny  their 
growing  importance  in  the  etiology  of  disease  and  the  great  value  of 
original  investigation  in  this  direction. 

With  the  advent  of  this  etiologic  element  the  subject  of  contagion 
has  naturally  been  pushed  into  the  foreground,  and  an  expression  of 
opinion  on  this  point  in  a  particular  disease  is  often  hedged  about  with 
difficulties.  While  admitting  the  probable  parasitic  origin  of  many  dis- 
eases, and  the  inferential  deduction  of  communicability  that  naturally 
follows,  still  observation  shows  that  in  many  instances,  more  especially 
in  those  in  which  the  disease  is  presumably  due  to  the  lower  organisms, 
contagiousness  does  not  seem  to  be  even  suggestively  demonstrated  in 
practice — at  least  not  with  any  degree  of  certainty.  In  many  diseases, 
therefore,  for  which  we  even  now  accept  a  parasitic  factor  we  must 
assume  that  favoring  conditions  of  the  systemic  state  or  the  local  tissues 
exist,  and  without  which  the  successful  invasion  or  pathogenic  multi- 
plication of  the  micro-organism  fails  or  remains  harmless.  Even  pro- 
longed exposure,  unless  conditions  are  favorable,  is  in  many  such  dis- 
eases without  result;  the  vegetable  parasitic  affection,  tinea  versicolor, 
judged  by  clinical  experience,  is  only  in  the  rarest  instances  communicated 
from  husband  to  wife  or  the  reverse,  and  yet  the  fungus  exists  in  abun- 
dance and  is  readily  demonstrable.  Nor,  apparently,  is  every  person  to 
the  same  extent  a  persona  grata  to  even  the  more  active  animal  parasites — 
bedbugs,  fleas,  and  even  the  louse  and  itch-mite,  although  the  last  two 
are  the  least  fastidious  as  to  the  character  of  their  prey.  Apparently 
some  inherent  peculiarity  of  the  skin  or  the  odor  of  its  secretions  measur- 
ably protects  some  individuals  against  successful  parasitic  invasion. 

1  Among  valuable  contributions  on  this  subject  may  be  mentioned  those  by  Payne, 
"Bacteria  in  Diseases  of  the  Skin,"  Lancet,  1896,  vol.  ii,  p.  i;  Elliot,  "The  Role  of 
the  Pus-organisms  in  Skin  Diseases,"  Trans.  Amer.  Derm.  Assoc.for  1899;  and  Jour. 
Cutan.  Dis.,  1900,  p.  49,  with  many  literature  references;  Gilchrist,  "Bacteriological 
and  Microscopical  Examination  of  Vesicular  and  Pustular  Lesions  of  the  Skin,"  Trans. 
Amer.  Derm.  Assoc.  for  1899;  C.  J.  White,  "The  R61e  of  the  Staphylococci  in  Skin 
Diseases,"  Boston  Med.  and  Surg.  Jour..  1899,  2,  p.  235  (with  bibliography);  and  Leslie 
Roberts,  "Diseases  of  the  Skin  in  Animals  Communicable  to  Man,"  Brit.  Jour.  Derm., 
I9°9>  P-  72  (review  and  some  references).  Other  references  will  be  found  in  the  course 
of  the  text  in  connection  with  the  special  diseases. 


GENERAL   PATHOLOGY 

WHILE  pathology,  in  the  correct  and  widest  employment  of  the 
term,  includes  practically  everything  concerning  the  study  of  disease, 
by  common  sanction  its  meaning  is  considerably  narrowed,  and  now 
refers,  in  the  main,  to  facts  to  be  gleaned  from  microscopic  and  bac- 
teriologic  examination.  To  the  knowledge  thus  gained,  however,  are 
to  be  added  other  facts  that  throw  any  light  upon  the  nature  of  the 
disease  and  the  morbid  processes  that  characterize  it,  such  as  macro- 
scopic features  and  mode  of  growth,  character  of  the  contained  fluids, 
as  in  vesicular,  bullous,  and  similar  diseases,  examination  of  the  urine, 
etc.  These  all  aid  in  a  final  conclusion.  It  is  needless  to  say  that  the 
study  of  pathologic  anatomy  must  primarily  be  based  upon  a  well- 
grounded  knowledge  of  normal  histology.  The  feeling  shared  by  many 
students  and  physicians,  judged  by  lack  of  interest,  that  in  the  study 
of  morbid  structures  and  processes  the  pathologic  anatomy  of  the  skin 
occupies  an  obscurely  subservient  position,  scarcely  to  be  considered 
except  by  the  dermatologic  specialist,  is  one  difficult  to  explain  in  view 
of  the  knowledge  that  its  investigation  has  disclosed.  We  have  to  do 
with  a  structure  subject  to  almost  all  the  phenomena  found  in  connec- 
tion with  internal  organs — hyperemia,  inflammation,  hypertrophies, 
atrophies,  neoplasms,  the  character,  behavior,  and  effects  of  micro- 
organisms, etc.,  and  that  can  be  the  more  clearly  studied,  not  only  in 
full  development,  but  in  various  stages  as  well,  and  in  tissues  that  are 
obtainable  during  life,  and  therefore  not  subject  to  the  changes  and 
consequent  errors  of  observation  and  deduction  necessarily  connected 
with  the  examination  of  tissue  from  the  dead.  A  thorough  study  of  the 
commoner  pathologic  processes  in  this  structure  should  not,  therefore, 
be  left  to  the  specialist  alone;  the  teacher  of  pathology  can  find  no  tissue 
so  well  adapted  for  the  elucidation  of  the  elementary  and  more  import- 
ant morbid  changes  to  the  student  mind,  and  no  structure  whose  careful 
study  of  its  various  diseases  will  throw  so  much  light  upon  the  problems 
of  pathology  in  general.  Indeed,  in  its  general  features  cutaneous  pathol- 
ogy can  scarcely  be  said  to  differ  from  that  of  other  organs,  although,  as 
would  naturally  be  suspected,  its  nearest  kin  in  this  respect  is  that  of  the 
neighboring  stratified  epithelial  surfaces — such,  for  instance,  as  the 
tongue. 

The  value  of  pathologic  studies  in  cutaneous  diseases,  in  adding 
to  our  knowledge  of  the  nature  of  the  cutaneous  malady,  its  anatomic 
seat,  the  morbid  changes,  and  its  causes,  has  already  been  demon- 
strated repeatedly.  The  significance  of  the  grosser  fungi  and  the  small 
micro-organisms  has  gradually  been  gaining  greater  and  greater  recog- 
nition, and  on  these  lines  the  clinician  looks  for  future  suggestions  of 

85 


86  GENERAL    PATHOLOGY 

increasing  value  for  treatment,  and  also  for  the  prevention  of  diseases 
in  which  these  organisms  hold  a  pathogenic  relationship. 

Pathology  and  etiology  are  closely  united,  and  one  bears  materially 
upon  the  other,  and  their  elucidation  bears  just  as  strongly  upon  the 
subject  of  the  therapeutic  management.  The  various  exciting  and 
contributory  causes  that  give  rise  to  the  pathologic  local  alterations  and 
appearances  have  been  referred  to  in  etiology,  and  the  initial  step  in  the 
local  action  leading  to  these  changes  may  be  in  the  vessels,  nerves,  rete, 
upper  part  of  the  epidermis,  the  corium,  especially  the  papillary  layer, 
in  the  glandular  structures  or  the  deeper  tissues.  The  papillary  layer 
and  the  rete  are  important  cutaneous  structures,  and  their  involvement, 
either  primarily  or  secondarily,  a  common  occurrence  in  cutaneous 
pathology,  the  latter  the  starting-point  of  epithelial  new  growths.  The 
hairs  and  nails  are  also  sometimes  the  seat  of  certain  changes.  Not  only, 
however,  may  the  disease  take  its  origin  in  some  particular  division  of  the 
skin,  and  from  a  particular  constituent  of  this  division,  but  also  from  a 
special  part  of  this  constituent:  it  may  be  in  the  cells  themselves,  in  their 
protoplasm,  in  the  interstitial  tissue,  fibrous  tissue,  elastic  tissue,  colla- 
gen, muscular  fibers,  endothelium,  or  other  component.  The  changes 
may  be  simply  congestive,  inflammatory,  atrophic,  hypertrophic,  neo- 
plastic;  show  hyperemia,  exudation,  and  infiltration,  hyperplasia,  with 
new-tissue  formation  or  degeneration.  Depending  upon  its  character, 
seat,  and  limitations,  it  may  appear  merely  as  a  diffused  change,  or  it 
may  result  in  wheals,  papules,  vesicles,  pustules,  blebs,  or  destructive 
alterations,  often  with  secondary  changes  as  a  direct  consequence  of  the 
process  itself,  or  partly  or  wholly  from  external  or  accidental  factors. 

The  presence  of  micro-organisms,  scantily  or  in  numbers,  in  the  in- 
volved tissues  of  certain  diseases  can  usually  be  readily  demonstrated, 
sometimes,  however,  requiring  special  preparation  and  staining  and  the 
corroboration  of  culture  experiments;  the  grosser  parasites  are  easily 
shown  by  moderate  power,  the  lower  organisms  often  requiring  extremely 
high  magnification. 

An  attempt  has  been  made  in  the  following  pages  to  present  the  chief 
data  and  gross  features  concerning  the  pathology  and  pathologic  anatomy, 
somewhat  briefly  from  necessity,  but  not  to  the  extent,  it  is  hoped,  of  the 
omission  of  details  for  a  proper  comprehension  of  the  essential  characters. 
The  subject,  however,  in  recent  years  has  broadened  to  such  an  extent 
that  the  writer  of  an  average-sized  volume  on  cutaneous  medicine, 
desirous  of  making  it  full  in  its  practical  working  parts,  can  scarcely 
present  the  histopathologic  matter  in  the  manner  and  to  the  extent  that 
might  be  wished,  unless  peculiarly  gifted  in  the  art  of  selecting  the 
essence  from  the  mass  of  material  and  expressing  it  in  terse,  clear-cut, 
but  yet  readily  understandable,  manner.  The  reader  desirous,  therefore, 
of  going  further  into  this  branch  of  the  subject  is  referred  to  Unna's 
Treatise  on  the  Histopathology,  to  Leloir  and  Vidal's  Histologic  Atlas, 
and  to  Macleod's  recent  handbook  on  the  Pathology  of  the  Skin  and  to 
the  various  monographs  referred  to  in  the  course  of  the  text. 


GENERAL   DIAGNOSIS 

IT  is  needless  to  say  that  without  the  ability  to  make  a  diagnosis 
in  cutaneous  diseases  the  management  of  the  case  in  hand  is  haphazard, 
unscientific,  and  culpable.  Apparently  it  is  the  most  difficult  part  of 
the  subject  to  the  student  and  practitioner,  and  yet  one  in  which  the 
seeming  difficulties,  if  some  careful  thought  and  study,  combined  with 
moderate  clinical  facilities  for  observation,  be  given  to  it,  will,  as  regards 
the  commoner  diseases — those  with  which  the  physician  is  most  likely 
to  come  in  contact — soon  disappear.  Text-books  cannot,  however,  take 
the  place  of  clinical  opportunities,  but  with  a  relatively  small  amount 
of  the  latter,  and  especially  with  the  added  advantage  of  good  atlas 
illustrations  or  cuts,  book  study  is  of  great  service  in  furthering  and  in- 
creasing the  knowledge  thus  gained.  This  presupposes,  of  course,  a  clear 
idea  of  the  characters  and  nature  of  the  elementary  and  consecutive  skin- 
lesions — the  a  b  c  of  dermatology.  So  much  knowledge  and  training 
possessed,  subsequent  errors  are  commonly  due  either  to  negligence  or  to 
lack  of  thoroughness  in  the  examination,  or  to  the  rarity  or  anomalous 
character  of  the  disease. 

For  diagnosis  are  required  a  good  light,  a  good  eye,  and  a  good 
microscope.  The  first  two  are  essential;  the  last  is  in  many  instances 
supplementary,  but  in  some  cases,  as  in  determining  the  nature  of 
tumors  and  growths  and  in  detecting  the  presence  of  parasites,  it  is 
indispensable.  In  fact,  its  great  value  in  studying  pathologic  proc- 
esses cannot  be  too  highly  appreciated.  In  the  examination  of  the 
eruption  gaslight  is  not  satisfactory,  as  the  color  and  other  characters 
of  the  efflorescences  are  obscured.  He  who  would  guard  against  error 
must  also  insist  upon  seeing  the  whole  or  at  least  the  greater  part  of  the 
eruption,  for  not  infrequently  the  disease  in  a  patch,  area,  or  region  may 
be  somewhat  atypical  or  not  wholly  clear,  and  yet  upon  other  parts  be 
so  characteristic  that  all  doubt  vanishes.  According  to  my  observations 
regarding  students  and  practitioners,  the  failure  to  recognize  the  disease 
most  often  hinges  upon  the  laxity  as  to  this  point,  and  most  of  my  own 
earlier  mistakes  were  likewise  due  to  this  cause.  To  avoid  this  pitfall, 
therefore,  a  large  portion,  and  in  doubtful  or  obscure  cases  the  whole  erup- 
tion, should  be  inspected.  The  word  of  the  patient  is  not  to  be  accepted 
in  lieu  thereof,  for  this,  especially  when  the  eruption  is  on  covered 
parts,  to  save  trouble  or  exposure  or  unintentionally  from  ignorance  as 
to  the  existence  of  other  spots,  areas,  or  patches,  is  frequently  unreliable. 
For  example,  the  scalp  may  show  a  scaly  eruption  not  always  readily 
differentiated  from  eczema  or  seborrhea,  and  yet  bearing  some  sugges- 
tion of  psoriasis;  if  the  latter,  small  spots  or  patches  will  almost  surely 
be  on  other  parts,  especially  the  extensor  surface  of  the  knees  or  elbows, 
ill  developed,  perhaps,  and  yet  their  existence,  even  if  of  scarcely  notice- 


88  GENERAL   DIAGNOSIS 

able  character,  and  probably  wholly  overlooked  by  the  patient,  will,  in 
almost  all  instances,  be  a  conclusive  factor  in  favor  of  psoriasis.  Full 
inspection  discloses,  moreover,  the  distribution,  the  color,  evolution  of 
the  lesions,  tendency,  if  any,  to  patch  formation,  scaliness,  etc.  The 
temperature  of  the  room  should  be  that  of  a  comfortable  living-room,  as 
cold  especially  is  apt  to  cause  a  confusing  paleness  or  mottling,  and  some- 
times materially  changes  the  color  of  the  lesions. 

The  distribution  is  of  great  importance  from  a  diagnostic  standpoint, 
and  especially  when  considered  in  connection  with  an  associated  factor, 
such  as  sex,  age,  duration,  and  the  presence  or  absence  of  subjective 
symptoms  or  some  other  features.  Pye-Smith1  and,  following  him, 
Hardaway2  are,  I  believe,  the  only  writers  who  have  sufficiently  em- 
phasized this  valuable  factor  in  diagnosis,  the  former  also  using  diagram- 
matic drawings  for  this  purpose. 

Some  regions  are  especially  liable  to  certain  affections,  and  free  or 
relatively  so  from  many  others,  and  this  fact,  known  to  its  fullest  extent, 
will  often  immediately  narrow  the  diagnostic  possibilities  down  to  a 
comparatively  small  number  of  diseases,  and  the  chance  for  error  is 
accordingly  reduced;  the  differentiation  can  be  then  made  by  a  con- 
sideration of  the  other  factors  or  features  of  the  case.  Duration  is  of 
considerable  import,  and  on  this  score  inquiry  can  be  made  before  in- 
spection. History,  though  often  valuable,  is,  as  a  rule,  apt  to  be  mis- 
leading in  many  instances,  except  with  patients  of  keen  perception  and 
unusual  intelligence,  and,  upon  the  whole,  is  best  reserved  for  a  supple- 
ment to  the  objective  examination.  The  character  of  the  lesion  is  to  be 
noted,  as  determined  by  sight  and  touch,  and  its  method  of  growth  or 
formation,  whether  erythematous,  papular,  vesicular,  etc.,  and  if  uni- 
formly so  or  mixed  with  other  lesions;  and  whether  there  is  any  tendency 
to  special  grouping  or  configuration,  or  any  disposition  to  atrophy,  ul- 
ceration,  and  scarring.  The  presence  or  absence  of  itching — usually 
disclosed,  if  intense  in  character,  by  excoriations — is  sometimes  a  factor 
of  value. 

Moreover,  the  age,  social  position,  and  environment  of  the  patient 
may  occasionally  be  of  some  moment.  For  instance,  in  infants  and 
young  children  eczema  of  the  face  and  scalp  is  quite  frequent,  and  in- 
flammatory disease  of  any  duration  in  these  parts  can  usually,  therefore, 
be  set  down  as  this  affection.  Lupus  vulgaris  and  the  scrofuloderm, 
having  its  origin  in  the  cervical  glands  usually  present  in  childhood,  and 
miliaria,  erythema  intertrigo,  and  impetigo  contagiosa  are  also  most 
common  at  this  period.  Acne  is  common  to  growing  youth;  sycosis  and 
trade  eczemas — usually  of  the  hands — to  the  active  working  period  of  life, 
while  in  advancing  years  pruritus,  eczema  of  the  legs,  face,  and  epi- 
thelioma,  and  some  of  the  other  grave  diseases,  are  more  frequent. 
Ringworm  of  the  scalp,  quite  common  in  children,  is  a  rare  anomaly  in  the 
adult,  and  may  be  considered  as  practically  never  occurring  in  the  latter. 
Parasitic  diseases  are,  as  is  to  be  expected,  more  prevalent  among  the 
lower  and  poorer  classes.  Syphilis  is  also  more  frequent  among  this 

1  Pye-Smith,  Diseases  of  the  Skin,  1893. 

2  Hardaway,  Morrow's  System,  vol.  iii  (Dermatology),  p.  48. 


DISTRIBUTION  AS  A   DIAGNOSTIC  FACTOR  89 

class,  and  the  late  tubercular  syphiloderm  much  more  so,  owing  to  the 
less  persistent  treatment  followed  by  this  class  of  patients.  Some  diseases 
are  more  common  in  the  one  or  the  other  sex,  and  a  few  are  practi- 
cally limited  to  males,  a  few  to  females,  but,  upon  the  whole,  this  is  of 
but  little  value  in  diagnosis. 

The  value  of  a  conspicuous  feature  or  symptom,  if  present,  in  the 
case  is  also  very  great,  usually  bringing  the  diagnosis  within  three  or 
four  diseases,  as  in  those  cases  where  the  malady  is  upon  the  scalp, 
and  of  which  a  striking  symptom  is  a  patchy  loss  of  hair;  or  in  cases,  say 
on  the  face  or  elsewhere,  where  ulceration,  or  its  result,  scarring,  is  an 
associated  factor.  With  these  preliminary  remarks  the  diagnosis  may 
now  be  considered  from  several  of  the  standpoints  named. 

DISTRIBUTION  AS  A  DIAGNOSTIC  FACTOR 

Scalp. — In  infants  and  young  children  the  visibly  inflammatory 
(quite  red,  sometimes  infiltrated)  diseases  commonly  met  with  and  in 
which  there  is,  as  a  rule,  no  hair  loss  and  never  patchy  hair  loss,  are 
eczema,  dermatitis  seborrhoica,  impetigo  contagiosa,  and  pediculosis; 
non-inflammatory,  or  seemingly  so — ordinary  seborrhea,  alopecia  areata, 
and  some  cases  of  pediculosis;  slightly  or  moderately  inflammatory, 
sometimes  scarcely  visibly  so,  and  with  patchy  hair  loss — ringworm, 
favus.  In  children  of  moderate  age  the  same  diseases,  with  the  possi- 
bility of  psoriasis  mildly  to  markedly  inflammatory.  Rarely,  also, 
boils,  cutaneous  abscesses,  and  syphilis  might  possibly  be  seen.  In 
youth  and  adults  the  same  diseases  as  above  except  ringworm,  and  only 
exceptionally  impetigo  contagiosa;  but  also  frequently  alopecia,  ex- 
ceptionally lupus  erythematosus  and  epithelioma,  and  some  rare  dis- 
eases. The  most  frequent  diseases  are  eczema,  dermatitis  seborrhoica, 
seborrhea,  ringworm  (except  in  youth  and  adults),  alopecia  areata, 
psoriasis,  and  pediculosis  (usually  in  dispensary  practice). 

Face.— In  infants  and  young  children  eczema  and  impetigo  con- 
tagiosa are  common,  especially  the  former,  and  constitute  the  bulk 
of  the  cases.  Dermatitis  seborrhoica,  ringworm,  miliaria,  seborrhea, 
herpes  simplex,  herpes  zoster,  and  milium,  furuncles,  or  cutaneous 
abscesses  occasionally;  lupus  vulgaris  somewhat  rarely;  syphilis  is 
possible,  and  pigmentary  and  vascular  naevi  are  not  uncommon.  In 
older  children  about  the  same,  but  lupus  vulgaris  and  other  scrofulo- 
dermata  less  rarely;  freckles  are  common,  erysipelas  occasional,  and  rhus 
poisoning  is  not  infrequent.  In  youth  and  adults  the  same,  but  miliaria 
practically  never,  except  in  connection  with  a  generalized  outbreak; 
impetigo  contagiosa  relatively  seldom,  herpes  simplex  and  ringworm  less 
frequently;  but  milium,  seborrhea,  dermatitis  seborrhoica,  syphilis,  rhus 
poisoning,  and  erysipelas  are  more  common.  Other  diseases  observed  are 
comedo,  acne,  acne  rosacea  frequently;  epithelioma  and  lupus  erythema- 
tosus occasionally,  and  hydrocystoma  rarely.  In  the  bearded  and 
mustache  region  of  the  male  adult,  sycosis,  alopecia  areata,  and  ring- 
worm (tinea  sycosis),  and  in  this  region,  as  well  as  about  the  eyebrows 
and  nose,  dermatitis  seborrhoica  is  not  uncommon.  The  brow  is  the 


9o 


GENERAL   DIAGNOSIS 


common  situation  for  chloasma,  and  also,  usually,  conjointly  with  the 
scalp,  for  that  rare  disease,  acne  varioliformis.  On  the  eyelids,  xan- 
thoma,  and  this  and  neighboring  skin  are  the  common  seat  of  milium; 
eczema  about  the  edges,  and  also  rarely  pediculosis;  at  the  inner  canthus 
epithelioma  often  originates.  The  eyebrows  may  also  be  the  seat  of 
alopecia  areata  and  rarely  pediculosis.  The  nose  and  immediate  neigh- 
borhood are  the  usual  site  of  acne  rosacea,  lupus  erythematosus,  and  a 
not  uncommon  situation  for  tubercular  syphiloderm  and  lupus  vulgaris, 
epithelioma,  seborrhea,  and  dermatitis  seborrhoica,  and  the  usual  loca- 
tion for  the  rare  affection,  adenoma  sebaceum.  At  the  edge  and  within 
the  nostril  orifice,  sycosis  (f olliculitis) ,  impetigo  contagiosa,  herpes 
simplex,  eczema,  and  furuncles  are  not  infrequent;  lupus  vulgaris, 
syphilitic  eruption  or  ulceration,  and  epithelioma,  not  infrequently 
begin  here,  as  well  as  rhinoscleroma,  an  exceedingly  rare  affection.  The 
lips  are  often  the  seat  of  eczema,  herpes,  and,  especially  at  the  angles, 
syphilis,  and  the  initial  lesion  is  occasionally  observed  here;  the  lower 
lip  is  a  common  site  for  epithelioma.  On  the  ears,  the  most  frequent 
diseases  seen  are  eczema,  dermatitis  seborrhoica,  lupus  erythematosus, 
tubercular  syphiloderm,  lupus  vulgaris,  and  epithelioma. 

Psoriasis  and  other  usually  more  or  less  generalized  diseases  are  never 
seen  limited  to  the  face,  nor  the  rare  diseases,  lichen  planus,  pemphigus, 
etc.  In  countries  where  leprosy  is  not  uncommon  this  region,  especially 
the  brow,  is  frequently  one  of  the  first  to  show  the  disease.  The  most 
frequent  benign  or  practically  non-destructive  diseases  upon  the  face 
in  youth  and  adults  are  eczema,  acne,  acne  rosacea,  seborrhea,  derma- 
titis seborrhoica,  and,  in  our  country,  dermatitis  from  rhus  plants. 
The  most  frequent  malignant  or  destructive  diseases — characterized  by 
atrophy,  ulceration,  and  scarring — are  syphilis,  lupus  erythematosus, 
epithelioma,  and  lupus  vulgaris. 

Neck. — In  children  intertrigo  is  common,  usually  anteriorly,  and 
eczema  resulting  from  this  or  arising  spontaneously  is  not  infrequent; 
occasionally  ringworm  is  observed,  and  also  scrofuloderm  beginning 
in  the  cervical  glands  just  beneath  the  angle  of  the  jaw.  In  growing 
youth  and  adults  eczema,  acne  lesions,  ringworm,  and,  at  the  upper 
(hairy)  part,  sycosis;  impetigo  contagiosa  is  also  occasionally  seen; 
at  the  nape,  furuncles  are  common,  and  carbuncles  are  not  infrequent; 
occasionally  also  herpes  zoster  extending  up  on  to  the  face  or  down  on  the 
shoulder  and  arm  is  observed. 

Arms. — Eczema  not  uncommon;  herpes  zoster  and  tubercular 
syphiloderm  occasional.  Extensor  surfaces,  especially  at  the  elbow  or 
most  marked  at  this  region:  Psoriasis,  ichthyosis,  and  very  exceptionally 
xanthoma  lesions;  on  the  flexor  aspects  eczema,  and  exceptionally 
xanthoma.  Below  the  elbow,  on  the  forearm,  particularly  the  flexor 
surface,  lichen  planus;  and  on  the  dorsal  aspect,  usually  extending  over 
the  hand  also,  the  papular  type  of  erythema  multiforme.  Ringworm 
is  not  unusual  in  this  situation.  Eczema  is  quite  commonly  seated 
conjointly  on  the  lower  forearms  and  hands.  The  arms  frequently  share 
in  other  more  or  less  generalized  diseases. 

Hands. — Dorsal  surface,  papules  and  rings  of  erythema  multiforme, 


DISTRIBUTION  AS  A   DIAGNOSTIC  FACTOR  9! 

usually  extending  part  way  up  the  forearm;  and  also  lichen  planus,  ring- 
worm, eczema,  and  very  rarely  lupus  erythematosus,  tuberculosis 
verrucosa  cutis,  blastomycetic  dermatitis;  and  occasionally  tubercular 
syphiloderm,  and  in  those  of  advancing  years,  epithelioma.  On  the 
palmar  aspect  eczema,  pompholyx,  callositas,  keratosis  palmaris,  bullous 
erythema  multiforme;  and  syphiloderm,  usually  of  squamous  character. 
Involving  all  the  parts  more  or  less,  but  generally  especially  pronounced 
about  the  ringers  and  the  interdigital  surfaces — eczema,  pompholyx,  and 
scabies,  the  last,  however,  only  in  association  with  the  eruption  else- 
where. This  region,  alone  or  with  the  forearms,  and  sometimes  the  face 
and  other  parts,  is  the  seat  of  rhus  poisoning  and  other  forms  of  derma- 
titis. The  rare  affections,  dermatitis  repens  and  erysipeloid,  are  also 
usually  seated  here.  The  fingers  alone  are  sometimes  the  seat  of  eczema, 
pompholyx,  and  frost-bite.  The  dorsal  surfaces  of  the  hands  and  fore- 
arms conjointly  with  the  face  are,  as  a  rule,  the  seat  of  the  bullous  iodid 
eruption.  The  dorsal  surface,  especially  over  the  wrist,  is  the  most 
frequent  seat  of  that  rare  condition,  granuloma  annulare. 

Axilla. — Eczema,  dermatitis  seborrhoica,  ringworm  (eczema  mar- 
ginatum),  and  furuncles;  the  lesions  of  scabies  are  usually  quite  numer- 
ous here,  especially  in  the  folds.  This  is  also  one  of  the  usual  sites 
for  the  rare  disease,  erythrasma. 

Chest. — Tinea  versicolor,  frequently  extending  down  over  the 
lower  part  of  the  trunk,  in  the  axillae,  and  occasionally  in  the  groins 
and  flexures  of  the  elbows  and  knees,  and  exceptionally  on  to  the  neck 
and  upward.  The  chest  region,  especially  the  sides,  is  also  the  starting- 
place  in  pityriasis  rosea.  Anteriorly  and  posteriorly,  one  or  both,  espe- 
cially in  the  sternal  and  interscapular  regions— seborrhcea  corporis, 
dermatitis  seborrhoica.  Over  the  sternum,  keloid;  eczema,  especially  in 
women  about  the  nipple;  and  under  the  breast,  frequently  beginning  as 
intertrigo.  Lesions  of  scabies  are  usual  about  the  nipple  in  connection 
with  their  presence  in  other  regions.  The  mammary  gland  is,  as  known, 
a  common  seat  for  carcinoma,  and  the  areola  and  nipple  for  eczema  and 
Paget's  disease.  Posteriorly,  and  over  the  shoulders,  acne  lesions  are 
common;  and  over  the  shoulders  and  upper  part  of  the  back  the  excoria- 
tions and  lesions  of  pediculosis  corporis  are  usually  most  numerous. 
The  side  of  the  thorax  region  is  one  of  the  most  frequent  sites  for  herpes 
zoster,  and  an  occasional  one  for  the  tubercular  syphiloderm.  The 
upper  part  of  the  back  is  a  not  unusual  site  for  carbuncle. 

Abdominal  Region. — This,  as  all  other  regions,  may  be  the  seat 
of  eczema,  and  the  umbilicus  is  a  favorite  site;  and  this  latter  region, 
as  well  as  the  lower  part  of  the  abdomen,  commonly  shares  in  the  erup- 
tion of  scabies.  Most  of  the  cutaneous  irritation  in  pediculosis  pubis  is 
about  the  pubes  and  lower  abdomen.  The  side  of  the  abdominal  region, 
like  that  of  the  thorax,  is  not  infrequently  the  seat  of  herpes  zoster.  The 
trunk,  as  a  whole,  is  the  chief,  and  sometimes  the  sole,  seat  of  pityriasis 
rosea  and  tinea  versicolor;  and  in  common  with  other  parts  of  the  surface 
usually  shares  in  the  general  eruptive  diseases,  such  as  urticaria,  lichen 
planus,  pityriasis  rubra  pilaris,  syphilis,  pruritus,  erythema  multiforme, 
dermatitis  herpetiformis,  pemphigus,  the  exanthemata,  etc. 


92 


GENERAL  DIAGNOSIS 


Nates. — The  eruption  of  congenital  syphilis  is  often  pronounced 
here,  and  this  region  also  usually  shows  an  abundance  of  lesions  in 
scabies,  especially  at  the  anal  cleft  and  in  children.  It  is  also  a  favorite 
situation  for  furuncles;  and  in  urticaria  often  exhibits  the  most  pro- 
nounced and  the  most  itchy  wheals.  The  anus  is  a  frequent  site  for 
eczema,  pruritus,  moist  papules,  and  occasionally  acuminated  warts. 

Genitocrural  Region. — Erythema  intertrigo,  eczema,  derma- 
titis seborrhoica,  pediculosis  pubis,  rhus  poisoning,  usually  numerous 
lesions  in  scabies,  ringworm  (eczema  marginatum),  and  erythrasma. 
The  scrotum — a  part  of  the  genitocrural  region — usually  shares  in  the 
eruptions  just  named,  but  may  alone  be  the  seat  of  diffused  or  follicular 
eczema,  pruritus,  ringworm,  furuncles,  and  elephantiasis.  The  same 
can  be  said  of  the  penis,  on  some  part  of  which  syphilis  generally  has  its 
starting-point,  and  on  which  also  several  or  more  lesions  in  scabies  are  to 
be  found;  herpes  simplex  is  usually  limited  to  the  glans  and  prepuce. 
The  vulva  is  likewise  the  seat  of  the  same  diseases  as  observed  in  the 
male,  pruritus  and  eczema  being  the  usual  ones;  lupus  vulgaris  is  also 
exceptionally  seen  here,  and  also  the  rare  affection  kraurosis  vulvae. 
Both  the  penis  and  vulva  are  occasionally  the  seat  of  epithelioma. 

I/eg. — On  the  upper  part,  or  thigh,  on  its  front  and  outer  aspects, 
keratosis  pilaris;  usually  here  alone,  but  occasionally  conjointly  with 
it  here,  is  also  seen  on  the  outer  and  posterior  portions  of  the  arms 
and  exceptionally  elsewhere.  On  the  same  aspects  of  the  thigh  also  the 
lesions  of  pediculosis  corporis  are  relatively  numerous,  while  the  inner 
sides  usually  share  predominantly  in  the  scabies  eruption.  The  thigh 
is  not  uncommonly  the  seat  of  a  sycosiform  or  follicular,  sometimes 
almost  furuncular,  eczema.  The  extensor  surface  of  the  whole  leg 
shows  marked  involvement  in  prurigo  and  ichthyosis,  the  latter  more 
especially  well  marked  at  the  knee.  This  latter  region  is  also,  usually 
conjointly  with  the  elbows,  and  in  most  cases  other  parts,  a  common  seat 
for  psoriasis  lesions.  The  popliteal  space  is  frequently  alone  or  one  of 
several  involved  regions  in  eczema.  Below  the  knee  purpura  lesions 
are  usually  most  numerous,  with,  as  a  rule,  some  but  relatively  less  abun- 
dant above  the  knee,  and  not  infrequently  upon  the  forearms,  and  occa- 
sionally more  or  less  generally.  The  tibial  surface  is  the  favorite  one  for 
erythema  nodosum,  and  the  sides  and  posterior  aspects  for  the  rare 
affection,  erythema  induratum.  By  far  the  most  common,  and,  one  might 
readily  say,  the  usual,  disease  of  this  region  (lower  part  of  the  leg)  is 
eczema,  frequently  associated  with  varicose  veins,  and  occasionally 
originating  in  a  dermatitis  from  the  coloring-matter  of  the  stockings. 
It  is  also  a  frequent  situation  for  that  relatively  infrequent  disease, 
lichen  planus.  Leg  ulcers  of  all  kinds,  traumatic,  varicose,  and  syphilitic, 
are  often  seen  here.  The  legs  are  also  common  locations  for  pruritus, 
especially  pruritus  hiemalis  and  bath  pruritus. 

Foot — Eczema,  callositas,  keratosis  plantaris,  pompholyx,  the 
last  two  usually  on  the  soles  alone,  occasionally  extending  up  over 
the  sides;  in  the  latter  region,  also,  hyperidrosis,  with  erythematous, 
soggy  edges.  The  toes  and  the  interspaces  are  often  the  seat  of  eczema, 
eczematoid  ringworm,  and  likewise  usually  share  in  the  scabies  eruption. 


DURATION  AS  A   DIAGNOSTIC  FACTOR  93 

More  or  I,ess  Generalised — Most  common:  Eczema,  exan- 
themata, psoriasis,  urticaria,  erythema  multiforme,  secondary  syphilo- 
dermata,  pediculosis  corporis,  scabies,  pruritus,  medicinal  eruptions. 
Less  frequent:  Ichthyosis,  miliaria,  sudamen,  dermatitis  seborrhoica, 
dermatitis  herpetiformis,  rhus  poisoning,  pityriasis  rubra  pilaris,  lichen 
planus,  granuloma  fungoides,  multiple  pigmented  sarcoma,  purpura, 
scleroderma,  xanthoma  diabeticorum. 

Universal. — Eczema,  psoriasis,  ichthyosis,  erythema  scarlatin- 
oides,  dermatitis  exfoliativa,  pityriasis  rubra  pilaris. 

DURATION  AS  A  DIAGNOSTIC  FACTOR 

Many  cases  of  skin  diseases  are,  as  to  duration,  essentially  chronic; 
others  are  more  or  less  acute.  This  fact  can  sometimes  be  utilized  in 
diagnosis,  for  very  often  when  patients  come  under  observation  the 
malady  has  already  been  of  some  days'  or  weeks'  standing,  and  if  so, 
if  no  spontaneous  tendency  to  natural  defervescence  has  set  in,  the  dis- 
eases of  short  duration,  which  the  one  in  hand  may  resemble,  may 
ordinarily  be  shut  out  in  the  diagnosis,  unless  the  malady  is  evidently 
kept  up  by  a  continuance  of  the  causative  factors,  as  is  possible  in  ery- 
thema intertrigo,  miliaria,  dermatitis  medicamentosa,  and  some  others. 

To  illustrate  how  this  factor  sometimes  comes  into  play,  take  im- 
petigo contagiosa  and  eczema,  which  sometimes  present  a  close  resem- 
blance. Both  are  common  in  infants  and  young  children,  the  former 
more  especially  in  the  dispensary  classes.  If  the  duration  has  been  more 
than  ten  days  or  two  weeks,  and  still  with  no  apparent  tendency  to  spon- 
taneous subsidence,  it  is  probably  eczema;  if  of  more  than  one  or  two 
months'  duration,  surely  so.  The  same  as  to  eczema  and  rhus  poisoning, 
the  latter  so  common  with  us  during  our  season  of  vegetation.  Another 
application  of  this  fact  is  in  the  differentiation  between  psoriasis  and  the 
secondary  general  papulosquamous  syphiloderm;  if  the  patient's  eruption 
is  more  than  of  several  months'  duration,  the  latter  diagnosis  becomes 
less  probable;  if  a  year  or  more,  absolutely  excluded. 

The  short -duration  eruptions,  those  scarcely  exceeding  several 
weeks'  duration,  and  sometimes  much  less,  are,  it  is  true,  relatively  few, 
but  among  these  usually  are:  Acute  circumscribed  edema,  dermatitis 
medicamentosa,  ecthyma,  erysipelas,  erythema  intertrigo,  erythema 
simplex,  erythema  scarlatinoides,  furuncle,  herpes  simplex,  herpes 
zoster,  impetigo  contagiosa,  miliaria,  urticaria,  rhus  poisoning,  and 
other  cases  of  dermatitis  due  to  temporary  chemical,  plant,  or  other 
irritant;  and  frequently  erythema  multiforme,  erythema  nodosum,  and 
ringworm  of  the  non-hairy  surface. 

The  moderate -duration  eruptions,  scarcely  exceeding  one 
or  two  months  or  by  that  time  showing  a  spontaneous  tendency  to  dis- 
appearance, excluding  those  of  variable  and  possible  or  probable  chron- 
icity,  are:  Dermatitis  exfoliativa  (some  cases),  erythema  multiforme, 
erythema  nodosum,  pityriasis  rosea,  pompholyx,  purpura  (some 
exceptions),  ringworm  of  the  non-hairy  surface,  and  most  cases  of  the 
secondary  syphilodermata. 


GENERAL   DIAGNOSIS 


TYPE  OF  ERUPTION  AS  A  DIAGNOSTIC  FACTOR 

It  is  superfluous  to  say  that  it  is  unnecessary  to  consider  eruptions 
of  a  vesicular,  pustular  character,  etc.,  in  the  diagnosis  of  a  case  in  which 
the  rash  is  distinctly  papular.  The  type  of  lesion  is  therefore  often  of 
great  service  to  the  student,  as  well  as  to  the  practitioner,  in  bringing  the 
disease  within  reasonable  proximity  to  a  correct  diagnosis.  To  a  limited 
extent  this  subject  was  touched  upon  in  describing  the  lesions  of  the 
skin,  but  an  elaboration  and  a  tabulation  of  the  different  more  common 
maladies  upon  this  basis  will  prove  of  value.  The  size  of  the  lesions, 
region,  and  other  characters  and  features  calculated  to  be  of  some 
additional  aid  will  be  parenthetically  commented  upon. 

ErythematoiiS  eruptions  may  be:  Common:  Eczema  (usu- 
ally with  slight  scaling;  about  face  if  acute,  sometimes  simulating  ery- 
sipelas), erythema  simplex,  erythema  intertrigo,  erythema  multiforme 
(usually  mixed  with  other  forms),  dermatitis  (as  from  ivy,  chemicals, 
sun's  rays,  etc.),  .scarlet  fever,  measles,  rotheln,  erysipelas  (usually 
face,  with  considerable  edematous  swelling  and  sharply  marginate 
border,  and  constitutional  disturbance),  medicinal  eruptions  (especially 
from  copaiba,  quinin,  belladonna,  chloral,  opium,  etc.). 
Rare:  Erythema  scarlatinoides. 

Brythematopapular. — Common:  Erythema  multiforme  (usu- 
ally dorsal  surface  of  forearm  and  hands),  urticaria  (more  or  less  gen- 
eral), insect-bites. 

Rare:  Dermatitis  herpetiformis  (occasionally  or  at  times),  measles 
(occasionally),  varicella  (earliest  stage),  variola  (earliest  stage). 

Papular. — Common:  Eczema  (small,  usually  aggregated  or  con- 
fluent, and  commonly  regional;  itchy),  miliaria — prickly  heat  (small, 
and  usually  in  infants  and  young  children;  often  itchy),  keratosis 
pilaris  (small,  discrete;  thighs,  outer  aspects),  erythema  multiforme 
— papular  variety  (large  and  usually  backs  of  hands  and  forearms, 
often  crowded  together;  rarely  itchy),  milium  (small,  whitish,  cystic, 
discrete;  commonly  about  eyelids),  papular  syphiloderm  (general, 
small  or  miliary  variety,  often  with  tendency  to  group;  large  variety 
irregularly  scattered;  dark  red  or  ham  colored),  acne  (face,  sometimes 
shoulders;  small  or  large,  discrete,  usually  mixed  \vith  pustules),  acne 
rosacea  (nose  and  immediate  neighborhood,  associated  with  passive 
hyperemia  and  often  capillary  dilatation),  sycosis  vulgaris  (bearded 
region — male;  associated  generally  with  a  predominance  of  pustules). 

Occasional:  Lichen  planus  (usually  flat,  dark  colored,  sometimes 
slightly  umbilicated;  tendency  to  aggregation  or  confluence,  with 
scaliness;  itchy),  xanthoma  palpebrarum  (yellowish,  soft,  tend  to  form 
confluent  band),  molluscum  contagiosum  (usually  face,  especially  about 
eyelids;  pearly,  translucent-looking,  discrete,  with  central  minute 
depression  and  aperture),  warts. 

Rare:  Pityriasis  rubra  pilaris  (scaly,  and  tend  to  form  solid  scaly 
sheets);  prurigo,  especially  on  extensors  of  legs,  with  board-like  hard- 
ness and  thickening;  itchy),  lichen  scrofulosus  (usually  on  trunk,  in  one 


TYPE    OF  ERUPTION  AS  A   DIAGNOSTIC  FACTOR  95 

or  several  patches,  as  yellowish-red  or  yellowish-gray  follicular  papules, 
closely  crowded  and  slightly  scaly). 

Follicular  papules  are  also  usually  seen  in  association  with  the  milder 
types  of  ichthyosis. 

Papulosquamous. — Common:  Psoriasis,  eczema,  keratosis  pila- 
ris.  Not  infrequent:  Lichen  planus,  papulosquamous  syphiloderm. 
Rare:  Pityriasis  rubra  pilaris,  lichen  scrofulosus. 

Tubercular  (Nodular) — Most  common;  Erythema  multiforme 
(dorsal  surface  of  hands  and  forearms;  rarely  itchy),  acne  (face,  some- 
times shoulder  and  back  also;  associated  with  pustules  and  papules), 
acne  rosacea  (nose  and  neighborhood,  sometimes  also  cheeks,  chin, 
and  middle  of  forehead;  associated  with  hyperemia  and  capillary  dila- 
tation and  commonly  with  pustules);  tubercular  syphiloderm  (usually 
limited  area,  with  tendency  to  segmental  configuration,  and  with  pig- 
mentation, atrophy,  or  ulceration) ,  xanthoma  palpebrarum  (see  under 
Papular). 

Infrequent:  Lupus  vulgaris  (commonly  about  face,  frequently  the 
nose,  usually  small  or  moderate-sized  area,  with  disposition  to  group, 
with  tendency  to  ulceration  and  scar-formation;  occasionally  whole 
region  involved),  molluscum  contagiosum  (see  under  Papular). 

Rare:  Xanthoma  multiplex  and  xanthoma  diabeticorum  (general 
distribution,  but  predominantly  on  the  extremities;  yellow).  Epithe- 
lioma  often  begins  as  a  tubercle. 

Vesicular. — Common:  Eczema  (regional,  small,  aggregated, 
confluent,  spontaneously  rupturing;  markedly  inflammatory  and  itchy; 
exceptionally,  as  on  the  fingers,  discrete  and  somewhat  firmer). 

Not  infrequent:  Miliaria  (as  a  rule,  general,  minute,  numerous,  and 
crowded,  but  discrete,  with  but  little  tendency  to  spontaneous  rupture; 
inflammatory,  usually  itching,  but  of  variable  degree),  herpes  simplex 
(usually  large — except  herpes  progenitalis;  regional,  generally  scanty, 
and  commonly  on  or  near  the  lips;  bunched  or  grouped,  but  little  tend- 
ency to  spontaneous  rupture),  herpes  zoster  (regional,  unilateral,  large 
lesions,  and  forming  groups  upon  hyperemic  or  inflammatory  skin,  with 
little  tendency  to  rupture;  frequently  neuralgic  pain  and  burning), 
sudamen  (general,  especially  trunk;  minute,  crowded,  but  discrete,  clear, 
translucent,  and  with  little  tendency  to  spontaneous  rupture;  not  in- 
flammatory; seen  in  association  with  systemic  febrile  diseases),  varicella 
(more  or  less  general,  most  on  trunk;  discrete),  scabies  (about  fingers 
especially,  associated  with  pustules,  and  with  evidences  of  the  eruption 
on  the  other  usual  parts),  rhus  poisoning  (small,  large,  discrete,  and 
crowded  and  confluent,  often  with  considerable  erythematous  swelling; 
most  common  about  face,  hands,  and  forearms,  sometimes  genitalia  or 
other  parts,  and  generally  quite  itchy),  impetigo  contagiosa  (usually 
face  or  face  and  hands,  after  early  stage  becoming  seropurulent,  flatten- 
ing, enlarging,  and  crusting). 

Occasional:  Erythema  multiforme,  urticaria  (in  both  diseases  an 
accidental  association  with  a  predominance  of  the  ordinary  lesions). 
Somewhat  rare:  Pompholyx  (hands,  feet,  or  both,  especially  palmar 
and  plantar  regions;  beginning  deep  seated;  discrete  and  confluent, 


o6  GENERAL   DIAGNOSIS 

commonly  going  on  to  bullous  development;  inflammatory,  and  usually 
of  rapid  development),  dermatitis  herpetiformis  (more  or  less  general, 
with  tendency  toward  small  groups  of  three  or  four,  and  often  associated 
with  bullous  and  erythematous  lesions;  inflammatory  and  usually 
markedly  itchy;  chronic,  with  exacerbations),  variola  (early  stage- 
general,  but  most  abundant  on  face  and  hands),  hydrocystoma  (face, 
scattered,  firm,  shiny,  translucent,  with  a  bluish  cast). 

Rare:  Hydroa  vacciniforme  (usually  in  boys,  develops  in  early  life, 
is  mostly  on  uncovered  parts,  and  generally  in  summer,  and  leaves 
variola-like  scars;  disappears  toward  adult  age).  Exceptionally  vesicu- 
lar eruptions  may  be  medicinal  in  origin.  Erysipelas  may  also  show 
vesiculation. 

Bullous.— Erythema  multiforme — erythema  bullosum  (an  acci- 
dental or  anomalous  development,  usually  about  the  hands,  forearms, 
and  face,  and  frequently  in  association  with  the  ordinary  symptoms 
of  the  malady),  urticaria — urticaria  bullosum  (likewise  an  accidental 
or  anomalous  development,  and  associated  with  the  ordinary  features 
of  the  disease;  the  bullous  lesions  most  commonly  on  the  extremities), 
impetigo  contagiosa  (in  some  cases  several,  and  exceptionally  all  the 
lesions,  are  distended  and  typical  blebs;  generally,  however,  in  associa- 
tion with  other  characteristic  lesions),  rhus  poisoning  (usually  with 
vesicles  and  considerable  erythematous  swelling;  face,  hands,  and 
forearms  common  sites,  sometimes  genitalia  or  other  parts),  dermatitis 
herpetiformis  (general,  with  tendency  toward  small  groups  of  three  or 
four,  usually  with  associated  vesicles  and  erythematous  lesions;  as  a 
rule,  markedly  itchy,  chronic,  with  exacerbations),  pemphigus  (general, 
irregularly  scattered,  well  distended,  rounded,  or  oval  blebs;  occasionally 
flaccid;  often  arising  from  sound  skin,  and  often  with  systemic  dis- 
turbance— an  extremely  rare  disease  in  this  country),  syphilis — bullous 
syphiloderm  (usually  congenital,  appearing  at  or  just  after  birth,  com- 
monly most  numerous  about  the  palms  and  soles,  becoming  purulent, 
and  associated  with  other  symptoms  of  the  disease) ,  medicinal  eruptions 
(exceptional;  from  iodids,  and,  as  a  rule,  or  predominantly,  on  the  ex- 
tremities and  face;  possibly  also  from  other  drugs). 

Pustular. — Common:  Acne  (face,  or  with  shoulders  and  back,  or 
exceptionally  this  last  alone;  discrete;  associated  with  papules,  come- 
dones, and  sometimes  small,  pit-like  scars),  eczema  (most  commonly 
about  scalp,  and  sometimes  in  association  with  pediculosis  capitis;  not 
infrequently  elsewhere,  especially  in  connection  with  the  hair-follicles, 
as  on  face,  thighs,  and  other  regions;  sometimes  minute,  crowded,  and 
rapidly  forming  crusts;  in  others  discrete  and  larger;  quite,  itchy). 

Not  infrequent:  Impetigo  contagiosa  (face,  hands,  and  sometimes 
elsewhere;  developing  from  vesicles  or  vesicopustules,  or  originating  as 
pustules;  if  the  latter,  usually  plump  and  rounded;  tendency  to  coales- 
cence and  crusting;  frequently  associated  with  the  ordinary  vesicular 
or  vesicopustular  lesions  of  this  disease),  bromid  and  iodid  eruptions 
(most  abundant  on  the  ordinary  acne  regions;  rather  bright  pink  or 
red  base,  with,  as  a  rule,  relatively  small  pustular  portion;  exceptionally 
much  larger,  and  even  the  size  of  blebs;  in  the  latter  usually  with  papil- 


TYPE    OF  ERUPTION  AS  A   DIAGNOSTIC  FACTOR  97 

lomatous  tendency),  furuncle  (commonly  single,  but  sometimes  several 
in  same  region,  always  discrete,  and  most  commonly  at  the  back  of  the 
neck;  markedly  inflammatory  base,  and  painful  and  tender;  sometimes 
beginning  deep  seated,  in  others  as  a  pustule  at  the  hair-follicle),  sycosis 
vulgaris  (bearded  and  mustache  region,  connected  with  hair-follicle; 
discrete,  crowded,  and  confluent;  some  lesions  may  be  papular;  inflam- 
matory and  chronic),  tinea  sycosis,  or  ringworm  of  the  bearded  region 
(deep  seated,  nodular,  or  lumpy,  furuncular,  or  pseudocarbuncular,  and 
usually  some  small  surface  pustules — see  tumor  eruptions  following), 
scabies  (especially  about  the  hands,  where,  as  well  as  on  the  other 
ordinary  parts  for  this  disease,  other  lesions  are  also  seen  associated), 
pediculosis  (occasional  pustules  not  uncommon;  in  pediculosis  capitis, 
chiefly  or  wholly  occipital;  pediculosis  corporis,  most  common  across 
shoulders  and  above  buttocks;  in  pediculosis  pubis,  scattered  over 
pubic  region),  syphiloderm  (generalized  and  secondary  eruptions — 
minute  miliary,  with  tendency  to  group,  and  associated  with  minute 
papules;  in  larger,  acne-like,  and  varioliform  eruptions — with  no  grouping 
tendency,  although  usually  numerous;  in  flat  and  large,  or  ecthymati- 
form  eruptions — rarely  in  numbers,  but  also  scattered  over  surface,  with 
usually  underlying  ulceration;  other  symptoms  present.  In  late  syphilis 
the  papulotubercular  or  tubercular  lesions,  forming  regional  or  limited 
area  or  patch,  may  become  pustular),  variola  (numerous  and  general, 
but  most  abundant  on  face  and  backs  of  hands;  usually  umbilicated; 
constitutional  symptoms). 

Infrequent:  Ecthyma  (large,  flattened,  markedly  inflammatory 
base  and  areola;  usually  on  legs,  and  commonly  in  those  of  the  vaga- 
bond class;  lesions  rarely  numerous).  As  is  well  known,  vesicles  often 
become  pustular. 

Squatnous. — Common:  Eczema  (usually  one  or  several  large 
areas;  regional;  rarely  extensive,  and  if  so,  frequently  a  history  or  pres- 
ence of  gummy  oozing  in  one  or  two  places;  seated  upon  a  thickened 
red  surface;  good  deal  of  infiltration,  and  rarely  sharply  defined;  back 
of  neck,  legs,  face,  and  hands,  common  sites),  psoriasis  (sharply  circum- 
scribed, variously  sized  patches,  usually  general  and  scattered,  with 
preponderance  toward  the  extensors,  especially  knees  and  elbows; 
scaliness  commonly  abundant,  and  seated  upon  slightly  elevated,  red, 
flat  papules  or  patches,  with  but  little  infiltration;  sometimes  scales 
have  been  rubbed  off  by  clothing  and  perspiration;  chronic  and  recurrent, 
usually  history  of  one  or  more  years;  exceptionally  universal,  and  then 
essentially  similar  to  dermatitis  exf oliativa) . 

Frequent:  Papulosquamous  syphiloderm  (in  general  aspects,  simi- 
lar to  psoriasis,  but  patches  rarely  larger  than  a  silver  quarter,  with 
no  predilection  for  the  extensor  surfaces,  less  disposition  to  abundant 
scaliness,  seated  upon  dark-red,  infiltrated  papules  or  patches,  with  al- 
ways some  solid  papules  with  no  scaling  tendency;  relatively  short  history 
and  associated  other  symptoms  of  syphilis;  may  persist  or  appear  as  a  late 
manifestation  in  the  palms  and  soles),  seborrhea  and  dermatitis  sebor- 
rhoica  (usually  scalp,  nose,  and  neighborhood,  bearded  region,  or  sternal 
and  interscapular  region;  greasy  or  unctuous  characters;  on  scalp,  com- 
7 


98 


GENERAL   DIAGNOSIS 


monly  diffused,  with  little,  sometimes  no,  underlying  redness;  on  nose 
and  neighborhood,  usually  thin,  greasy  scales  or  thin  crusts,  on  pale  or 
hyperemic  surface  often  showing  sebaceous  gland-duct  involvement. 
On  sternal  and  interscapular  regions,  greasy  scales  or  crusts,  red  base, 
often  segmental  in  arrangement,  and  often  showing  follicular  dipping; 
sometimes  projecting  and  pseudopapular) .  Dermatitis  seborrhoica 
represents  the  cases  in  which  there  is  underlying  redness,  with  slight,  but 
variable,  infiltration. 

Less  frequent:  Lichen  planus  (usually  regional  and  most  frequently 
on  flexor  surface  of  forearms  and  on  the  lower  part  of  legs;  when  con- 
fluent, form  thick,  scaly  plaques,  but,  as  a  rule,  at  the  edge  or  just  beyond 
it  are  discrete,  flattened,  often  slightly  umbilicated,  dark-red,  purplish, 
or  violaceous  papules,  with  and  without  a  minute  scale;  chronic  and 
usually  markedly  itchy;  exceptionally  more  general),  ringworm  (scalp, 
scaliness  branny,  and  extremely  slight;  patch  or  patches  usually  rounded, 
and  some  hair  loss  and  hair  stumps;  on  non-hairy  surfaces  ring-like 
patch  with  clearing  center,  scaliness  slight;  slightly  or  moderately  in- 
flammatory edges;  sharply  defined  and  usually  of  short  duration;  on 
crurogenital  region,  features  of  eczema,  but  sharply  marginate). 

Occasional:  Ichthyosis  (appears  from  first  to  third  years,  various 
degrees:  slight  grade,  usually  noticeable  only  on  extensors  of  the  arms 
and  legs,  especially  about  knees  and  elbows,  and  disappears  in  warm 
weather.  Moderately  developed, — more  marked  on  above  situation, 
and  often  arranged  somewhat  like  squarish  plates,  frequently  with  some 
follicular  elevation,  and  also  slight  general  scaliness, — disappears  partly 
or  completely  in  summer;  in  extreme  of  winter  may  also  show  some  scali- 
ness about  face,  and  likewise  an  eczematous  tendency.  Marked  grade — 
scaliness  more  or  less  general,  most  marked  on  extensors,  where  it  con- 
sists of  thick  plates;  eczematous  tendency  or  exposed  parts  in  cold 
weather;  much  better  in  warm  weather,  but  does  not  disappear  entirely. 
Ordinarily,  unless  complicated  by  eczema,  the  malady  is  not  inflamma- 
tory). Favus  (scalp  usually,  and  in  irregular  patches  or  areas;  yellowish, 
mortar-like  crusting,  generally  here  and  there  saucer-  or  cup-shaped, 
and  the  skin  beneath  usually  red  and  atrophic;  hair  involvement  and 
loss),  lupus  erythematosus  (usually  face,  and  often  on  or  near  nose; 
well-defined,  red,  elevated  margin,  with  generally  a  tendency  to  in- 
volution or  atrophy  in  central  part;  scaliness  slight  and  adherent,  whitish 
or  grayish  in  color;  gland-ducts  usually  perceptibly  involved  and  often 
patulous),  pityriasis  rosea  (usually  limited  to  trunk  or  extending  to 
thighs  and  upper  arms,  sometimes  further;  faint  red,  and  often  with 
salmon  tint;  scaliness  slight  to  moderate,  and  patches  variously  sized, 
some  or  many  with  tendency  to  clear  centrally;  comes  out  within 
several  days  or  a  week,  and  lasts  from  one  to  two  months;  as  a  rule, 
not  itchy). 

Somewhat  rare:  Dermatitis  exfoliativa  (more  or  less  universal); 
scaliness  slight  or  marked,  and  often  exfoliated  in  large  masses  or  sheets; 
skin  red,  in  some  cases  infiltrated,  and  in  others  often  apparently  thinned; 
sometimes  preceded  and  accompanied  by  constitutional  disturbance; 
lasts  several  months  or  indefinitely;  usually  recurrent;  exceptionally 


TYPE    OF  ERUPTION  AS  A   DIAGNOSTIC  FACTOR  99 

fatal),  lupus  vulgaris  (sometimes,  instead  of  undergoing  destruction, 
lupus  patches  exfoliate, — lupus  exfoliativus — the  other  characters  being 
as  already  described  under  Tubercular). 

Rare:  Pityriasis  rubra  pilaris  (more  or  less  general,  but  usually  with 
some  places  showing  the  beginning  follicular  papules;  thickening  and 
variable  scaliness,  usually  abundant,  grayish,  and  quite  hard.  Ery- 
thema scarlatinoides,  scarlet  fever,  etc.,  present  a  thin,  paper-like  ex- 
foliation or  scaling;  a  slightly  scaly  condition  is  also  not  infrequently 
seen  with  scleroderma,  elephantiasis,  and  leprosy. 

Multiform  (Mixed— Two  or  More  I/esional  Forms).— Ec- 
zema (any  part  or  several  regions;  usually  a  predominance  of  one  lesional 
form;  itchy),  erythema  multiforme  (more  or  less  general;  commonly 
papules  and  erythematous  patches  or  rings,  exceptionally  with  vesicles 
and  even  blebs),  dermatitis  herpetiformis  (general,  commonly  vesicles, 
blebs,  and  erythematous  patches;  less  frequently  pustules  also;  usually 
very  itchy),  acne  (face,  or  face,  shoulders,  and  back,  or  exceptionally 
last  alone;  comedones,  papules,  and  pustules),  scabies  (more  or  less 
general,  but  usually  worse  on  fingers,  hand,  wrists,  axillary  folds,  geni- 
talia,  anal  cleft,  and  feet;  papules,  vesicles,  pustules,  sometimes  blebs, 
and  often  "burrows";  very  itchy),  pediculosis  (papules,  often  scanty, 
small  and  large  pustules,  and  excoriations;  pediculosis  corporis — general, 
except  face,  head,  and  hands,  but  most  marked  over  shoulders,  about 
waist,  sacrum,  and  outside  of  thighs),  sycosis  vulgaris  (papules  and 
pustules — bearded  and  mustache  region),  granuloma  fungoides  (usually 
generalized,  with  eczematous-looking  patches,  nodules,  and  fungating 
tumors). 

Crusted. — Vesicular  and  pustular  eczema,  eczema  rubrum,  sebor- 
rhea,  dermatitis  seborrhoica,  favus  (see  under  Squamous),  impetigo 
contagiosa,  ecthyma,  and  sometimes  the  various  other  vesicular,  pustular, 
and  bullous  diseases. 

Papillomatous.— Warts,  syphilis,  sycosis  vulgaris,  epithelioma, 
tuberculosis  verrucosa  cutis,  lupus  vulgaris,  blastomycetic  dermatitis, 
mycetoma,  some  bromid  and  iodid  eruptions. 

Atrophic  or  Cicatricial  (Without  Preceding  Suppura- 
tion or  Ulceration). — The  most  common  are  favus  (scalp),  lupus 
erythematosus  (usually  face  and  sometimes  scalp),  acne  (some  cases, 
slight  pitting). 

Less  frequent:  Tubercular  syphiloderm  (some  cases;  atrophic  thin- 
ning, usually  with  pigmentation),  lupus  vulgaris  (some  cases;  atrophic 
thinning). 

Rare:  Morphea  (usually  one  or  several  areas;  on  trunk,  limbs, 
or  face),  scleroderma  (extensive  distribution;  extremities,  trunk,  and 
face),  folliculitis  decalvans  (scalp),  glossy  skin  (fingers),  maculae  et 
strise  atrophicae  (usually  trunk  or  limbs),  leprosy.  Also  acne  varioli- 
formis,  in  which  the  pustulation  is  sometimes  scarcely  noticeable. 

Ulcerative.— Chiefly  syphilis,  epithelioma,  lupus  vulgaris,  and 
other  varieties  of  tuberculosis  cutis.  Rare:  Blastomycetic  dermatitis, 
mycetoma,  actinomycosis,  erythema  induratum,  leprosy;  sometimes 
ecthyma,  sycosis  vulgaris,  tinea  sycosis,  acne,  and,  in  rare  instances, 


IOO  GENERAL   DIAGNOSIS 

ingestion  of  iodids  and  other  drugs,  produce  superficial  destruction; 
both  furuncle  and  carbuncle  may  destroy  a  variable  amount  of  tissue. 
The  ordinary  leg  ulcer,  commonly  varicose  ulcer,  is  also  a  well-known 
ulcerative  lesion. 

Tumor. — More  or  less  generalized:  Fibroma  (variously  sized 
nodules  and  tumors,  mostly  sessile,  with  occasionally  some  pendulous), 
granuloma  fungoides  (small  and  large  tumors,  and  fungating  growths, 
commonly  associated  with  erythematous,  eczematous-looking  areas), 
sarcoma  (usually  melanotic  and  multiple  pigmented  varieties),  mollus- 
cum  contagiosum  (pearly-looking,  usually  sessile,  with  central  punctum 
and  depression — extremely  rare  as  a  generalized  eruption),  leprosy. 

Regional:  Steatoma,  gumma,  molluscum  contagiosum  (usually 
about  face;  see  Tubercular),  ringworm  (chin  and  bearded  region,  espe- 
cially under  jaws,  several  or  crowded,  tumor-like,  deep  seated;  frequently 
discharging;  exceptionally  may  consist  of  a  single  circumscribed  nodular 
mass,  suggestive  of  carbuncle),  erythema  induratum  (usually  legs  from 
knees  down,  especially  laterally  and  posteriorly;  several  or  more,  as  a 
rule;  tendency  to  break  down),  keloid,  and  some  others,  both  of  regional 
and  general  distribution. 

Pigmentary  and  Pseudopigmentary  (Discoloration) — 
Common:  Chloasma  (usually  about  forehead,  ill-defined,  patchy,  or 
irregular  areas;  yellowish  brown  to  brown;  no  textural  change),  freckles, 
tinea  versicolor  (chiefly  the  trunk,  and  especially  upper  part,  variously 
sized  yellowish  or  fawn-colored  patches,  areas,  and  sheets;  often  ex- 
tremely slight  branny  desquamation  noticeable;  no  other  symptoms; 
sometimes  itchy  when  patient  is  warm),  vitiligo  (in  whites,  the  brownish 
pigmentation  surrounding  whitened  vitiligo  patches  proper  may  in 
some  instances  be  much  the  more  conspicuous  feature ;  face  and  back  of 
hands  favorite  situations;  no  other  symptoms).  The  various  syphilo- 
dermata  (usually  but  temporary,  although  in  some,  as  in  the  flat  pustular, 
it  is,  especially  on  the  legs,  often  more  or  less  lasting) ,  naevus  pigmentosus 
(generally  single;  various  kinds,  from  simply  freckle-like  spot  to  one 
thickened,  dark,  and  hairy),  sebaceous  wart  (usually  in  the  old,  about 
face,  back,  or  hands;  elevated,  and  generally  covered  with  greasy,  ad- 
herent, thin  crust),  purpura  (most  commonly  about  legs;  spots  small 
or  large,  red,  changing  to  bluish,  yellowish,  and  fading;  hemorrhagic; 
no  textural  changes),  scurvy  (dark  reddish-brown  to  brownish-black 
areas  usually  about  the  ankles),  pediculosis  corporis  (if  long  continued, 
with  the  consequent  scratching,  more  or  less  pigmentation  remains,  often 
well  pronounced  over  the  back  and  shoulders). 

Rare:  Lichen  planus  (frequently  more  or  less  permanent  brownish 
discoloration,  especially  when  on  the  lower  part  of  leg),  chromidrosis 
(especially  about  the  eyes,  where  it  is  dark  colored;  also  the  axilla, 
where  it  may  be  variously  colored,  often  due  to  the  presence  of  bacteria), 
urticaria  pigmentosa  (more  or  less  general ;  urticarial  efflorescences  leav- 
ing sometimes  yellowish,  thin,  xanthoma-like  lesions,  but  usually  yellow- 
ish to  violaceous  stains;  begins  in  early  life,  and  persists,  as  a  rule,  to  late 
youth),  xeroderma  pigmentosum  (more  or  less  general,  freckle-like  spots, 
and  telangiectases;  later,  with  epitheliomatous  growths;  begins  early  in 


A    CONSPICUOUS  FEATURE  AS  A   DIAGNOSTIC  FACTOR      IOI 

life),  acanthosis  nigricans  (more  or  less  general,  usually  presenting  features 
of  pigmented  nevus,  verruca,  and  ichthyosis). 

Scleroderma  has  often  associated  with  it  a  variable  degree  of  brown- 
ish pigmentation,  and  chronic,  persistent  eczema  of  the  region  of  the 
ankle  is  frequently  followed  by  more  or  less  permanent  staining.  Pig- 
mentation is  likewise  observed  in  long-continued,  markedly  itchy 
cases  of  dermatitis  herpetiformis.  It  is  also  a  not  uncommon  feature 
of  leprosy. 


A  CONSPICUOUS  CHARACTER  OR  FEATURE  AS  A 
DIAGNOSTIC  FACTOR 

In  some  instances  many  of  the  difficulties  in  the  way  of  a  diagnostic 
conclusion  can  be  surmounted  by  picking  out  a  striking  or  somewhat 
unusual  symptom  or  combination,  and,  when  possible,  letting  this  be 
the  point  from  which  the  differentiation  is  approached.  This  is  already 
indicated  in  the  consideration  of  the  value  of  lesion  type  in  the  diagnosis. 
Taking  only  the  diseases  with  which  the  student  or  general  practitioner 
is  likely  to  meet,  omitting  therefore  the  rare  diseases,  the  value  of  this 
method  in  many  cases  becomes  in  practice  clearly  evident,  and  few  of 
these  points  may  be  here  profitably  touched  upon,  even  if  necessitating 
some  repetition. 

Patchy  Hair  I/OSS. — This,  if  present,  even  when  but  a  single 
area  and  not  complete,  is  a  striking  and  visible  sign,  and  one  that  in 
children  usually  brings  the  diagnosis  within  three  diseases — ringworm, 
alopecia,  areata,  and  favus.  It  is  true  that  a  bald  area  might  result 
from  a  "blind  boil"  or  cutaneous  abscess,  not  uncommon  with  children 
of  the  dispensary  class;  or  from  traumatism,  or  from  some  other  de- 
structive agent  or  disease,  but  the  first  and  second  are  almost  inva- 
riably self-evident  from  inspection  or  history,  and  the  others,  rare. 

In  adults  ringworm  of  the  scalp  is  necessarily  excluded,  and  the 
diseases  are  narrowed  to  two,  and  if  the  case  does  not  correspond  to 
the  one  or  the  other,  then  other  rarer  diseases  in  which  this  feature 
occurs  are  to  be  considered — lupus  erythematosus  and  folliculitis  de- 
calvans.  Scar  tissue,  evidently  resulting  from  previous  ulceration,  if 
present,  will  also  suggest  syphilis.  Patchy  hair  loss  of  the  eyebrow  is 
sometimes  an  associated  part  of  alopecia  areata  of  the  scalp,  although 
it  may  be  the  first  sign  of  this  disease.  In  the  bearded  region  it  generally 
means  the  same,  or  tinea  sycosis,  or  possibly  sycosis  vulgaris  or  lupus 
erythematosus,  or,  if  due  to  previous  ulceration,  syphilis  or  lupus  vul- 
garis. 

Ulceration.— The  diseases  likely  to  be  met  with  in  which  this, 
or  its  result,  scarring,  is  a  feature,  especially  when  on  the  face  or  other 
region,  excepting  the  lower  part  of  the  leg,  are  syphilis,  epithelioma, 
and  lupus  vulgaris,  or  occasionally  other  varieties  of  tuberculosis  cuds; 
syphilis — usually  the  tubercular  or  gummatous  syphiloderm — being 
responsible  for  the  very  large  majority,  lupus  vulgaris  being,  in  this 
country  especially,  relatively  rare.  It  is  true  boils,  carbuncles,  acne, 


102  GENERAL   DIAGNOSIS 

and  other  diseases  already  alluded  to  (see  under  head  of  "Ulcerative" 
Eruptions)  may  produce  destruction  and  scarring,  but  these  are  acci- 
dental, readily  explainable,  or  a  rare  feature.  The  scarring  of  lupus  ery- 
thematosus  is  more  of  the  nature  of  atrophy— no  previous  actual  de- 
struction, as  commonly  understood.  On  the  lower  part  of  the  leg,  in 
addition  to  the  several  diseases  named,  it  may  be  traumatic  or  a  simple 
ulcer,  so  often  present  here,  and  not  infrequently  associated  with  varicose 
veins  and  eczema;  and  it  may  exceptionally  be  due  to  erythema  induratum 
or  other  rare  affection.  As  a  rule,  ulceration  of  this  region  in  those  under 
the  age  of  thirty-five,  if  not  traumatic  or  due  to  varicose  veins,  is  almost 
invariably  of  syphilitic  origin;  occasionally  to  lupus  vulgaris,  and  ex- 
ceptionally erythema  induratum. 

Ring-like  Configuration. — Clearly  cut  annular  patches  or 
rings,  with  partially  or  wholly  normal  central  portion,  are  seen  in  ery- 
thema multiforme  (erythema  annulare,  erythema  iris,  herpes  iris), 
occasionally  in  some  patches  of  psoriasis  and  the  older  patches  of  ring- 
worm and  pityriasis  rosea  (some  patches) ;  with  partially  clear  or  clear- 
ing central  portions — ringworm,  psoriasis,  syphilis,  erythema  multi- 
forme  (especially  some  of  the  older  papules  in  the  papular  type),  and 
both  secondary  (more  especially  in  the  negro)  and  the  late  tubercular 
syphiloderm,  pityriasis  rosea,  dermatitis  seborrhoica  (more  especially 
on  sternal  and  interscapular  regions),  impetigo  contagiosa  (rarely  more 
than  one  or  two  patches),  and  to  a  slightly  developed  extent  in  lupus 
erythematosus.  It  is  also  usually  seen  as  a  part  of  the  eruption  in  the 
erythematous  type  of  dermatitis  herpetiformis,  and  occasionally  in  the 
bullous  form.  Exceptionally  it  may  also  be  observed  in  one  or  several  of 
the  larger  papules  of  lichen  planus,  in  lupus  vulgaris,  and  in  some  patches 
in  extensive  general  urticaria.  On  the  face,  when  of  short  duration,  it 
usually  signifies  ringworm;  syphilis  or  lupus  erythematosus  when  of 
considerable  duration  (the  former  frequently  with  ulceration);  on  the 
hands  or  forearms,  ringworm,  erythema  multiforme  (recent,  either  per- 
fect rings,  as  in  erythema  annulare,  or  merely  with  less  pronounced  fading 
center,  as  in  papular  erythema),  or  tubercular  syphiloderm;  on  the  trunk, 
possibly  the  last  two,  but  about  as  probably  dermatitis  seborrhoica  (cir- 
cinate,  segmental,  and  irregular,  usually  sternal  or  interscapular,  with 
greasy  scales  or  crusts;  recent  or  of  long  duration  with  fluctuations),  pso- 
riasis (in  some  or  many  patches,  but  not  in  all;  clearing  or  clear  center, 
elevated,  inflammatory,  and  scaly  band-like  border,  occasionally  fusing 
and  forming  gyrate  figures;  eruption  also  elsewhere);  or  pityriasis  rosea 
(recent,  slightly  scaly  spreading  rings,  clearing  centrally,  often  fusing, 
along  with  variously  sized,  slightly  scaly  macules).  About  the  genito- 
crural  region,  usually  ringworm.  Granuloma  annulare  is  a  rare  ring-like 
or  crescentic  formation,  most  frequently  seen  on  the  dorsal  surface  of  the 
hand  and  about  the  wrist,  sometimes  elsewhere. 

Segmental  or  Crescentic  Grouping  or  Outline.— This  may 
be  seen  in  the  various  maladies  just  referred  to  except  lupus  erythema- 
tosus and  lichen  planus,  and  especially  in  ringworm  and  psoriasis  as  the 
patches  are  finally  disappearing;  but  most  frequently  points  to  the 
tubercular  syphiloderm  (usually  of  long  duration  and  often  with  ulcera- 


A    CONSPICUOUS  FEATURE  AS  A   DIAGNOSTIC  FACTOR      103 

tion),  and  to  dermatitis  seborrhoica  (usually  on  trunk;  occasionally  on 
scalp;  exceptionally  elsewhere). 

Itching". — Generalized. — This  immediately  suggests  the  possible 
generalized  maladies,  and  the  investigation  most  commonly  leads  to 
a  diagnosis  among  the  diseases,  urticaria,  eczema,  pruritus,  scabies, 
pediculosis  corporis,  sometimes  psoriasis  (itching  cases).  If  such  con- 
clusion is  impossible  after  examination,  then  other  diseases,  such  as 
lichen  planus,  miliaria,  some  medicinal  eruptions,  and  the  rarer  affec- 
tions in  which  this  symptom  is  usually  a  factor  can  be  taken  up.  The 
syphilodermata  do  not  itch;  to  this  statement,  however,  exception  must 
be  noted  as  to  the  negro,  who  often  complains  of  pruritus  in  connection 
with  these  eruptions,  especially  with  the  miliary  papular  and  pustular 
manifestations. 

Localized  itching  as  a  symptom  in  regional  eruptions  is  also  of  some 
value,  the  most  common  maladies  thus  characterized  being  eczema, 
pruritus,  pediculosis  capitis,  pediculosis  pubis,  seborrhea,  and  derma- 
titis sebor-rhoica  (often  absent),  lichen  planus,  urticaria  of  limited  dis- 
tribution (uncommon;  the  eruption  usually  general),  regional  miliaria, 
rhus  poisoning,  and  other  forms  of  dermatitis  venenata,  etc.,  and  also 
in  some  of  the  less  frequent  maladies.  Pompholyx  (hands,  feet,  or 
both)  in  some  cases  is  quite  itchy,  but,  as  a  rule,  the  subjective  symptoms 
are  more  frequently  or  predominantly  those  of  burning  and  soreness. 

Color. — This  has  already  been  partly  considered  under  the  sub- 
heading of  "pigmentary  and  pseudopigmentary"  in  discussing  the 
lesional  types  of  eruption.  The  yellowish  or  fawn  color  of  tinea  versi- 
color;  the  brownish  of  chloasma;  the  bright  red,  not  disappearing  upon 
pressure,  and  changing  through  several  shades  to  yellowish,  of  purpura, 
the  yellowish  to  black  of  the  freckle,  pigmentary  nevus,  etc. — all  are  of 
value  in  leading  to  a  correct  diagnosis.  The  character  of  the  color — 
the  brightness  or  deepness  of  the  red  in  inflammatory  and  other  dis- 
eases— is  sometimes  of  at  least  corroborative  aid  in  limited  or  general 
eruptions,  whether  erythematous,  papular,  or  other  type.  The  brilliant 
red  of  scarlet  fever  and  the  usually  deeper  brilliant  red  of  erythema 
scarlatinoides  are  much  alike,  but  the  shade  of  difference  sometimes 
exists  and  is  recognized  by  the  practised  eye.  The  brighter,  more  in- 
flammatory tint  of  eczema,  psoriasis,  etc.,  as  compared  to  the  sluggish 
red,  coppery,  or  ham  tint  of  the  syphilodermata,  may  also  sometimes 
be  utilized.  The  usually  slight  yellowish  cast  mellowing  the  red  of 
lupus  vulgaris  frequently  may  be  used  as  one  point  of  difference  from 
the  copper  or  ham  tint  of  the  red  of  the  tubercular  syphiloderm.  The 
yellowish  tinge  very  commonly  present  in  dermatitis  seborrhoica  is,  as  a 
rule,  not  observed  in  ordinary  eczema.  The  deep  red,  with  violaceous 
tint,  or  distinctly  purplish  papules  of  lichen  planus,  is  different  from 
other  papular  manifestations.  The  yellow  color  of  the  tubercles  of 
continuous  band  about  the  eyelid  is  characteristic  of  xanthoma,  and 
also  of  the  more  generalized  eruption  exceptionally  seen  in  this  disease  and 
xanthoma  diabeticorum.  The  yellow  color  of  the  friable  crust-masses 
of  favus  is  also  usually  helpful,  sometimes  distinctive. 

The  value  of  these  positive  differences  in  color  is  recognizable  both 


IO4  GENERAL   DIAGNOSIS 

by  the  general  physician  as  readily  as  by  the  expert,  but  for  the  finer 
differences  of  shade  some  training  and  experience  are  necessary. 

Odor.— This  is  occasionally  of  some  value,  as  the  mousy  odor  of 
favus,  the  characteristic  fetid  odor  of  small-pox,  the  often  offensive 
smell  of  the  ulcerative  syphilitic  lesions,  while  that  of  bromidrosis  is 
peculiarly  penetrating  and  disagreeable,  and  that  of  gangrene  usually 
characteristic,  as  also  the  nauseating  odor  of  the  condition  sometimes 
brought  about  in  pediculosis  capitis.  It  is  subject,  however,  to  so 
much  modification,  lessening,  or  intensification,  or  covered  up  by  other 
or  worse  smells,  due  to  the  habits  and  environment  of  the  patient,  that, 
except  as  a  corroborative  factor,  it  is  not  very  reliable. 


GENERAL   REMARKS  ON   TREATMENT 

THE  guiding  principles  in  the  treatment  of  diseases  of  the  skin  differ 
in  no  respect  from  those  which  govern  in  the  management  of  maladies 
of  other  organs.  A  correct  diagnosis  is  essential  except  in  diseases 
running  an  acute  course,  which  get  well  in  spite  of  the  bungling  often 
consequent  upon  error;  but  such  affections  are  not  very  common  in 
dermatologic  practice,  and  usually  a  sine  qua  non  to  success  is  first  to 
know  what  the  disease  is. 

The  proper  diagnosis  in  its  relation  to  therapeutics  does  not  con- 
sist, however,  in  merely  naming  the  disease  correctly,  but  also  includes 
an  appreciation,  so  far  as  possible,  of  the  etiologic  and  pathologic  factors 
in  the  case.  Thus  founded,  treatment  will  be  most  promising  as  to 
results,  especially  as  to  permanency.  It  is  true,  in  most  instances,  that 
it  is  not  always  possible  to  discover  the  true  etiologic  influences,  and  to 
a  great  extent,  therefore,  the  therapeutic  management  is  often  that  which 
practical  experience  has  proved  of  service. 

A  cure,  if  possible,  should  be  brought  about  as  quickly  as  practicable. 
The  belief  of  the  laity  that  impurities  are  trying  to  get  out,  and  that  it  is, 
therefore,  dangerous  to  the  general  health  to  cure  or  to  cure  too  rapidly, 
and  which  formerly  found  honest  believers  among  physicians,  is  wholly 
without  foundation.  This  view  has  been  strongly  supported  pur- 
posely by  advertising  nostrums,  and  has  likewise  been  a  convenient 
cloak  for  medical  advisers  helplessly  at  sea  in  cutaneous  therapeutics. 
On  the  contrary,  the  putting  of  the  skin,  an  important  organ  and  emunc- 
tory  of  the  body,  into  a  healthy  state,  will  not  only  relieve  the  patient 
of  an  annoyance  and  worry,  but  conduce  to  his  general  well-being.1 
The  main  difficulty,  unfortunately,  in  many  diseases  is  our  inability  to 
cure  quickly  enough. 

In  most  diseases  both  local  and  constitutional  measures  are  required. 
There  is  some  diversity  as  regards  the  value  of  internal  medication, 
which  in  times  remote  held  the  prominent  place  in  treatment,  but  which 
was  gradually  displaced  by  those  holding  the  opinion  that  skin  diseases 
are  purely  local  maladies,  with  no  relationship  to  the  general  organism, 
and  therefore  manageable  by  purely  external  measures — a  view  which 
reached  its  greatest  prevalence  under  the  late  Professor  Hebra,  and  is 
still  held  to  a  greater  or  less  extent  by  most  of  the  German  writers,  the 
French,  English,  and  Americans  taking  a  conservative  middle  ground. 
The  strongest  support  of  this  latter  view  is  found  in  the  fact  that  many 
American  specialists,  as  well  as  many  in  England,  spent  a  few  years  under 
the  distinguished  tutelage  of  Hebra,  Neumann,  and  Kaposi,  whose 

1  This  is  also  referred  to  under  Eczema. 

105 


106  GENERAL   REMARKS   ON  TREATMENT 

views  as  to  local  treatment  practically  coincided,  and  returned  home 
thoroughly  imbued  with  this  idea,  but  which,  under  the  test  of  in- 
creasing personal  experience,  has  gradually  given  place  to  the  opinion 
that  while  external  remedies  are  essential  in  almost  all  cases,  the  proper 
constitutional  management  in  many  diseases  is  likewise  important,  and 
that  the  maintenance  of  good  health  keeps  up  the  tissue-resisting  power, 
and  therefore  is  of  potent  influence  in  the  permanency  of  cure  in  cuta- 
neous as  well  as  other  diseases.1  It  is  true  that  many  affections  are 
purely  local,  often  parasitic,  and  that,  therefore,  systemic  measures 
are  scarcely  called  for,  but  in  some  of  these,  doubtless,  cutaneous  tissue 
weakness,  induced  by  general  ill  health  due  to  constitutional  or  organic 
disease,  favors  successful  parasitic  invasion,  and  therefore  systemic  in- 
vigorating measures  are  sometimes  of  service.  This  is  often  demon- 
strated also  in  pulmonary  tuberculosis.  The  various  therapeutic  meas- 
ures and  special  remedies,  both  local  and  constitutional,  will  be  referred 
to,  more  at  length,  in  connection  with  the  individual  diseases.  A  brief 
preliminary  review  of  the  underlying  principles  and  of  some  of  the  chief 
remedies,  may,  however,  be  of  some  service. 


CONSTITUTIONAL  TREATMENT 

For  the  most  part,  in  the  general  constitutional  management  of 
those  diseases  of  the  skin  in  which  this  seems  advisable,  it  is  not  so 
much  to  be  based  upon  the  malady  present  as  it  is  upon  the  patient 
— in  short,  the  individual  is  to  be  studied  rather  than  the  skin  disease 
with  which  he  is  afflicted,  and  in  the  general  run  of  cases  much  more 
is  to  be  expected  than  if  remedies  with  alleged  direct  specific  action 
upon  the  malady  or  the  cutaneous  tissues  are  depended  upon.  Such 
remedies,  though  relatively  few  in  number,  are  not,  however,  com- 
pletely to  be  ignored,  for  they  sometimes  have  a  decidedly  useful  in- 
fluence. As  remarked  in  discussing  the  physiology  of  the  skin,  it  is  to 
be  considered  as  one  of  the  four  emunctories  of  the  body,  and  when  this 
is  diseased  or  its  full  usefulness  compromised,  the  functional  deficiency 
is  partly,  sometimes  completely,  made  up  by  compensatory  activity  of 
the  other  three,  more  especially,  however,  the  kidneys  and  intestinal 
tract;  and,  conversely,  impairment  of  one  of  the  latter  may  indirectly, 
or  possibly  directly,  be  influential  in  provoking  cutaneous  disorders,  as 
referred  to  under  general  etiology,  either  by  the  superinduced  increased 
activity,  or,  and  more  probably,  by  the  action  of  certain  excretory 
products  which  ordinarily  should  find  their  outlet  through  the  kidneys 
or  intestinal  tract.  This  possibility  is  to  be  borne  in  mind  in  the  treat- 
ment. Very  often  in  the  management,  increased  activity  of  the  kidneys 
and  intestinal  tract,  by  remedies  which  increase  the  flow  of  urine,  and 
promote  free  movement  of  the  bowels,  has  a  material  influence  in  lessen- 
ing and  modifying  cutaneous  disturbances,  particularly  those  of  an  in- 

1  Duhring,  "Treatment  of  Certain  Chronic  Inflammatory  Skin  Diseases,"  Jour. 
Cutan.  Dis.,  1909,  p.  379,  has  been  throughout  a  strong  exponent  of  this  view,  and  his 
long  and  large  experience  (as  indicated  in  this  paper)  has  served  to  confirm  him  in  this 
belief. 


CONSTITUTIONAL    TREATMENT  IO/ 

flammatory  character.  The  general  treatment,  therefore,  is  to  keep  in 
view  the  maintenance  of  a  proper  condition  of  the  general  health  of  the 
patient,  and  if  that  be  defective,  be  corrected  or  modified,  if  possible,  by 
suitable  measures  and  remedies.  A  clue  is  sometimes  given  by  the 
amount  or  character  of  the  urine.  In  fact,  all  etiologic  possibilities 
are  to  be  considered.  In  the  absence  of  any  special  indications,  and 
yet  where  the  character  and  extent  of  the  malady,  especially  in  inflam- 
matory affections,  are  strongly  suggestive  of  some  systemic  factor,  the 
family  history  will  often  throw  light  upon  the  possible  underlying  dis- 
ease tendency — diathesis,  or  constitutional  weakness. 

Hygienic  living,  proper  food,  well-ventilated  rooms,  plenty  of  sun- 
light, outdoor  life,  unless  contra-indicated  by  the  weather;  and,  espe- 
cially in  those  of  sedentary  habits,  exercise  in  moderation;  rest  in  some 
diseases  and  cases;  and  sometimes,  when  feasible,  temporary  change 
of  scene  and  climate — are  all  to  be  considered  of  therapeutic  importance. 
As  already  indicated  in  discussing  general  etiology,  in  the  large  majority 
of  cases  commonly  met  with,  digestive  disorders,  such  as  dyspepsia, 
gastric  catarrh,  constipation,  etc.,  are  the  factors  which  most  frequently 
call  for  correction,  and  the  various  known  remedies  for  these  conditions 
accordingly  play  an  important  role. 

The  dietary,  therefore,  is  often  of  importance,  and  sometimes  requires 
supervising  directions.  In  some  affections,  it  is  true, — as,  for  instance, 
taking  the  extreme  examples  of  verruca  and  xanthoma  palpebrarum 
and  the  parasitic  affection,  scabies,  etc., — the  consideration  of  the 
question  of  food  would  be  an  absurdity.  On  the  other  hand,  however, 
the  cases  of  extensively  distributed  eczema,  of  xanthoma  diabeticorum, 
many  instances  of  pruritus,  psoriasis,  acne,  dermatitis  herpetiformis, 
and  others,  improper  feeding  is  often  an  important  factor,  or  at  least 
an  aggravating  influence,  and  its  proper  regulation  requires  attention. 

The  patient  is  not,  however,  to  be  wholly  ignored  in  this  considera- 
tion: his  tastes,  wants,  and  idiosyncrasies  are  to  be  consulted,  for  some- 
times articles  of  food  usually  readily  digested  by  others  may,  in  individual 
instances,  be  not  only  distasteful,  but  disturbing  and  fermentative. 
As  a  rule,  the  well-to-do  class  consumes  too  much  nitrogenous  food, 
and  this  is  not  infrequently  a  more  or  less  damaging  factor  in  some  of  the 
inflammatory  diseases.  Even  with  this,  however,  an  extreme  position 
is  generally  unwarrantable,  for  there  are  cases  encountered  in  which 
gastric  weakness  is  a  cause,  and  in  which  starches  are  badly  borne,  the 
stomachic  condition  being  overcome  or  palliated  by  chiefly  a  meat  diet, 
the  eruption  often  undergoing  perceptible  improvement  as  the  digestion 
is  thus  improved.  In  other  cases  a  purely  milk  diet  can  be  employed  for 
a  time  with  benefit;  or,  more  frequently,  conjointly  with  meat  once  daily. 
The  use  of  alcohol  is,  in  the  inflammatory  affections,  particularly  eczema, 
prejudicial  and  directly  damaging,  and  should  be  interdicted  or  at  least 
limited,  depending  upon  the  habits  and  needs  of  the  patient — as,  for 
instance,  in  the  old  and  feeble.  The  excessive,  and  sometimes  moderate, 
use  of  tea,  coffee,  and  tobacco  is  likewise  to  be  prohibited.  As  to  par- 
ticular foods,  those  of  difficult  digestion,  and  others  concerning  which 
there  may  be  a  possibility  of  unfavorable  influence,  are  best  avoided;  and 


IO8  GENERAL   REMARKS   ON  TREATMENT 

among  such  may  be  named  pork  in  all  forms,  especially  sausage  and 
scrapple,  lobsters,  crabs,  clams,  oysters  (except  in  cold  winter  season), 
and  other  "shell-fish,"  veal,  fish,  pastries  of  all  kinds,  fresh  breads, 
"hot  cakes,"  waffles,  cheese,  dressed  salads,  acid  fruits,  seeded  and  acid 
berries,  pickles,  usually  condiments,  except  in  moderation,  nuts,  and 
sweets;  potatoes  in  excess,  cauliflower,  cabbage,  and  onions  are  likewise, 
especially  in  some  individuals,  often  detrimental.  The  cereal  foods  may 
ordinarily  be  taken  in  moderation,  with  milk  or  cream  and  salt,  if  desired, 
but  ordinarily  with  no  sugar. 

General  tonics,  both  simple  and  nutritive,  as  readily  to  be 
inferred  from  etiologic  considerations,  are  often  useful  in  certain  skin 
diseases  in  which  debility  or  loss  of  general  tone  is  an  influence,  as 
often  in  eczema,  pompholyx,  seborrhea,  acne,  and  other  affections. 
Anemic  conditions  are  met  with — iron,  manganese,  sometimes  small 
doses  of  arsenic  and  the  hypophosphites;  quinin  and  strychnin  are 
also  indirectly  not  infrequently  of  service.  The  most  valuable  general 
nutritive  tonic,  however,  in  some  cases,  is  cod-liver  oil  in  small  or  moder- 
ate dosage.  The  digestives  and  ordinary  bitter  digestive  tonics,  some- 
times with  an  acid,  sometimes  with  an  alkali,  by  their  influence  on  diges- 
tion are  often  of  service  in  promoting  general  invigoration ;  frequently 
such,  with  a  laxative,  as  required  to  keep  the  bowels  free,  will  be  all  that 
seems  necessary  or  indicated. 

Aperients  find  more  than  occasional  use  in  cutaneous  disease, 
and  the  maintenance  of  a  free  action  of  the  bowels,  especially  in  the 
inflammatory  affections,  cannot  be  overestimated,  as  aiding  in  getting 
rid  of  toxic  products,  and  usually  improving  digestion  as  well.  Ex- 
cept in  anemic  individuals,  the  salines  are  usually  to  be  preferred;  they 
are  given  in  dosage  sufficient  to  produce  free  action,  but  not,  except 
rarely,  active  purgation.  As  a  frequent  or  daily  saline,  magnesium 
sulphate  is  probably  the  best,  often  usefully  given  with  iron,  as  in  the 
"mistura  ferri  acida,"  but  sodium  sulphate,  sodium  phosphate,  and  the 
various  natural  aperient  mineral  waters  are  likewise  valuable.  Calomel, 
usually  in  quickly  following  small  doses,  administered  at  intervals  of 
several  days  or  more,  can  sometimes  be  employed  with  advantage, 
especially  if  there  is  suspected  torpidity  of  the  liver.  One  of  the  most 
valuable  laxatives,  as  an  occasional  one,  is  the  antacid  magnesia,  particu- 
larly valuable  when  gastro-intestinal  toxin  development  is  probable. 
Among  the  vegetable  laxatives  cascara,  as  the  extract  or  fluid  extract,  is, 
in  my  judgment,  the  most  useful,  although  the  other  well-known  drugs 
are  often  used.  For  infants  and  young  children  castor  oil,  cascara,  and 
gray  powder  are  the  most  serviceable.  Plain  enemata,  often  used,  both 
in  infants  and  adults,  as  a  rule  are  not  to  be  commended  except  as  a 
temporary  measure,  although  in  some  instances  in  adults  an  occasional 
full  flushing  out  of  the  lower  bowel  may  prove  beneficial. 

Gastro-intestinal  antiseptics  are  of  considerable  value  in 
some  instances  of  eruptions  seemingly  due  to  auto-intoxication,  as 
urticaria,  erythema  multiforme,  some  cases  of  eczema,  etc.  Among 
those  that  may  often  be  used  with  advantage  are  the  laxative  antacid 
magnesia,  minute  doses  of  calomel  administered  at  half-hour  intervals 


CONSTITUTIONAL    TREATMENT 


109 


every  several  days,  charcoal,  salol,  sodium  salicylate,  minute  doses  of 
carbolic  acid,  and  some  others. 

Diuretics. — These  are  often  useful,  and  the  free  action  of  the 
urinary  flow  thus  promoted,  together  with  occasional  laxatives,  often 
proves  very  serviceable  in  some  of  the  inflammatory  and  hyperemic 
affections.  They  can  often  be  employed  with  advantage  especially 
in  eczema,  psoriasis,  markedly  inflammatory  acne,  and  acne  rosacea, 
dermatitis  exfoliativa,  dermatitis  herpetiformis,  and  like  inflammatory 
disorders.  The  saline  diuretics  are,  upon  the  whole,  the  best,  and 
in  this  class  potassium  acetate  and  potassium  bicarbonate.  These 
are  also  valuable  antilithemic  remedies,  and  it  is,  as  a  rule,  especially 
in  cases  with  this  etiologic  basis,  that  they  are  found  most  useful.  In 
such  cases,  too,  sodium  salicylate,  ammonium  salicylate,  salophen,  etc., 
often  find  an  important  place.  In  pruritus  and  other  neurotic  affections 
small  doses  of  belladonna  can  be  conveniently  used  conjointly,  as  this 
also  has  diuretic  action,  as  well  as  other  influence.  Other  vegetable 
diuretics  are  also  sometimes  given.  In  all  instances  water  should  be 
taken  freely,  as  this  in  itself  is  a  good  diuretic.  Possibly  the  influence 
of  oil  of  turpentine,  oil  of  copaiba,  etc.,  noted  occasionally  in  a  few  dis- 
eases, may  be  due,  in  a  measure  at  least,  to  diuretic  action. 

General  Alteratives.— All  remedies,  whether  simple  tonics,  di- 
gestives, etc.,  which  improve  nutrition  are  naturally  to  be  classed  as 
general  alteratives,  but  the  drugs  referred  to  here  are  those  which  possess 
this  property  independently  of  such  influence.  The  chief  alteratives 
of  this  class  are  the  mercurials,  iodin  preparations,  and  the  animal  ex- 
tracts. It  is  not  unlikely  that  the  alleged  alterative  effect  of  some  of 
these  drugs  may  in  fact  be  attributable  to  their  germicidal  influence,  as 
referred  to  further  on.  There  can  be  no  question  of  the  value  of  mer- 
cury in  both  the  early  and  late  stages  of  syphilis,  and  of  the  iodids  in  the 
late  syphilitic  manifestations,  for  the  evidence  of  eruptions  quickly  melt- 
ing away  under  their  influence  is  overwhelming.  As  will  also  be  seen  in 
the  course  of  the  text,  the  iodin  preparations  are  not  without  effect  in 
some  cases  of  strumous  affections.  The  favorable  action  of  the  iodid  salts 
in  actinomycosis  and  blastomycetic  dermatitis  is  also  attested;  its  in- 
fluence in  large  doses  in  some  cases  of  psoriasis  is  undoubted,  but  whether 
from  alterative  action  or  its  effect  as  an  alkaline  salt  is  not  definitely 
known.  The  potassium  iodid  is  the  salt  most  commonly  prescribed,  but 
in  my  own  experience  sodium  iodid  is  just  as  effectual  in  syphilis,  and  less 
apt  to  be  disturbing.1  Arsenic  is  also  a  valuable  alterative. 

The  preparation  of  the  mercurial  to  prescribe  is  greatly  a  matter 
of  prejudice  or  personal  custom.  The  protiodid  for  active  administra- 
tion in  the  early  eruptions  of  syphilis,  and  the  biniodid  in  association 
with  potassium  or  sodium  iodid  salt  in  the  late  syphilodermata,  are  prob- 
ably in  most  general  use,  and  are  those  which  I  usually  prefer.  In 
the  later  stages,  however,  corrosive  sublimate  is  likewise  a  favorite 
remedy  with  many.  Mouth  administration  is  usually  satisfactory, 
but  cases  are  encountered  which  dfl  not  seem  to  yield  to  this  plan, 
and  in  such,  inunctions  with  blue  ointment  are  generally  curative. 
1  See  Dermatitis  medicamentosa. 


HO  GENERAL   REMARKS   ON  TREATMENT 

The  hypodermic  method  is  a  favorite  plan  with  some.  This  remedy  is 
likewise  found  useful  in  some  cases  of  lichen  planus  and  a  few  other 
affections. 

Tar  and  carbolic  acid  are  also  remedies  which  occasionally  appear 
to  possess  alterative  properties,  and  are  sometimes  prescribed  for  this 
purpose,  especially  in  psoriasis  and  eczema.  The  same  may  be  said 
of  phosphorus,  which,  in  T^  to  -^  grain  (0.0007  to  °-°°35  gm-)  dose 
thrice  daily,  in  pill  or  oily  solution,  is  sometimes  prescribed  for  lupus 
erythematosus,  lupus  vulgaris,  and  other  diseases.  It  presumably 
acts  through  the  nervous  system,  but  there  is  no  uniformity  of  opinion 
as  to  its  value;  it  has  practically  no  place  in  treatment  with  the  large 
majority  of  dermatologists.  In  one  or  two  instances  of  erythema  indura- 
tum  it  seemed  to  me  of  value;  and  in  zoster,  zinc  phosphid,  from  -^  to  \ 
gram  (0.007  to  0.014  gm-)  f°ur  or  nve  times  daily,  is  sometimes  of  dis- 
tinct service.  Antimony,  warmly  supported  by  Malcolm  Morris  for 
acute  and  subacute  inflammatory  diseases  in  robust  individuals,  notably 
in  eczema  and  psoriasis,  is  prescribed  in  dosage  of  from  3  to  10  minims 
or  more  of  the  wine  three  or  four  times  daily.  Although  this  remedy 
is  also  somewhat  favorably  referred  to  by  Crocker,  Duhring,  and  a  few 
others,  it  is  not  in  very  general  use,  probably  owing  to  the  care  required 
in  its  continued  administration,  lest  depressing  or  other  untoward  action 
should  result.  Turpentine  has  been  advised  in  the  same  affections  by 
Crocker,  to  be  given  conjointly  with  free  diluent  drinks.  Copaiba, 
according  to  my  observations,  occasionally  acts  favorably  in  the  same 
class  of  cases.  It  is  probable  that  the  last  two,  in  addition  to  some 
general  alterative  action,  benefit  by  their  diuretic  effect  as  well  and  pos- 
sibly also  have  some  special  alterative  influence  directly  upon  the  cuta- 
neous structures.  Quinin,  which  is  sometimes  apparently  useful  in  ery- 
thema multiforme,  erythema  nodosum,  herpes  zoster,  eczema,  and  other 
diseases,  especially  if  there  is  an  underlying  malarial  element,  might 
also  be  included  in  this  class. 

Animal  extracts  have  lately  been  playing  an  important  experi- 
•  mental  role  in  cutaneous  therapeutics,  as  well  as  in  other  branches 
of  general  medicine,  and  that  some  have  a  general  alterative  influence, 
as  well,  possibly,  as  a  special  alterative  action,  cannot  be  denied;  the 
action  is  not,  however,  a  regular  one,  but,  on  the  contrary,  exceptional. 
Thyroid  extract  has  proved  valuable  in  myxedema,  and  occasionally  has 
some  influence  in  cases  of  psoriasis,  and  has  also  been  employed  with 
alleged  benefit  in  lupus  vulgaris  and  other  chronic  diseases,  but  its 
possible  untoward  effects  have  limited  its  use.  The  dose  of  the  desic- 
cated extract,  as  furnished  in  tablet  form,  varies  from  \  to  10  grains 
(0.035  to  0.65  gm.)  or  more  three  times  daily,  always  beginning  with 
moderate  doses,  and,  if  necessary,  increasing,  but  cautiously.  A  glycerin 
extract  is  also  made.  Suprarenal  gland  extract  has  recently  been  ex- 
tolled for  vitiligo. 

Special  Alteratives — The  influence  of  the  various  remedies  men- 
tioned under  Germicides,  as  well  as,  some  of  those  under  General  Altera- 
tives and  other  heads,  might  also  possibly  be  due  to  special  alterative 
or  direct  action  upon  the  skin,  but  the  chief  exponent  of  this  class,  which 


CONSTITUTIONAL    TREATMENT  III 

might  likewise  be  termed  "special  cutaneous  stimulants,"  is  arsenic,1' 
when  administered  in  dosage  to  get  its  special  effects,  and  which  Ts 
entirely  distinct  from  its  use  in  small  doses  as  a  general  tonic.  This  drug/_ 
probably  acts  both  directly  and  through  the  nervous  system,  and  par- 
ticularly,  as  shown  in  the  experiments  by  Ringer,  Murrell,  Nunn,  and  ' 
others,  upon  the  epithelial  layers.  Clinical  observation,  both  as  to  its 
therapeutic  action  and  toxic  effects,  is  corroborative  of  these  observations.2 
It  is  likewise  to  be  considered  a  potent  nerve  stimulant,  and  therefore  also 
of  possible  value  in  some  diseases  of  neurotic  origin.  It  is  a  remedy  which 
is  more  especially  indicated  in  the  superficial  dermatoses.  Like  most 
remedies  which  possess  some  certain  value,  it  was  formerly  given  almost 
the  standing  of  a  panacea,  Hunt  being  one  of  its  most  extreme  ad- 
vocates; and  following  this  comes  the  rebound,  and  in  comparatively 
recent  years  there  has  been  a  tendency  with  some  dermatologists  to 
belittle  its  value  and  set  it  aside,  but  this  is,  in  my  judgment,  just  as 
unwarranted  as  the  other  extreme.  It  is,  it  is  true,  still  much  overrated 
by  the  general  profession,  who  often  prescribe  it  indiscriminately,  fre- 
quently upon  the  basis  of  a  "skin  disease,"  and  much  harm  thus  results. 
Its  chief  value,  upon  the  whole,  is  in  sluggish  and  sluggishly  inflam- 
matory cases  of  cutaneous  disease,  those  which  originate  in  the  epithelial 
layers  or  in  which  these  are  prominently  involved,  as  psoriasis,  lichen 
planus,  and  a  limited  number  of  persistent  dry  eczemas;  and  also  in  those 
diseases  of  neurotic  character,  as  pemphigus,  dermatitis  herpetiformis, 
and  some  others. 

Jaborandi,  or  its  active  ingredient,  pilocarpin,  is  sometimes  of  value 
in  cases  in  which  benefit  is  to  be  derived  from  stimulation  of  the  sweat 
function,  as  in  the  dry,  scaly  diseases,  ichthyosis,  psoriasis,  etc.  Cal- 
cium sulphid,  sulphur,  elsewhere  referred  to,  and  some  other  remedies 
have  also  been  accredited  with  special  alterative  action  in  certain  dis- 
eases, the  sulphur  preparations  especially  in  the  diseases  of  the  glandular 
structures. 

Germicides. — While  probably  no  remedy  administered  internally 
is  distinctly  germicidal,  there  are,  doubtless,  some  which,  in  a  few  dis- 
eases, in  some  manner,  make  the  body  and  its  tissues  an  unfavorable 
habitat  for  micro-organisms,  or  which  are  antidotal  to  their  products. 
We  know  that  the  value  of  quinin  in  malaria  is  based  upon  this  fact, 
and  it  is  scarcely  to  be  doubted  that  mercury  and  arsenic  (salvarsan) 

1  Sodium  cacodylate  and,  more  recently,  atoxyl — arsenical  preparations — have  been 
variously  extolled  as  valuable  substitutes  for  the  ordinary  preparations;  their  alleged 
lessened  possibility  of  producing  toxic  action  being  lauded.     They  have  some,  probably 
an  equal,  value,  but  observations  do  not  support  the  early  published  statements  of 
marked  superiority.     Salvarsan  has  recently  largely  supplanted  these  preparations. 

2  In  a  recent  elaborate  and  exhaustive  paper  on  "The  Action  of  Arsenic  on  the  Skin 
as  Observed  in  the  Recent  Epidemic  of  Arsenic  Beer-poisoning,"  Brit.  Jour.  Derm., 
1901,  p.  121  (with  many  case  and  histologic  illustrations,  review  of  the  subject,  and 
references),  Brooke  and  Leslie  Roberts  conclude  as  follows:    "In  the  face  of  the  facts 
which  we  have  endeavored  to  place  before  the  reader,  we  have  no  hesitation  in  saying 
that  arsenic,  and  the  other  members  of  the  nitrogen  group,  must  be  distinguished  from 
all  other  medicaments  by  the  fact  that  their  action,  whether  therapeutic,  pharmaco- 
logic,  or  toxicologic,  is  entirely  dynamic,  and  consists  essentially  in  altering  the  ratio  to 
the  tissues  of  one  of  the  most  active  normal  ingredients  of  the  body — namely,  oxygen." 
See  also  Dermatitis  medicamentosa  for  toxic  effects  upon  the  skin  and  for  other  litera- 
ture references. 


112  GENERAL   REMARKS   ON  TREATMENT 

Cactpthe  same  way  in  syphilis.  It  is  not  improbable  that  other  remedies 
strikingly  useful  in  other  diseases  may  owe  part  of  their  success  to  this 
Action.  Cod-liver  oil  often  seems  to  have  this  property,  independently  of 
its  nutritive  influence.  Sulphur,  owing  to  its  exhalation  through  the  skin, 
internally,  may  also  possibly  have  a  slight  influence  in  lessening  the  hold 
of  cutaneous  micro-organisms,  as  in  the  alleged  favorable  action  of 
calcium  sulphid  in  boils,  seborrhea,  acne,  etc.  It  has  appeared  to  me 
that  those  whose  skin  has  naturally  more  or  less  of  a  sulphurous  exhala- 
tion, as  shown  by  the  rapidity  with  which  silver  or  silver-containing 
jewelry  is  tarnished,  are  less  liable  to  exhibit  such  parasitic  diseases  as 
tinea  versicolor,  ringworm,  etc.,  and  on  this  supposition  its  administra- 
tion in  such  affections  may  be  an  advantage  conjointly  with  the  proper 
local  treatment. 

Tuberculin  and  other  prepared  toxins  or  vaccines  are  remedies  or 
agents  whose  anticipated  effects  were  presumably  based  upon  some 
germicidal  or  antidotal  properties.  It  is  well  known  that  in  recent 
years  the  hypodermic  injections  of  "tuberculin"  for  lupus  vulgaris 
and  the  other  forms  of  cutaneous  tuberculosis  have  been  employed, 
and  sometimes  with  a  decided  effect  upon  the  disease,  which  is  more 
fully  referred  to  in  connection  with  these  maladies.  The  uncertain 
and  variable  effect,  however,  of  this  and  other  prepared  toxins,  or  vac- 
cines, gradually  led  to  their  practical  abandonment;  but  in  the  past 
few  years,  chiefly  through  the  enthusiastic  work  of  WVight  and  others,1 
who  have  endeavored  to  place  their  employment  upon  a  scientifically 
exact  bases,  various  "vaccines"  are  again  being  cautiously  and  tentatively 
tried  in  several  dermatoses.  Wright  found  by  experimental  investiga- 
tion in  certain  diseases,  as,  for  instance,  sycosis,  furunculosis,  acne, 
tuberculosis,  and  a  few  others,  that  the  phagocytic  power  of  the  blood 
was  reduced,  and  that  this  was  neither  due  to  the  serum  nor  to  the 
leukocytes,  but  to  the  diminution  of  some  unknown  constituents,  which 

1  Literature,  Wright  and  Douglass,  "An  Experimental  Investigation  of  the  Role 
of  the  Blood  Fluids  in  Phagocytosis,"  Proceedings  of  the  Royal  Society  of  London,  1903, 
vol.  Ixxii,  p.  357  and  1904,  vol.  Ixxiii,  p.  128;  Potter,  Ditman,  and  Bradley,  "The 
Opsonic  Index  in  Medicine,"  Jour.  Amer.  Med.  Assoc.,  1906,  pp.  1722  and  1793  (with 
review  of  important  papers  and  complete  bibliography);  Houghton,  "A  Review  of  the 
Opsonins  and  Bacterial  Vaccines,"  Therapeutic  Gazette,  January  15,  1907  (with  com- 
plete bibliography);  Fernet  and  Bunch,  "The  Opsonic  Treatment  of  Certain  Diseases 
of  the  Skin,"  Brit.  Jour.  Derm.,  1906,  pp.  339,  307,  and  427;  and  Houston  and  Rankin, 
"The  Blood  in  Relation  to  Skin  Diseases,"  Brit.  Med.  Jour.,  October  6,  1906;  Gilder- 
sleeve  (Monthly  Encyclopedia  of  Practice  of  Medicine,  September,  1907)  gives  a  clear 
account  of  the  technique;  A.  E.  Wright,  "Principles  of  Vaccine  Therapy,"  Jour.  Amer. 
Med.  Assoc.,  1907,  vol.  xlix,  p.  479;  Potter,  "Further  Observations  on  Opsonins  in 
Normal  and  Pathologic  Sera,"  ibid.,  p.  1815;  Varney,  "Opsonic  Therapy  in  Skin 
Diseases,"  ibid.,  pp.  316,  487,  and  567;  "Inoculation  of  Polyvalent  Staphylococcic 
Suspensions  in  Staphylococcic  Infections  of  the  Skin,"  ibid.,  vol.  liii,  1909,  p.  680; 
Whitfield,  "The  Opsonic  Method  in  Skin  Diseases,"  Jour.  Cutan.  Dis.,  1907,  p.  529; 
Von  Eberts,  "Bacterial  Inoculation  in  the  Treatment  of  Suppurative  and  Tuberculous 
Diseases  of  the  Skin  after  the  Method  of  Wright."  ibid.,  p.  538;  and  Schamberg, 
Gildersleeve,  and  Harlan  Shoemaker,  "Bacterial  Injections  in  the  Treatment  of  Dis- 
eases of  the  Skin,"  ibid.,  p.  544;  Engman,  "Bacteriotherapy  in  Certain  Diseases  of  the 
Skin,"  ibid.,  1910,  p.  553;  Gilchrist,  "Vaccine  Therapy  as  Applied  to  Skin  Diseases," 
ibid.,  p.  568;  Towle  and  Lingenfelter,  "Vaccine  Therapy  in  the  Treatment  of  Diseases 
of  the  Skin  at  the  Massachusetts  General  Hospital."  ibid.,  1910,  p.  583;  King  Smith, 
"The^Relationship  of  Vaccine  Therapy  to  the  Treatment  of  Certain  Diseases  of  the 
Skin,"  Jour.  Cutan.  Dis.,  1911,  p.  432  (see  under  Acne  for  other  references). 


CONSTITUTIONAL    TREATMENT  113 

he  called  "opsonins,"  and  further,  that  the  hypodermic  injection  of  an 
appropriate  "vaccine"  would  influence  the  quantity  or  activity  of  the 
''opsonins,"  and  have  an  effect  upon  phagocytosis,  and  indirectly  upon 
the  disease.  If  the  dosage  of  the  vaccine  was  correct,  the  "opsonic" 
power  of  the  blood,  and  consequently  phagocytosis,  was  increased,  and 
by  a  series  of  proper  dosages  could  be  brought  up  to  normal  and  exert 
a  favorable  curative  action;  but  on  the  other  hand  too  large  a  dosage 
would  still  further  decrease  the  "opsonins"  and  thus  lessen  the  phago- 
cytic  power  and  probably  have  an  intensifying  effect  upon  the  disease. 
This  opsonic  action  was  believed  to  be  due  to  some  alteration  in  the  mi- 
crobes which  permits  their  being  ingested  by  the  leukocytes ;  but  the  effect 
is  now  attributed  to  an  increase  and  stimulation  of  the  "antibodies." 
He  devised  a  method  (a  modification  of  Leishman's  method)  of  measuring 
the  opsonic  power  of  the  blood  which  need  not  be  detailed  here,  and  by 
doing  this  from  time  to  time  he  was  enabled  by  this  "opsonic  index"  to 
reach  an  approximately  correct  dosage,  and  also  to  regulate  its  frequency; 
and  in  the  various  diseases  named,  as  stated  by  him  and  a  few  other 
observers,  the  curative  influence  was  striking.  As  is  readily  inferred, 
therefore,  if  "vaccine"  treatment  of  any  disease  is  determined  upon,  the 
first  doses  should  be  the  smaller,  and  subsequent  doses,  as  well  as  fre- 
quency, regulated  by  a  study  of  the  "opsonic  index."  ' 

Vasomotor  ConstringentS. — Several  drugs  are  credited  with 
this  action  upon  the  cutaneous  vessels,  leading  to  their  contraction  and 
the  reduction  of  hyperemia.  They  are  more  especially  employed  in 
acne  rosacea,  and  less  frequently  in  purpura,  pruritus,  and  a  few  other 
affections.  Ergot  is  sometimes  prescribed  for  this  purpose,  principally 
in  acne  rosacea  and  purpura,  usually  in  moderate  dosage.  It  has  also 
been  used  in  ordinary  acne,  where  lack  of  tone  in  the  muscular  fibers  of 
the  skin  is  suspected.  Inasmuch,  however,  as  there  is  in  these  cases  often 
gastric  irritability  or  digestive  weakness,  which  the  drug  frequently  seems 
to  increase,  its  field  of  usefulness  is  somewhat  restricted.  Ichthyol  has 
been  highly  extolled,  especially  by  Unna,  for  promoting  vasomotor  con- 
traction, and  as  especially  useful  in  acne  rosacea,  and  also  in  such  affec- 
tions as  lupus  erythematosus  and  other  hyperemic  diseases.  It  is  usually 
administered  in  capsules,  3  to  15  minims  or  more  three  times  daily,  but 
opinion  as  regards  its  value  as  a  constitutional  remedy  is  by  no  means 
unanimous.  My  own  observations  do  not  give  it  very  high  rank. 
Thiol  has  also  been  suggested  as  possessing  the  same  properties  as 
ichthyol. 

Analgesics Antipruritics.—  It  may  be  stated,  as  a  rule,  that 

in  the  inflammatory  dermatoses  most  drugs  known  as  analgesics  are 
often  of  aggravating  influence  in  their  after-effects;  less  frequently 
they  are  directly  damaging.  This  scarcely  holds  true,  however,  in  such 
diseases  as  herpes  zoster,  which  sometimes,  on  account  of  the  neuralgic 
pain,  requires  the  administration  of  such  remedies.  In  this  malady 
opium  or  morphin  can  be  used  if  deemed  advisable,  but  in  others,  espe- 

1  More  recently,  most  observers  have  dispensed  with  the  opsonic  test,  owing  to 
its  difficulties  and  tediousness,  and  to  the  belief  that  the  effect  of  one  or  two  trial 
doses  gives  sufficient  indication  as  to  frequency  of  administration  and  quantity. 

8 


114  GENERAL   REMARKS   ON  TREATMENT 

daily  those  of  itchy  character,  it  is  apt  in  its  later  influence  to  increase 
this  symptom.  The  safest  drugs  to  employ  for  the  pruritus,  when  neces- 
sary, as  it  sometimes  is,  to  procure  a  night's  rest,  are  the  bromids  and 
chloral;  belladonna,  gelsemium,  phenacetin,  and  antipyrin  may  also  be 
used  for  this  purpose,  and  in  some  cases  lupulin  in  full  doses  may  be 
tried.  Upon  the  whole,  'however,  they  are  best  avoided  if  possible; 
relief  from  the  itching  can  usually  be  obtained  by  certain  local  applica- 
tions, to  be  referred  to. 

Natural  Mineral  Waters.— The  use  of  the  stronger  natural 
aperient  waters  has  already  been  incidentally  referred  to;  their  good 
effects  are  due  to  their  laxative  action.  The  milder  aperient  waters, 
usually  taken  at  the  various  springs,  have  the  same  influence,  but,  in 
addition,  the  large  quantities  taken  serve  to  keep  the  kidneys  in  free 
action  as  well,  and  thus  act  in  two  ways.  The  value  of  the  alkaline  waters 
taken  freely  is  undoubted,  but  whether  of  any  more  service  than  the  ad- 
ministration of  ordinary  alkalies  with  plenty  of  drinking-water  is  some- 
what problematic.  The  iron  waters  and  arsenic  waters  are  also  well 
known,  and  as  substitutes  for  the  ordinary  drugs  have  a  value,  and  the 
same  may  be  said  of  the  sulphur  waters,  in  which  laxative  influence  and 
alterative  and  probably  antilithemic  action  are  combined;  but  these 
waters  are  not  useful  in  gastric  catarrh  or  dyspeptic  cases.  Inasmuch 
as  the  underlying  factor  in  many  cases  is  a  gastro-intestinal  catarrhal 
or  digestive  disturbance,  usually  with  constipation,  the  most  useful 
spring  waters,  on  the  whole,  are  those  of  alkaline  and  slightly  laxative 
character.  These  are  also  beneficial  in  underlying  rheumatic  conditions. 
The  moderately  active  laxative  waters  of  an  alkaline  character  are  more 
especially  to  be  preferred  with  bans  vivants — those  who  have  been  storing 
up  the  effects  of  overfeeding  and  overdrinking. 

No  one  can  doubt  the  favorable  influence  of  the  natural  spring  waters 
if  taken  liberally,  for  the  reasons  given,  but  taken  at  home,  their  effect 
is  relatively  nil  compared  to  the  influence  gained  at  the  resorts  them- 
selves, where,  in  addition  to  the  free  drinking  of  a  mildly  therapeutic 
water,  are  conjoined  usually  a  rigorous  dietary  supervision  and  the  un- 
questioned effect  of  change  of  scene,  climate,  release  from  care,  etc. 
These  last  are  the  influential  factors  at  drinking  springs;  the  medicinal 
ingredients  of  the  water  are  the  least  potent  in  the  final  effect  gained. 

Simon1  has  made  favorable  reports  of  the  value  of  injections  of  sea- 
water  in  skin  diseases,  but  others,  among  whom  C.  J.  White,2  have  not 
been  able  to  corroborate  this  alleged  favorable  action. 

Electricity — The  general  tonic  and  alterative  action  of  general 
faradism,  galvanism,  or  static  insulation  or  shock  can  sometimes  be 
made  use  of  with  advantage  in  cutaneous  diseases  associated  with  lack 
of  nervous  tone,  especially  galvanism  and  static  electricity.  Shoemaker, 
Brocq,  and  one  or  two  others  are  the  only  ones  who  have  given  much 
attention  to  the  advantages  of  electrization,  an  adjuvant  in  the  manage- 
ment of  some  cases  which,  from  my  own  experience  with  its  use,  I  can 

1  Robert  Simon,  "Applications  therapeutiques  de  1'eau  de  mer,"  Paris. 

C.  J.  White,  "Injections  of  Sea-water  in  Skin  Diseases,"  Boston  Med.  Sure.  Jour., 
July  29,  1909. 


LOCAL    TREATMENT  115 

indorse.  In  some  cases  of  eczema,  urticaria,  pruritus,  and  other  mala- 
dies or  cases  showing  neurotic  relationship  its  influence  is  sometimes  con- 
siderable. 

LOCAL  TREATMENT 

As  a  rule,  in  cutaneous  diseases  external  applications  are  necessary 
both  for  the  favorable  or  curative  action  exerted  upon  the  malady  itself, 
as  well  as  for  the  relief  of  the  accompanying  itching  or  other  troublesome 
subjective  symptoms.  External  treatment  is,  therefore,  of  great  im- 
portance, and  generally  much  more  essential  for  immediate  relief  than 
systemic  remedies,  although  in  many  affections,  as  already  stated,  a 
judicious  blending  of  the  two  will  give  far  more  satisfactory  permanent 
results  in  the  aggregate  than  local  measures  alone.  It  is  true  some  of 
those  running  an  acute  short  course,  and  some  of  the  chronic  disturb- 
ances,— relatively  few  in  number,  however, — are  not  influenced  by 
external  treatment,  and  unless  demanded  by  annoying  itching,  burning, 
or  pain,  local  applications  are  unnecessary. 

The  measures  employed  in  the  external  management  of  skin  diseases 
are  varied,  and  are  mentioned  with  more  or  less  detail,  and  their  special 
manner  of  employment  described  in  connection  with  the  diseases  in 
which  they  are  employed,  each  more  particularly  in  that  disease  wherein 
the  method  or  drug  finds  its  most  prominent  employment.  To  avoid 
unnecessary  repetition,  but  brief  reference  in  a  general  way  will,  therefore, 
be  made  here,  and  only  to  those  most  commonly  resorted  to.  The  essen- 
tial underlying  principles  of  external  treatment  should  be  mild,  soothing, 
and  protective  applications  for  acutely  inflamed  surfaces;  similar  prepara- 
tions in  the  early  part  of  the  treatment  of  subacute  inflammatory  types, 
moderately  stimulating  for  those  of  sluggishly  subacute  or  with  slight 
infiltration,  and  actively  stimulating  for  thickened,  infiltrated,  sluggish 
areas.  Various  modifications  are  often  required  to  suit  the  individual 
case.  Fortunately,  most  of  the  remedies  thus  employed  are  antiseptic, 
and  this  is  a  very  important  factor  in  cutaneous  therapeutics. 

Water. — Baths. — Water  is  employed  for  two  purposes — cleanli- 
ness and  to  remove  the  products  of  disease.  As  a  general  rule,  in  acute 
inflammatory  disease,  notably  in  many  cases  of  eczema,  it  is  prejudicial, 
and  its  use,  therefore,  restricted  as  much  as  is  consistent  with  the  require- 
ments just  stated;  in  some  instances  of  acute  irritability  its  place  must 
be  taken  by  some  cleansing  oil  or  grease,  such  as  olive  oil,  almond  oil, 
cold  cream,  or  vaselin.  A  thorough  soaking  with  one  of  these,  especially 
the  oils,  will  usually  soften  crusts  or  scales  rapidly  and  facilitate  their 
removal;  sometimes  the  parts  must  be  kept  bathed  with  it  by  means  of 
compresses,  and  renewed  from  time  to  time.  In  such  instances  water  can 
almost  be  dispensed  with  or  used  only  at  intervals.  Rain  water  or  boiled 
water  is  less  irritating  than  ordinary  water. 

In  some  of  the  hyperemic  and  more  acute  diseases,  and  in  chronic 
diseases  of  a  somewhat  acute  or  subacute  type,  such  as  dermatitis 
exfoliativa  and  some  cases  of  eczema,  baths  made  mucilaginous  with 
gelatin  (about  \  to  i|  ounces  to  the  gallon),  starch  (about  \  to  i  ounce 
to  the  gallon),  bran  (about  i  or  2  ounces  to  the  gallon),  are  usually 


Il6  GENERAL   REMARKS   ON  TREATMENT 

soothing  in  character,  and  sometimes  permissible  and  palliative  in  their 
effect.  On  the  other  hand,  in  some  cases  and  some  diseases  of  a  sluggish, 
chronic,  scaly  character,  such  as,  for  instance,  ichthyosis  and  most  cases 
of  psoriasis,  the  free  use  of  water  for  washing  and  cleansing,  or  in  the  form 
of  baths,  plain  or  medicated,  is  not  only  not  damaging,  but  is  often  a  very 
important  factor  in  the  treatment.  The  warm  to  hot  bath  is  frequently 
sufficient  in  the  less  aggravated  cases,  or  it  can  be  made  alkaline,  as  is 
frequently  necessary,  by  the  addition  of  a  varying  quantity  of  an  alkaline 
salt,  depending  upon  the  character  and  tenacity  of  the  scales  and  the 
irritability  of  the  skin.  Those  commonly  used  for  this  purpose  are 
sodium  bicarbonate  (averaging  i|  drams  to  the  gallon),  sodium  borate, 
potassium  carbonate,  or  ammonium  muriate  (averaging  a  dram  to  the 
gallon).  The  sulphur  bath  is  occasionally  used  in  the  chronic  sluggish 
dermatoses,  and  is  best  made  with  potassium  sulphid  or  Vleminckx's 
solution  (averaging  a  dram  to  the  gallon).  The  salt  bath  (averaging  3 
ounces  to  the  gallon),  as  commended  by  Piffard,  is  also  useful  in  some  of 
these  cases.  Tar  baths  are,  at  present,  not  much  used.  Corrosive 
sublimate  baths  will  be  referred  to  in  the  course  of  the  text.  An  ordinary 
tub-bath  takes  about  30  gallons.  The  bath  should  always  be  taken  warm 
enough  to  permit  of  immersion  for  from  three  to  twenty  minutes  without 
chilling. 

Steam  and  hot-air  baths  are  only  occasionally  advisable  in  derma- 
tologic  practice,  and  in  the  same  diseases  in  which  alkaline  baths  are 
prescribed.  The  cold  shower  or  plunge  may  also  be  of  service  in  ex- 
ceptional instances,  but  in  cutaneous  therapeutics  has  an  extremely  lim- 
ited usefulness.  The  same  may  be  said  of  the  wet-pack.  The  natural 
spring-water  baths  are  also  sometimes  resorted  to,  and  the  effects,  owing 
to  the  methodic  manner  in  which  they  are  carried  out,  and  supplemented 
by  the  advantages  of  change  of  environment,  diet,  etc.,  are  sometimes 
striking. 

Soaps  are  frequently  demanded  in  connection  with  the  use  of  water 
for  cleansing  purposes,  but  should  be  even  more  rigorously  excluded  in 
acute  eczematous  diseases  and  similar  conditions.  But  the  same  reasons 
why  water  must  sometimes  be  used  also  hold  with  soap,  but  great  care 
should  be  taken  to  remove  such  washings  with  clean  water.  There  are 
two  classes  of  soaps,  the  mild  and  the  strong — the  soda  soaps,  of  which 
Castile  soap  is  a  representative,  and  the  potash  soaps,  of  which  sapo 
viridis  is  the  one  commonly  employed.  The  soda  soap  should  be  as 
nearly  neutral  as  possible.  Its  use  for  toilet  purposes  has  an  influence  in 
keeping  the  skin  in  healthy  condition,  but  in  those  of  thin  epidermis  and 
sensitive  skin  must  be  employed  in  moderation,  and  exceptionally 
individuals  are  met  with  whose  exposed  skin,  especially  the  face,  does 
not  bear  well  even  its  occasional  use;  in  some  instances,  however,  this 
signifies  that  the  soap  contains  too  much  free  alkali.  As  a  rule,  the 
washing  of  the  face  when  using  soap,  especially  on  skin  at  all  sensitive, 
should  be  done  at  bedtime ;  if  done  during  the  day,  the  exposure  to  wind 
and  weather  is  irritating.  An  attempt  to  overcome  this  has  led  to  the 
manufacture  of  a  "superfatty  soap,"  which  is  less  irritating  to  some  skins, 
but  it  is  sometimes  uncertain  in  this  respect  with  others.  Soda  soap, 


LOCAL    TREATMENT 

more  freely  used  than  for  ordinary  toilet  purposes,  is  of  advantage  in  the 
treatment  of  acne  and  some  other  affections,  and  it  may  also  be  used  in 
some  cases  in  connection  with  the  warm  bath  in  place  of  the  alkaline 
salt.  Sapo  viridis  may  also  be  so  used,  but  it  represents  a  stronger 
alkaline  bath. 

This  latter,  known  also  as  sapo  mollis,  or  green  soap,  is  a  strong  soap, 
and  should  not  be  employed  in  diseases  of  an  acute  or,  as  a  rule,  subacute 
type.  For  removing  adherent  scales  and  crusts  in  sluggish  conditions, 
however,  it  is  sometimes  valuable;  also  in  some  cases  of  acne,  seborrhea, 
and  psoriasis  of  the  scalp,  etc.  It  may  often  in  these  cases  be  used  with 
greater  advantage  in  the  form  of  the  tincture  of  sapo  viridis,  corresponding 
to  the  spiritus  saponatus  kalinus  of  Hebra.  The  best  sapo  viridis  is  that 
imported  from  Germany;  the  extemporaneously  made  soap  having,  espe- 
cially in  tincture  form,  proved,  in  my  experience,  often  unsatisfac- 
tory. 

Medicated  soaps,  made  by  the  addition  of  various  drugs  to  the 
soda  soap  basis,  are  now  prepared  by  various  manufacturers,  and  while 
their  action  is  often  questionable  and  their  field  of  usefulness  small, 
occasionally  they  may  be  prescribed  advantageously — as,  for  instance, 
the  sulphur-naphthol  soap,  for  body  toilet  use  after  an  apparent  cure 
of  tinea  versicolor.  Medications  have  also  been  made  to  the  super- 
fatted basic  soda  soap.  The  tincture  of  green  soap  can  often  be  ad- 
vantageously medicated  with  resorcin  and  other  drugs  for  use  in  the 
shampoo  for  seborrhea,  etc. 

Dusting-powders  have  a  somewhat  limited  field  in  cutaneous 
medicine.  They  are  prescribed  in  the  erythemata,  especially  ery- 
thema intertrigo,  in  erythematous  eczema,  hyperidrosis,  bromidrosis, 
and  some  other  affections.  Those  in  more  common  use  are  zinc  oxid, 
starch,  lycopodium,  rice,  talcum,  magnesium  carbonate,  boric  acid, 
zinc  oleate,  zinc  stearate,  and  others,  those  most  valuable  being  referred 
to  under  eczema  and  other  diseases  in  which  they  are  employed.  They 
are  variously  used  for  their  protective,  antiseptic,  astringent,  and  drying 
properties.  They  are  not  applicable  where  there  is  free  gummy  or  puru- 
lent discharge.  The  first  requisite  of  a  good  dusting-powder  is  that  it 
should  be  absolutely  free  from  grittiness,  which  can  be  readily  ascer- 
tained by  rubbing  some  between  the  two  finger-ends.1 

I/Otions  are  much  more  agreeable  applications  than  ointments, 
and  are  useful  in  many  diseases,  in  some  of  which  they  may  be  used 
alone.  In  others  they  are  found  too  drying  to  employ  continuously, 

1  Kapp  ("Ueber  Toilette-  and  Schmink-puder,"  Derm.  Wochenschr.,  1912,  liv,  p. 
458)  has  studied  the  various  vegetable  and  mineral  powders,  especially  from  the 
point  of  their  mechanical  action  on  the  skin,  and  also  made  examinations  for  germ 
contamination.  The  material  was  (67  specimens — powders,  powder-boxes,  powder- 
puffs,  etc.)  obtained  from  private  patients  of  the  better  class.  Only  5  specimens  were 
free  from  organisms.  In  53  were  found  non-pathogenic  organisms;  2  showed  mucor 
mucedo;  i,  a  hyphomycete;  3,  staphylococcus  pyogenes  aureus;  i,  Unna's  morococcus; 
i,  streptococcus;  i,  tubercle  bacilli.  The  vegetable  powders  have  the  disadvantage  of 
the  swelling  of  the  granules  from  moisture,  and  when  within  the  follicular  openings 
possibly  provoking  enlarged  pores;  in  this  respect,  rice  powder  is  the  least  harmful. 
Mineral  powders  may  produce  mechanical  irritation  by  the  sharp  edges  and  spiculae 
of  the  grains;  the  least  harmful  mineral  powders  being  zinc  oxid,  precipitated  magne- 
sium carbonate,  and  magnesium  silicate. 


Il8         GENERAL  REMARKS  ON  TREATMENT 

but  can  be  satisfactorily  used  intermittently  or  conjointly  with  oint- 
ments. They  are  probably  most  frequently  applicable  in  acne,  urti- 
caria, pruritus,  erythema  intertrigo,  some  cases  of  eczema,  etc.  In 
some  cases  the  drying  effect  can  be  lessened  or  abolished  by  the  addition 
of  from  i  to  5  or  10  minims  (0.065  to  0.33  or  0.65  gm.)  of  glycerin  to  the 
ounce  (32  gm.),  but  this  ingredient  should  rarely  exceed  this  amount 
in  most  instances,  as  it  may  prove  irritating,  whereas  in  minute  quantity 
it  is  often  a  valuable  addition.  From  5  to  10  minims  (0.33  to  0.65  gm.) 
of  alcohol  to  the  ounce  (32  gm.)  may  also  frequently  be  added  with 
advantage  for  the  pleasant,  cooling  sensation  it  produces — when  not 
contra-indicated,  as  it  would  be  in  exceedingly  acute  conditions,  more 
especially,  however,  when  the  rete  or  corium  is  exposed. 

According  to  the  effect  desired,  lotions  are  of  various  characters,  as , 
indicated  by  the  following  qualifying  names — soothing  lotions,  anti- 
septic lotions,  astringent  lotions,  stimulating  lotions,  antipruritic  lotions, 
etc.     They  will  be  found  specifically  referred  to  in  connection  with  the 
various  diseases  in  which  they  find  application. 

As  an  example  of  an  extremely  mild,  soothing  lotion  may  be  men- 
tioned that  usually  designated  calamin  liniment,  calamin-zinc-oxid 
liniment,  consisting  of  i  to  2  drams  (4-8  gm.)  of  zinc  oxid  and  calamin, 
4  to  10  minims  (0.26-0.65  gm.)  of  carbolic  acid,  and  2  ounces  (64  gm.) 
each  of  lime-water  and  oil  of  sweet  almonds.  These  pulverulent  ingre- 
dients make  it  of  a  slightly  astringent  and  protective  character.  In 
some  instances  olive  oil  instead  of  the  almond  oil  seems  more  accept- 
able. It  is  to  be  applied  frequently  by  tapping  it  on,  or  the  parts  can  be 
kept  enveloped  with  cloths  or  lint  wet  with  it.  Closely  similar,  but  dis- 
tinctly drying  in  its  character,  is  the  plain  or  aqueous  well-known  cal- 
amin-and-zinc-oxid  lotion,  consisting,  in  the  average  formula,  of  about 
i  or  2  drams  (4-8  gm.)  each  of  calamin  and  zinc  oxid  to  the  4  ounces 
(128  gm.)  of  water,  or  of  2  ounces  (64  gm.)  each  of  lime-water  and  plain 
water;  to  this  is  sometimes  added,  in  minute  quantity,  as  stated  above, 
carbolic  acid  and  glycerin.  This  is  especially  valuable  in  some  cases  of 
erythematous  and  vesicular  eczema  of  the  acute  type,  in  erythema 
intertrigo,  and  some  other  affections.  Both  these  powders  seems  also 
to  be  slightly  antiseptic,  but  this  property  of  the  lotion  can  be  further 
emphasized  by  the  addition  of  from  5  to  15  grains  (0.35-1  gm.)  of  boric 
acid  to  the  ounce  (32  gm.),  and  which  does  not  compromise  its  soothing 
character.  Lotio  nigra,  with  an  equal  quantity  of  water  or  lime-water, 
is  another  example  of  a  soothing  antiseptic  lotion.  As  a  plain  antiseptic, 
soothing  lotion,  free  from  sediment,  may  be  mentioned  one  of  boric  acid 
of  the  strength  just  indicated,  and  which  can  often  be  used  alone,  but 
also  more  frequently  with  great  advantage  conjointly  with  a  soothing 
salve.  It  is  one  of  the  most  valuable  mild  antiseptic  lotions  we  possess, 
and  in  my  practice  is  indispensable.  Astringent  lotions  in  the  strictest 
sense  are  those  containing  tannin,  alum,  zinc  sulphate,  and  the  like,  used 
most  commonly  in  hyperidrosis.  The  stimulating  lotions  are  well  illus- 
trated by  the  sulphur  washes  and  tarry  lotions,  prescribed  respectively 
in  acne  and  chronic  eczema.  Antipruritic  lotions  will  be  referred  to 
under  the  head  of  Antipruritics. 


LOCAL    TREATMENT  119 

Ointments  are  the  most  frequently  employed  preparations  in 
cutaneous  therapeutics,  and,  upon  the  whole,  in  many  cases,  are  by 
far  the  most  valuable;  they  probably  find  their  greatest  usefulness  as 
applications  in  eczema,  to  which  the  reader  is  referred  for  many  points 
concerning  the  various  formulas  and  other  matters  not  here  touched 
upon.  The  best  ointment  bases  are:  (i)  Prepared  lard,  which  is  the 
best  all-round  base,  possessing  penetrating  powers  scarcely  exceeded  by 
any  other  fat,  but  which  has  the  disadvantage  of  tending,  after  a  time, 
to  rancidity,  and  should  therefore  always  be  fresh;  (2)  petrolatum,  or 
its  equivalent,  vaselin  or  cosmolin,  is  also  valuable,  having  but  little 
tendency  to  change,  constituting  a  good  protective,  but  lacking  some- 
what in  its  power  of  penetration,  although  Luff's  experiments  point 
to  the  contrary;  occasionally,  either  from  imperfect  purification  or  for 
other  cause,  it  is  found  to  disagree;  (3)  cold  cream  (unguentum  aquae 
rosae)  is  soothing  and  cooling,  and  is  to  be  considered  an  admirable  base, 
when  properly  made,  and  may  often  be  used  when  other  fatty  applications 
disagree.  These  three,  used  sometimes  separately,  sometimes  in  mixture 
of  two  or  all,  are  those  which  will  be  found  most  satisfactory.  To  these, 
other  fatty  substances,  such  as  spermaceti,  wax,  suet,  and  the  like  are 
sometimes  added  for  special  purposes,  and  of  which  simple  cerate  (cera- 
tum  simplex),  simple  ointment  (unguentum  simplex),  are  some  pharma- 
ceutic  examples.  The  stiffer  substances  are  necessary  when  a  good  deal 
of  liquid  medication  is  to  be  added,  such  as  lead- water,  oil  of  cade,  etc. ; 
if  an  aqueous  substance,  and  in  much  quantity,  enough  lanolin  with 
which  it  can  first  be  rubbed  up,  together  with  variable  amounts  of 
simple  cerate  and  lard,  or  petrolatum,  can  be  satisfactorily  employed 
as  the  base.  Lanolin,  introduced  by  Liebreich,  and  since  more  or  less 
generally  advised,  is  said  to  surpass  in  its  power  of  penetration  all  other 
bases,  but  this  is  not  borne  out  by  experience ;  and  it  is  an  unsatisfactory 
and  even  impracticable  base  when  used  alone,  but  in  the  proportion  of 
from  10  to  20  per  cent,  to  other  bases,  it  is  sometimes  a  valuable  addition 
in  seborrhcea  and  ringworm  of  the  scalp,  and  some  other  maladies. 
Water  readily  mixes  with  it,  but  this  ingredient  with  this  fat  does  not 
seem  to  have  the  cooling  influence  that  it  does  in  cold  cream.  Adeps 
lanae  is  a  closely  similar  preparation  to  lanolin.  Glycerite  of  starch  is 
another  base  occasionally  employed,  but  is  not  in  general  use,  and 
sometimes  produces  irritation.  Upon  exposed  surfaces  it  is  some- 
times an  advantage,  purely  cosmetic,  to  add  a  small  quantity  of 
calamin,  umber,  etc.,  to  give  the  ointment  selected  a  skin  color  (see 
under  Eczema). 

Ointments  are  of  various  characters  as  regards  the  incorporated 
medicament — soothing,  stimulating,  etc.  Soothing  or  mild  ointments 
find  their  use  in  irritable  and  acutely  inflamed  cutaneous  maladies,  as  in 
eczema  of  such  type,  and  not  only  protect  the  skin  from  irritation,  moist- 
ure, air,  or  other  injurious  influences,  but  are  directly  comforting  and 
healing  to  the  diseases  surface.  The  best  exponents  of  this  class  are  the 
zinc-oxid  ointment,  cold  cream,  simple  ointment,  cucumber  ointment,  and 
a  few  others.  Zinc  oxid,  as  well  as  calamin,  bismuth  subnitrate,  and 
some  other  substances,  in  the  proportion  of  from  5  to  15  per  cent,  or 


120  GENERAL   REMARKS   ON  TREATMENT 

more,  add  slightly  astringent  and  mildly  antiseptic  properties  to  such 
ointments,  and  are  rarely  detrimental.  The  addition  of  from  2  to  5 
grains  (0.135-0.33  gm.)  of  salicylic  acid  or  from  5  to  10  grains  (0.33-0.65 
gm.)  of  boric  acid,  adds  still  further  to  the  antiseptic  character,  and,  as  a 
rule,  is  not  in  this  quantity  disturbing,  even  in  acute  conditions,  but  all 
such  additions  in  these  cases  must  be  made  with  caution.  Cocoa-butter 
can  also  sometimes  be  added  with  advantage  in  the  quantity  of  from 
5  to  10  per  cent. ;  it  has  a  stiffening  influence  on  the  ointment  consistence. 
Diachylon  ointment  is  much  used  in  Vienna,  and  if  well  made  and  fresh, 
is  in  many  cases  grateful,  but  it  does  not  seem  possible  to  be  sure  of  a 
good  preparation,  and  one  improperly  compounded  or  old  or  rancid  is 
sure  to  irritate.  Mild  ointments  are  applied  either  by  anointing  or  by 
spreading  on  patent  lint  or  other  suitable  material;  if  lint  is  used,  the 
ointment  should  be  spread  on  the  woven  side,  as,  being  free  from  fuzzy 
particles  which  are  apt  to  stick  to  the  skin,  as  well  as  being  less  likely  for 
the  fibers  to  break  apart  when  the  salve  is  spread  on.  It  may  also  be 
applied  on  paraffined  or  waxed  paper,  being  thinly  spread;  this  is  more 
especially  applicable  on  parts  where  there  is  but  little  motion. 

A  good  example  of  an  antiseptic,  and  yet  mild  salve,  in  addition  to 
those  named,  is  the  boric  acid  ointment  (unguentum  acidi  borici). 
Stimulating  ointments  are  constituted  of  one  or  more  of  the  several  bases 
named,  with  the  addition  of  a  drug  having  stimulating  properties,  such 
as  sulphur,  tar,  white  precipitate,  calomel,  or  other  mercurial,  resorcin, 
salicylic  acid,  chrysarobin,  etc.,  and,  according  to  the  proportion  present, 
they  vary  from  one  scarcely  stronger  than  a  soothing  salve  to  that  actually 
caustic.  Stimulating  salves  are  usually  to  be  well  rubbed  in. 

Pastes  are  a  form  of  ointment  suggested  by  Lassar  and  elaborated 
by  Unna  and  others,  which  are  largely  made  up  of  pulverulent  sub- 
stances, most  commonly  starch  and  zinc  oxid,  with  usually  a  petroleum 
fat  as  the  fatty  constituent.  Lassar's  formula — Lassar's  paste — 
consists  of  i  part  each  of  zinc  oxid  and  starch  and  2  parts  of  vaselin,  to 
which  is  commonly  added  i  or  2  per  cent,  of  salicylic  acid — salicylic 
acid  or  salicylated  paste.  Duhring  commends  highly  a  somewhat 
softer  paste,  and  more  cleanly,  consisting  of  i  part  boric  acid,  3  parts 
each  of  zinc  oxid  and  starch,  and  12  parts  vaselin.  Others  will  be  found 
referred  to  under  Eczema.  These  preparations  are  often  of  greater 
value  than  ordinary  ointments  in  some  cases  of  eczematous  disorders  of  a 
subacute  or  not  too  acute  type,  owing  to  their  stiffer  consistence  and  to 
their  greater  adhesiveness,  and  also  to  their  porosity;  they  make  a  thin, 
usually  rapidly  drying,  protective  coating. 

Attempts  have  been  made  from  time  to  time  to  find  cleaner,  ready- 
made  and  spread  ointment  applications  to  take  the  place  of  the  ordinary 
salves  but  so  far  the  preparations  known  as  salve-mulls  or  salve-muslins, 
devised  by  Unna  and  manufactured  in  Germany,  and  now  obtainable 
in  most  of  our  large  cities,  are  the  only  satisfactory  substitutes;  these 
often  act  very  satisfactorily,  the  zinc  oxid  salve-mull  being  especially 
valuable.  Their  costliness  is  a  disadvantage,  and  considerably  limits 
their  employment.  Plaster-mulls,  or  plaster  muslins,  also  devised 
by  Unna,  are  adhesive,  plaster-like  applications,  variously  medicated 


LOCAL    TREATMENT  121 

with  mild  to  stimulating  or  caustic  ingredients  which  have  a  more 
limited  field;  a  tolerably  fair  substitute  is  now  found  in  the  "rubber 
plasters"  of  our  own  plaster  manufacturers.1 

Oils  are  sometimes  used  in  place  of  salves,  both  for  the  removal 
of  crusts  and  scales  and  for  the  purpose  of  medication,  especially  upon 
the  scalp;  they  may  be  variously  medicated.  Olive  oil,  almond  oil, 
liquid  petrolatum,  and  oil  of  cade  are  among  those  most  frequently 
employed.  These  and  others  will  be  referred  to  in  connection  with  the 
diseases  in  which  they  are  used.  Oily  preparations,  as  well  as  lotions 
without  sediment,  are  best  applied  to  the  scalp  by  means  of  an  "eye- 
dropper,"  putting  a  drop  here  and  there  and  then  spreading  or  rubbing 
in  with  a  piece  of  woolen  rag. 

Fixed  Dressings.— But  little  reference  need  be  made  to  such  in 
this  place,  inasmuch  as  those  commonly  used  are  sufficiently  fully  con- 
sidered under  Eczema  and  Psoriasis.  In  a  way  the  salve-mulls,  plaster- 
mulls,  and  rubber  plasters  already  referred  to  are  to  be  considered  in  this 
class,  especially  the  latter  two,  which  are  adhesive  and  can  sometimes  be 
kept  applied  several  days  without  change.  Their  use  is,  however, 
limited,  and  principally  to  some  sluggish,  chronic,  thickened,  dry  types 
of  eczema,  patches  of  lichen  planus,  keratosis  palmaris,  and  other  epider- 
mic thickenings,  as  clavus,  and  in  some  cases  of  lupus  and  tubercular 
syphiloderm. 

Tragacanth,  bassorin,  and  acacia  mucilaginous  applications,  as  well 
as  gelatin  dressings  (glycogelatin) ,  have  been  employed  in  recent  years, 
and  will  be  referred  to  specifically  under  Eczema. 

Collodion  and  liquor  gutta-perchse  also  furnish  rapidly  drying  coat- 
ings, and  may  likewise  be  variously  medicated.  Collodion  is  more  valu- 
able than  the  gutta-percha  solution,  as  it  dries  more  quickly,  is  a  thicker, 
firmer  film,  and  exerts  a  more  positive  compressing  action,  which  is  of 
advantage.  It  has  its  chief  field  in  psoriasis,  in  lupus  erythematosus,  in 
ringworm,  small  thickened  patches  of  sclerous  eczema  and  of  lichen 
planus,  callositas,  and  other  keratoses.  In  psoriasis  and  ringworm, 
chrysarobin,  formerly  known  as  chrysophanic  acid,  is  usually  the  medic- 
inal ingredient,  in  from  10  to  15  per  cent,  proportion,  sometimes  with 
from  2  to  5  per  cent,  salicylic  acid;  and  frequently  this  last  alone,  as  in 
occasional  cases  of  ringworm,  callosities,  clavus,  etc.  Oil  of  cade,  pyro- 
gallol,  known  formerly  as  pyrogallic  acid,  and  other  drugs  are  also  thus 
used.  Collodion  paintings,  especially  of  pyrogallol  and  resorcin,  some- 
times act  with  unexpected  energy,  so  that  some  caution  is  at  first  neces- 
sary. As  a  rule,  unless  the  added  ingredient  is  an  oily  one,  a  mixture 
of  equal  parts  of  plain  collodion  and  flexible  collodion  is  a  more  satis- 
factory vehicle,  the  former  alone  tending  to  crack  too  easily,  the  latter 
drying  somewhat  less  rapidly  and  not  possessing  the  same  compressing 
power.  In  those  instances  where  this  last  property  is  especially  desired, 
as  usually  in  lupus  erythematosus,  the  plain  collodion  is  the  best.  Other 
details  will  be  found  in  connection  with  the  various  diseases  in  which  this 
vehicle  is  employed,  especially  psoriasis.  The  gutta-percha  solution, 

1  Stelwagon,  "Notes  on  the  Use  of  Medicated  Rubber  Plasters  in  Certain  Cuta- 
neous Diseases,"  Med.  News,  October  8,  1887. 


j22  GENERAL   REMARKS   ON  TREATMENT 

or  traumaticin,  is  used  chiefly  as  a  vehicle  for  chrysarobin  or  salicylic 
acid,  in  the  treatment  of  psoriasis  and  some  keratoses. 

Salve-pencils  and  paste-pencils,  the  former  composed  of  wax,  oil, 
sometimes  with  a  gummy  or  resinous  substance  added,  and  the  latter 
usually  of  a  variable  mixture  or  compound  of  tragacanth,  acacia,  starch, 
and  other  ingredients,  have  been  brought  forward,  with  different  medica- 
ments incorporated,  for  application  to  small  spots  or  areas,  but  their 
field  of  usefulness  is  so  extremely  small  that  special  comment  is  not 
necessary. 

Antipruritics. — Carbolic  acid  is  the  most  valuable  antipruritic, 
and  is  often  added  for  this  purpose  to  ointments  or  lotions — in  the 
former  from  3  to  30  grains  (0.2  to  2  gm.),  and  in  the  latter  from  2  to  about 
10  grains  (0.135-0.65  gm.)  to  the  ounce  (32  gm.),  the  proportion  depend- 
ent upon  the  condition  of  the  skin  and  the  obstinacy  of  the  pruritus, 
markedly  inflammatory  cases,  and  especially  in  children,  requiring  the 
smallest  quantity.  It  is  most  agreeably  prescribed  in  lotion  form. 
Occasionally  it  is  not  well  borne.  Liquor  carbonis  detergens  (formula 
under  Eczema),  a  solution  of  coal-tar  in  an  alcoholic  solution  of  soap-bark, 
is  somewhat  similar,  and  an  exceedingly  valuable  remedy,  used  in  lotions 
chiefly  from  i  to  3  drams  (4-12  gm.)  or  more  to  the  half -pint  (256  gm.); 
or  in  ointments,  5  to  30  minims  (0.35-2  gm.)  to  the  ounce  (32  gm.). 
Resorcin,  from  \  to  5  or  10  grains  (0.035-0.65  gm.)  to  the  ounce,  accord- 
ing to  the  condition  or  disease,  frequently  exercises  an  antipruritic  and 
quieting  action.  Boric  acid  in  solution,  usually  saturated,  also  seems  at 
times  to  exert,  probably  indirectly,  a  mild,  quieting,  soothing,  or  anes- 
thetic action,  and  can  often  with  advantage  be  made  the  basis  for  the 
other  more  active  remedies  just  mentioned.  Weak  alkaline  lotions,  2 
to  1 6  grains  (0.135-1  gm.)  of  borax  or  sodium  bicarbonate  to  the  half- 
pint  (256  gm.),  are  also  sometimes  of  service  in  certain  itching  diseases, 
but  are  usually  not  to  be  employed  in  eczema.  Menthol,  hydrocyanic 
acid,  liquor  picis  alkalinus,  other  tarry  preparations,  and  other  drugs,  are 
sometimes  employed  for  antipruritic  effect,  and  will  be  referred  to  else- 
where, especially  under  Eczema  and  Pruritus. 

Parasiticides  are  those  remedies  which  are  destructive  more  espe- 
cially to  the  grosser  animal  and  vegetable  parasites.  Among  the  most 
valuable  are  sulphur  and  its  compounds;  among  the  latter,  especially 
sulphurous  acid,  the  sulphite  and  hyposulphite  of  sodium,  the  sulphid  of 
calcium,  especially  as  the  compound  known  as  Vleminckx's  solution, 
and  potassium  sulphid.  These,  as  others,  such  as  naphthol,  the  mer- 
curials, and  carbolic  acid,  are  destructive  to  both  animal  and  vegetable 
parasites,  and  find  their  employment  chiefly  in  ringworm,  favus,  tinea 
versicolor,  and  scabies.  Chrysarobin  and  iodin  are  also  valuable  vege- 
table parasiticides,  and  both  Shoemaker  and  Crocker  speak  well  of 
copper  oleate  in  ringworm,  and  the  former  commends  its  action  also 
in  other  vegetable  parasitic  diseases.  In  scabies  precipitated  or  sub- 
limed sulphur  and  naphthol,  of  those  named,  are  most  commonly  em- 
ployed; frequently  also  styrax  and  balsam  of  Peru.  The  mercurials, 
especially  corrosive  sublimate  solution,  white  precipitate,  sulphur, 
stavesacre,  and  naphthol  ointments,  are  commonly  used  against  pediculi. 


LOCAL    TREATMENT  1 23 

In  fact,  the  so-called  parasiticides  are  numerous,  as  will  be  found  in  the 
text  devoted  to  the  parasitic  diseases.  They  are  in  reality  the  same  as 
antiseptics  and  bactericides,  these  latter  usually  meaning  those  which  are, 
as  a  rule,  somewhat  weaker,  and  employed  against  the  lower  organisms, 
such  as  the  pus-cocci,  etc.  In  this  class  are  boric  .acid,  carbolic  acid, 
resorcin,  weak  corrosive  sublimate  solutions,  weak  solutions  of  formal- 
dehyd,  washings  with  tincture  of  green  soap  and  water,  and  many  others, 
the  most  valuable  in  dermatologic  practice  being  boric  acid  and  resorcin. 
The  value  of  ichthyol  as  an  external  application,  the  first  knowledge  of 
which  we  owe  to  Unna,  is,  in  part  at  least,  due  to  its  bactericidal  property, 
as  attested  by  its  favorable  action  in  sycosis,  furuncles,  acne,  etc.  There 
are  two  varieties  on  the  market,  sodium  ichthyol  and  ammonium  ichthyol, 
the  former  usually  going  under  the  name  of  ichthyol.  Aristol,  acetanilid, 
iodoform,  and  others  are  also  occasionally  resorted  to,  but  the  last  named, 
owing  to  its  offensive  odor  and  its  venereal  suggestiveness,  should  find 
rare  application  among  respectable  ambulatory  patients. 

Caustics  are  substances  or  agents  which  are  more  or  less  active 
destroyers  of  tissue.  Among  the  strongest  more  commonly  employed 
in  dermatologic  practice,  and  which  are  destructive  alike  to  normal 
and  morbid  tissue,  are  caustic  potash,  chromic  acid,  zinc  chlorid,  and 
the  galvanocautery  and  actual  cautery,  including  the  Paquelin  cautery. 
They  are  used  in  malignant  growths;  chromic  acid  and  caustic  potash 
are  sometimes  used  on  wyarts.  Caustic  potash  is  an  active  caustic,  and 
sometimes  misleading  at  the  time  of  its  application  as  to  the  actual 
amount  of  destruction  taking  place ;  unless,  therefore,  care  is  exercised,  it 
may  destroy  too  much.  When  sufficient  action  has  been  effected,  vine- 
gar or  dilute  acetic  acid  should  be  applied  to  the  part  to  neutralize  it  and 
prevent  further  destruction.  The  pain  is  considerable  at  the  time,  but 
rapidly  subsides.  Zinc  chlorid,  usually  applied  in  paste  (see  Lupus  and 
Epithelioma),  is  slow  and  increasingly  painful,  but  valuable,  producing 
a  hard,  leathery  slough.  Another  caustic  frequently  resorted  to,  and 
which  is  in  a  sense  elective,  sparing,  as  a  rule,  normal  tissue  unless  ap- 
plied for  too  long  a  time,  is  arsenic.  It  is  used  in  limited  growths,  such 
as  small  epitheliomata,  as  a  paste  with  usually  i  or  2  parts  of  acacia;  or  to 
more  extensive  areas,  as  in  lupus,  as  a  5  to  10  per  cent,  ointment.  It 
requires  from  one  to  several  days,  according  to  the  strength  used;  some- 
times a  repetition  is  necessary.  It  is  painful,  and  produces  marked  in- 
flammatory edematous  swelling,  but  if  used  with  proper  precautions 
it  can  scarcely  be  said  to  be  dangerous.  Pyrogallol  has  the  same  elective 
action,  but  not  so  constantly.  Its  method  of  application,  as  well  as  that 
of  the  other  caustics,  will  be  referred  to  under  Lupus  vulgaris  and  Epi- 
thelioma. Pyrogallol  in  collodion  sometimes  acts  unusually  sharply, 
and  when  so  prescribed,  must  be  done,  at  first  at  least,  with  caution. 
Nitric  acid  and  the  acid  nitrate  of  mercury,  are  comparatively  super- 
•  ficial  caustics,  and  are  sometimes  employed  in  warts,  naevi,  and  other 
cases  in  which  slight  or  surface  destruction  is  sought.  Trichloracetic 
acid  (the  deliquesced  crystals,  or  saturated  solution)  is  also  an  extremely 
useful,  somewhat  superficial  discutient  and  caustic  which  has  recently 
been  much  extolled  (C.  N.  Davis,  D.  W.  Montgomery  and  Culver, 


124  GENERAL   REMARKS   ON  TREATMENT 

Heidingsfeld,1  and  others)  for  seborrhceic  and  senile  keratoses,  warts, 
simple  moles,  xanthoma,  and  similar  lesions.  Lactic  acid,  if  used  freely 
and  continuously,  also  has  caustic  action,  but  if  applied  scantily  its  effect 
is  superficial,  or  more  that  of  a  discutient.  Among  other  discutients  or 
keratolytics  is  salicylic  acid,  used  as  a  10  to  25  per  cent,  rubber  plaster 
or  plaster-mull,  or  as  a  10  to  25  per  cent,  solution  in  collodion,  or  a  10  to 
25  per  cent,  ointment  (applied  as  a  plaster) ;  in  epidermic  thickenings  it  is 
often  of  great  service.  Other  caustics  are  occasionally  used,  and  will 
be  found  referred  to  in  the  course  of  the  text. 

I/iquid  Air  and  Carbon-dioxid  Snow.— While  treatment  of 
certain  cutaneous  diseases  by  intense  refrigeration,  mildly  or  actively 
destructive  according  to  degree  and  application,  has  been  from  time  to 
time  recorded  and  liquid  air  had  several  times  been  publicly  and  pre- 
viously lauded  by  A.  C.  White  and  others,  it  remained  for  Dade's  brilliant 
demonstration  of  the  use  of  liquid  air2  at  the  meeting  of  the  American 
Dermatological  Association  in  New  York,  1905,  to  give  this  method  an 
established  and  accepted  standing;  especially  valuable  in  pigmented  and 
vascular  naevi,  lupus  erythematosus,  keratoses,  superficial  epithelioma, 
and  the  like. 

Liquid  air  as  an  efficient,  and  probably  the  best,  destructive  refrig- 
erant or  freezing  cauterant,  has  since  had  the  endorsement  of  Jackson, 
Saalfeld,  Beckett,  Trimble,  Zeisler,  Whitehouse,  and  others,  but  the 
almost  insuperable  difficulty  in  obtaining  and  preserving  it  has  almost 
led  to  its  entire  abandonment,  the  more  readily  owing  to  Pusey's  valu- 
able discovery  (1905)  of  a  practical  substitute  for  it  in  the  easily  and 
always  procurable  carbon-dioxid  snow.  Its  degree  of  cold  is  not  so 
low  as  that  of  liquid  air,  but  it  is  low  enough,  and  the  action  is  about 
the  same.  Since  then  its  value  has  been  repeatedly  attested  by  Pusey, 
Heidingsfeld,  Zeisler,  Bowen  and  Towle,  Sutton,  Jackson  and  Hub- 
bard,  Hutchins,  Gottheil  and  Schalek,  and  others.3  My  own  expe- 
rience has  been  equally  favorable.  Liquid  air  is  applied  with  a  cotton 

1  Heidingsfeld,  "Trichloracetic  Acid  in  Dermatology,"  Archiv,  ex,  1911,  Heft  i  and 
2;  D.  W.  Montgomery  and  Culver,  "Trichloracetic  Acid  as  a  Keratolytic  Agent  in 
Seborrhceic  Keratoses,"  Jour.  Cutan.  Dis.,  1912,  p.  523. 

2  Literature  concerning  therapeutic  uses  of  liquid  air:  A.  C.  White,  Medical  Record. 
New  York,  vol.  Ivi,  1899,  p.  109;  Jour.  Amer.  Med.  Assoc.,  vol.  xxxvi,  1901,  p.  426; 
Interstate  Med.  Jour.,  vol.  ix,  1902,  p.  657;  and  Gaillard's  Med.  Jour.,  vol.  Ixxix,  p. 
410;  Saalfeld,  Dermatolog.  Zeitschr.,  1900,  p.  997;  Beckett,  Australasian  Med.  Gaz., 
vol.  xxiv,  1905,  p.  313;  Trimble,  Med.  Rec.,  New  York,  vol.  Ixviii,  1905,  p.  58,  and 
Jour.  Cutan.  Dis.,  vol.  xxv,  1907,  p.  409;  Bade,   Trans.   VI.  International  Dermal. 
Congress,  1907,  vol.  ii,  p.  672;  Whitehouse,  Jour.  Amer.  Med.  Assoc.,  vol.  xlix,  1907, 
P-  37I-. 

8  Literature  concerning  therapeutic  uses  of  carbon-dioxid  snow:  Pusey,  Jour.  Amer. 
Med.  Assoc.,  vol.  xliv,  1907,  p.  1354,  and  Berlin  klin.  Wochenschr.,  June  15,  1908;  Zeis- 
ler, Dermatolog.  Zeitschr.,  1908,  p.  409,  and  Jour.  Cutan.  Dis.,  1909,  p.  32;  Bowen  and 
Towle,  Boston  Med.  and  Surg.  Jour.,  vol.  Iviii,  p.  868;  Heidingsfeld,  Ohio  State  Med. 
Jour.,  August,  1908;  Heidingsfeld  and  Ihle,  Cincinnati  Lancet  Clinic,  January  30,  1909; 
Hubbard,  Jour.  Cutan.  Dis.,  1908,  p.  134;  Jackson  and  Hubbard,  Med.  Rec.,  New  York, 
April  17, 1909;  Sutton,  Dublin  Jour.  Med.  Sci.,  July,  1909,  and  Jour.  Amer.  Med.  Assoc., 
vol.  Hi,  1909,  p.  464;  Gottheil,  Internal.  Jour.  Surg.,  vol.  xxii,  1909,  p.  7;  Schalek, 
Dietetic  and  Hygienic  Gazette,  November,  1909;  Stelwagon,  Therapeutic  Gazette,  Aug.. 
1910;  Pusey,  Jour.  Cutan.  Dis.,  1910,  p.  352  (review  of  therapeutic  uses,  and  bibliog- 
raphy); Bunch,  "Treatment  of  Naevi,  Based  on  More  Than  200  Cases,"  Brit.  Med. 
Jour.,  August  10,  1912;  R.  Cranston  Low,  "Carbonic-acid  Snow  as  a  Therapeutic 
Agent  in  the  Treatment  of  Diseases  of  the  Skin,"  Wm.  Wood  &  Co.,  New  York,  1911. 


LOCAL    TREATMENT  135 

swab,  made  by  wrapping  a  piece  of  cotton  around  the  terminal  part  of 
a  flat  piece  of  wood,  which  can  be  made  of  suitable  size  and  shape  for 
the  case  in  hand.  It  is  applied  with  moderately  firm  pressure,  and  for 
from  ten  to  thirty  seconds  or  more  in  deep-seated  formations.  The 
degree  of  action  depends  upon  the  amount  of  pressure  and  the  duration 
of  the  application.  The  after-effect  is  almost  the  same  as  that  following 
the  application  of  carbon-dioxid  snow,  as  described  below. 

Carbon-dioxid  snow  is  generally  obtained  from  the  large  steel  cylinder 
of  liquid  carbon  dioxid,  supplied  by  soda-water  fountain  supply  com- 
panies; it  can  be  kept  in  the  office  or  cellar  and  drawn  from  as  the  snow 
is  needed.  It  is  a  clumsy  apparatus  and,  for  the  office,  unsightly.  A 
much  more  elegant  and  convenient  source  is  the  small  cylinder  (12  inches 
long,  i  j  inches  in  diameter)  of  liquid  carbon  dioxid  sold  by  certain  auto- 
mobile supply-houses  for  the  easy  inflation  of  the  tire;  one  cylinder 
furnishes  ample  snow  for  a  single  treatment.  With  several  of  these 
cylinders  and  the  necessary  valve-cock  at  hand  one  is  sufficiently  well 
supplied.  When  necessary  an  angioma  in  an  infant  can  be  treated  at  its 
home,  as  a  cylinder  and  the  valve-cock  can  be  easily  slipped  into  one's 
pocket.  The  method  of  procuring  the  snow  is  simple.  A  somewhat 
thick  chamois  skin  (or  a  thin  one  doubled)  is  tied  over  the  gas-nozzle  in 
such  a  manner  as  to  leave  a  small  pocket  opposite  the  gas  outlet;  the  out- 
let end  of  the  cylinder,  if  the  large  one  is  used,  should  be  dipped  down 
about  6  inches  lower  than  the  other  end;  if  the  small  cylinder,  the  outlet 
end  is  held  about  perpendicularly  down.  The  gas  is  then  turned  on  (by 
puncture  of  the  seal  in  the  small  cylinder)  and  the  snow  collects  in 
the  chamois  pocket,  which,  when  ready,  is  detached  from  the  nozzle. 
It  is  either  then  manipulated  through  the  chamois  to  form  a  ball,  which 
may  be  cut  to  the  required  shape  and  size,  or  it  may  be  packed  or  rammed 
into  a  hard-rubber  mold,  such  as  an  ear  or  nose  speculum  or  a  small 
section  of  a  larger  tube.  It  is  then  ready  for  the  application.1  The 
snow  pencil  or  mass  is  to  be  handled  by  the  operator  with  a  small  piece 
of  chamois  so  as  to  avoid  personal  damage  to  the  skin ;  it  is  then  applied 
to  the  diseased  patch  with  a  moderate  pressure,  and  held  there  from  ten 
to  sixty  seconds;  even  longer  in  deep-seated  disease.  The  duration  de- 
pends upon  the  object  desired;  as  a  stimulant  and  discutient,  as,  for  ex- 
ample, in  thickened  patches  of  lichen  planus  or  eczema,  a  few  seconds 
may  be  sufficient;  in  small  superficial  angiomata,  in  thin  pigmented  naevi, 
superficial  lupus  erythematosus,  etc.,  ten  to  thirty  seconds;  in  lupus, 
epitheliomata,  etc.,  from  thirty  to  sixty  seconds  or  longer.  In  with- 
drawing the  snow  pencil  or  mass  the  area  is  seen  depressed  and  frozen 
white  and  hard,  with  a  slight,  narrow  surrounding  zone  of  erythema.  It 
thaws  out  in  a  few  minutes,  becomes  red,  and  possibly  slightly  swollen: 
later,  trifling  vesiculation  or  a  distinct  bleb  or  blister  forms.  This  can 
be  punctured.  Later,  slight  exfoliation  or  thin  crusting  usually  takes 
place,  and  after  a  time  drops  off,  leaving  a  scarcely  noticeable  scar;  in 
cases  where  the  action  has  been  superficial,  scarcely  more  than  a  whitish 
mark,  sometimes  no  permanent  trace.  When  the  action  has  been  long 

1  Several  observers  have  claimed  an  advantage  from  mixing  the  snow  with  ether, 
or  dipping  the  snow  pencil  or  molded  mass  in  ether  before  applying. 


126  GENERAL   REMARKS   ON  TREATMENT 

continued  and  with  considerable  pressure  there  may  follow  thin  sloughing, 
usually  of  a  dry  character.  There  is  not  much  (rarely  objectionable) 
pain,  as  a  rule,  in  the  application,  but  while  thawing  and  for  a  short  time 
subsequently  there  may  be  in  some  instances  considerable  discomfort, 
rarely  troublesome.  In  most  instances  no  after-treatment  or  dressing  is 
necessary,  unless  on  covered  parts  where  the  clothing  may  rub.  Later, 
the  superficial  abrasion  or  ulcer  may  need  a  simple  protective  application. 
If  later  observation  shows  that  the  action  has  not  been  sufficient,  the 
snow  application  is  to  be  repeated.  A  large  area  of  disease,  as,  for 
instance,  in  lupus  erythematosus  or  in  naevi,  should  not  be  treated  at  the 
one  time,  but  in  sections,  and  in  such  instances  it  is  advisable  to  apply 
the  snow  in  square-block  form,  so  that  the  surface  may  be  treated 
evenly. 

Mechanical  or  Operative  Measures — Excision  is  practised 
in  epithelioma,  lupus,  and  other  malignant  formations.  The  cases  of 
lupus  and  epithelioma,  the  two  principal  affections  sometimes  thus 
treated  by  dermatologists,  in  which  permanent  success  is  most  promising, 
are  those  in  which  the  disease  exists  as  a  small,  sharply  defined,  circum- 
scribed patch,  the  knife  going  well  beyond  the  apparent  limiting  border. 
In  more  extensive  cases  of  lupus  this  method  has  also  been  recently 
employed,  following  it  up  with  skin-grafting  by  the  Reverdin  or  Thiersch 
plan;  with  proper  technic  and  under  antiseptic  precautions,  good  results 
have  been  secured  by  those  skilled  in  this  method. 

Curetting,  with  the  ordinary  cutaneous  curets,  is  a  much  more 
common  recourse  in  dermatologic  practice,  and  is  extremely  valuable 
in  certain  diseases,  more  especially  in  lupus  vulgaris  and  epithelioma, 
but  it  should  rarely  be  relied  upon  alone,  a  supplementary  light  cau- 
terization, especially  with  pyrogallol  salve  or  caustic  potash  solution, 
as  described  under  these  diseases,  always  being  practised.  Under  this 
conjoint  plan  recurrences  are  much  less  likely  to  present  than  if  curetting 
alone  is  depended  upon.  This  instrument,  with  sharp  or  blunted 
edges,  is  also  employed  for  other  minor  purposes,  and  such  will  be  re- 
ferred to  in  the  discussion  of  the  individual  diseases  in  which  it  finds 
use. 

The  galvanocautery  and  Paquelin  cautery,  and  Unna's  small  modifi- 
cation of  the  latter,  the  microcautery  (Microbrenner),  already  men- 
tioned under  caustics,  are  often  used  to  destroy  tissue,  in  lupus  espe- 
cially. Besnier  was  a  strong  advocate  for  the  galvanocautery  in  this 
disease,  used  with  sharp  and  pointed  instruments. 

Linear  and  punctate  scarifications  with  the  single  blade  or  sharp 
point,  or  with  the  variously  devised  multiple  scarifiers,  are  found  useful 
chiefly  in  lupus  vulgaris.  They  are  sometimes  employed  also  in  lupus 
erythematosus,  and  occasionally  in  small  thickened  sclerous  eczematous 
areas.  Punctate  scarification  is  also  resorted  to  in  acne  rosacea.  The 
puncturing  and  incising  knife  or  acne  lance  can  often  be  employed  with 
advantage  in  sluggish  and  suppurating  acne  lesions. 

The  cutaneous  punch  or  trephine,  brought  into  prominence  by 
Keyes,  and  made  in  various  sizes  from  that  with  scarcely  more  than  a 
pin-sized  opening  to  one  \  to  \  of  an  inch  or  greater  in  diameter,  is  occa- 


LOCAL    TREATMENT  I2/ 

sionally  resorted  to  for  minor  operations,  as  in  the  removal  of  gun- 
powder grains,  small-sized  tattoo-marks,  moles,  epitheliomata,  and 
other  growths.  Probably  its  most  common  use  is  in  the  removal  of 
diseased  tissue  for  pathologic  investigation. 

Comedo  extractors  are  variously  shaped  small  instruments  with  a 
central  hole,  varying  from  that  of  the  ordinary  watch-key-like  instru- 
ment to  that  somewhat  similar  to  a  long  double  curet,  but  with  the 
shank  curved  toward  the  ends. 

Electrolysis,  sometimes  termed  the  electric  or  electrolytic  needle 
operation,  which  we  owe  principally  to  Hardaway,  is  an  extremely 
valuable  procedure  in  certain  diseases  or  conditions,  as  in  the  smaller 
naevi,  telangiectasis,  acne  rosacea,  warts,  for  the  removal  of  superfluous 
hair,  etc.,  and  its  method  of  employment  will  be  found  described  in 
connection  with  these  maladies.  Electrolytic  destructive  action  can 
also  be  effected  by  means  of  small  metallic  discs,  and  is  sometimes  em- 
ployed for  this  purpose  in  lupus  vulgaris  (q.  ».),  as  originally  recom- 
mended by  Gartner,  Lustgarten,  and  Jackson. 

Electricity  can  also  be  used  in  other  ways,  the  faradic  current  being 
valuable  in  some  cases  of  acne,  in  alopecia,  alopecia  areata,  and  a  few 
other  diseases;  in  the  first,  applying  it  by  means  of  an  ordinary  electrode 
or  roller  electrode,  and  in  alopecia  by  a  special  metallic  comb  or  brush,  and 
in  alopecia  areata  by  means  of  a  tinsel  brush.  The  galvanic  current  is 
also  a  decided  cutaneous  stimulant,  and  is  useful  in  sluggish  conditions, 
in  alopecia  areata  used  cautiously,  in  acne  rosacea,  acne  vulgaris,  in 
herpes  zoster,  and  in  some  other  affections.  It  is  not  improbable  that 
there  may  be  much  more  value  in  the  treatment  of  superficially  circum- 
scribed dermatoses  by  drugs  introduced  by  means  of  electric  cataphoresis 
than  the  past  few  experiments  in  this  direction  would  seem  to  indicate. 
The  static  current  is  likewise  of  adjuvant  service,  especially  in  diseases 
of  a  neurotic  character,  the  roller  applied  over  the  clothing  sometimes 
starting  the  absorption  of  infiltration;  and  the  spark  applied  with  the 
pointed  electrode,  carefully  used,  a  decided  stimulant  to  the  patches 
of  alopecia  areata. 

Radiotherapy1  (Rontgen-ray  Treatment.— x-Ray  Treatment).— 
Ever  since  the  experimental  therapeutic  use  of  this  agent  was  stimulated 
by  the  recognition  of  its  occasional  accidental  action  on  the  cutaneous 
structures,  observed  by  various  skiagraphers,  the  literature  of  the  day 
has  furnished  varying  statements  of  its  value  in  many  of  the  dermatoses. 
Led  mainly  by  Freund  and  Schiff  in  Vienna,  Pusey  and  Williams  in  this 
country,  Walsh,  Morris,  and  Sequeira  in  England,  and  Oudin,  Barthe- 
lemy,  and  Darier  in  France,  its  employment  has  been  gradually  adopted 
by  all,  or  almost  all,  those  engaged  in  dermatologic  practice.  For  the 
past  several  years  it  has  outranked  everything  else  in  its  wide  applica- 
tion, and  the  cutaneous  disease  was  rare  indeed  that  has  escaped  its 
trial.  Continued  observation  and  experience,  including  my  own, 
though  showing  that  some  of  the  claims  were  extravagant,  nevertheless 

1  Those  desiring  to  pursue  the  subject  further  are  referred  to  the  book  publications 
on  Radiotherapy,  by  Freund,  Williams,  Pusey  and  Caldwell,  Allen,  and  Belot.  in  which 
references  to  the  extensive  journal  literature  will  also  be  found. 


128  GENERAL    REMARKS   ON  TREATMENT 

very  properly  accord  it  a  most  important  position  in  the  treatment  of 
certain  diseases  of  the  skin;  while  it  should  not  be  allowed  to  supplant 
other  means  and  methods,  it  is  to  be  recognized  as  a  potent  and  helpful 
addition  to  our  resources,  especially  in  epithelioma,  lupus  vulgaris,  and 
other  cutaneous  tuberculoses,  in  lupus  erythematosus,  sycosis,  extreme 
and  obstinate  types  of  acne,  in  limited  rebellious  cases  of  eczema,  ring- 
worm of  the  scalp,  and  some  other  diseases  to  be  referred  to  in  the  course 
of  the  text.  Its  possibilities  for  evil,  both  for  the  patient  and  operator, 
should  rightly  limit  its  use  within  reasonable  bounds  and  under  sufficient 
precautions.  Its  reckless  and  indiscriminate  application  to  any  derma- 
tosis,  otherwise  easily  treated  and  handled,  is  to  be  deplored.  It  is 
true  that  the  dangers,  with  improved  technic,  and  the  exercise  of  care, 
have  been  almost  reduced  to  insignificance.  There  are,  however,  in- 
dividual idiosyncrasies  to  be  considered.  Caution,  therefore,  should 
be  the  invariable  rule  in  the  use  of  this  powerful  agent,  and  the  first 
several  exposures  should  be  tentative,  not  closer  than  10  inches  to  the 
tube,  and  not  more  than  3  to  5  minutes'  duration.  A  certain  amount 
of  bold  hazard,  when  one  is  experienced,  is  occasionally  permissible 
in  such  cases  as  the  more  malignant  epitheliomata  and  extreme  cases 
of  cutaneous  tuberculosis,  for  frequently  improvement  is  not  brought 
about  till  the  first,  and  sometimes  the  second,  degree  of  x-ray  dermatitis 
is  provoked;  but  in  such  diseases  as  acne,  sycosis,  eczema,  and  the  like 
no  such  risk  would  be  warranted,  and  action  beyond  the  production 
of  the  mildest  erythema  should  be  carefully  guarded  against.  While 
the  general  hints  given  here  and  in  connection  with  the  diseases  in  which 
it  is  used  will  probably  suffice  for  the  intelligent,  cautious  worker,  it 
would  be  a  great  advantage  for  those  desiring  to  employ  this  treatment 
largely  and  thoroughly,  if  opportunity  were  first  sought  to  gain  at  least 
a  moderate  practical  knowledge  with  the  apparatus  and  technic  from 
one  already  familiar  with  the  method. 

While  it  would  be  exceptional  to  use  more  than  one  tube  at  the 
one-treatment  exposure,  Lawrence,1  in  the  treatment  of  granuloma 
fungoides,  generalized  eczema,  and  psoriasis,  has  employed  with  benefit 
as  many  as  six  tubes  at  a  time. 

The  re-ray  tube  can  be  excited  by  either  a  coil  or  a  static  machine, 
and  either  will  prove  satisfactory  in  cutaneous  cases.  As  to  the  size 
of  the  coil  or  static  machine,  the  larger  (within  reasonable  limit),  prob- 
ably the  better,  but  the  coil  capable  of  a  good  6-inch  spark,  or  a  static 
machine  capable  of  an  8-inch  spark,  will  be  capable  of  doing  good  work; 
the  small  apparatus  requires  a  somewhat  longer  exposure,  and  the  rays 
from  a  static  machine  are  weaker  than  those  from  a  coil,  but  such  can 
be  readily  compensated  for  by  longer  exposure  or  shorter  distance,  or 
both.  A  coil  capable  of  a  1 2-inch  spark  is  that  in  most  common  use, 
and  this,  as  well  as  the  larger  and  heavier  static  machines,  are  to  be 
preferred,  especially  if  they  are  also  to  be  used,  with  the  additional 
requisite  apparatus,  for  the  production  of  high-frequency  currents. 
The  static  machine  can  be  operated  by  hand,  water,  or  electric  power; 
the  coil  with  currents  from  storage  batteries  or  the  street  current.  The 
1  Lawrence,  "X-ray  Baths,"  Jour.  Cutan.  Dis.,  1908,  p.  247. 


LOCAL    TREATMENT 


129 


coil  has,  as  is  well  known,  the  greater  advantage  of  reliability.  Of  the 
various  forms  of  interrupters — mechanical  or  vibratory,  mercury  dip, 
or  mercury  jet  or  turbine,  and  electrolytic— the  so-called  mechanical 
interrupter  is,  upon  the  whole,  the  simplest  and  least  troublesome, 
although  they  are  all  efficient,  and  each  has  advocates.  It  is  not  pos- 
sible to  give  a  fast  rule  as  to  the  necessary  amperage  of  current  for  the 
coil  in  the  treatment,  as  this  varies,  depending  upon  voltage,  and  size 
and  construction  of  the  coil.  Now  that  such  instruments  of  precision 
as  special  ammeters  to  measure  amperage  and  voltage  of  the  energizing 
current,  and  the  number  of  milliamperes  actually  going  through  the  tube, 
supplemented  by  the  Wehnelt  or  Benoist's  penetrometer,  Sabouraud- 
Noire  pastilles,  etc.,  are  on  the  market,  greater  accuracy  and  standardiza- 
tion of  current  may  soon  be  realized;  such  are  very  essential  if  the  so- 
called  "single  dose"  method  is  practised;1  but  one  learns  a  great  deal 
from  experience  and  observation,  and  safe  and  successful  treatment  of 
most  cutaneous  diseases  is  possible  in  cautious  hands  without  these 
various  additional  appliances. 

The  x-ray  tube  should  be,  preferably,  the  kind  that  admits  of  regu- 
lation of  the  vacuum,  as  the  vacuum  of  a  tube  is  an  important  factor 
in  the  treatment  of  cutaneous  diseases.  As  is  Well  known,  the  rays  from  a 
tube  of  low  vacuum  exert  their  action  chiefly  superficially,  and  those  from 
one  of  high  vacuum,  mainly  in  the  deeper  parts.  As  a  rule,  in  skin  dis- 
eases, with  some  exceptions,  a  deep  action  is  not  required;  it  should  not 
be  more  than  equal  to  a  2-inch  spark-gap — in  other  words,  a  so-called 
low  vacuum  or  "soft"  tube.  This  has  seemed  to  me  the  most  efficient. 
Some,  however,  favor  a  higher  or  "medium"  or  "medium  soft"  vacuum, 
and  others,  again,  a  higher  vacuum,  or  "hard"  tube.  If  the  dermatosis  is 
exceedingly  superficially  seated,  the  vacuum  can  be  set  low — \  to  f-inch 
spark-gap — and  then  allowed  to  rise.  Should  the  desire  be,  in  some  in- 
stances or  at  times,  to  have  the  extreme  outer  surface  of  the  skin  rela- 
tively spared,  as  obtains  in  some  stages  of  the  treatment  of  epithelioma 
and  lupus,  where  surface  action  is  to  be  avoided  or  has  already  been 
sufficient  or  troublesome,  then  a  thin  sheet  of  aluminum  can  be  inter- 
posed (Thompson)  between  the  tube  and  the  part  treated,  thus  shutting 
off  or  limiting  the  short  or  superficially  acting  rays;  instead  of  the  alu- 
minum sheet  old  tubes  that  have  become  considerably  darkened  and 
coated  with  metal  can  be  used. 

Great  care  should  be  exercised  that  the  wires  connecting  the  tube 
with  the  coil  or  static  machine  are  firmly  attached  and  so  placed  that 
there  is  no  possibility  of  their  getting  loose  or  in  any  other  way  coming 
in  contact  or  even  in  close  proximity  to  the  patient,  in  order  that  un- 
pleasant shock  and  unnecessary  alarm  may  be  prevented. 

An  important  desideratum  in  x-ray  treatment  is  the  protection  of 
the  other  parts  not  being  treated.     Various  plans  are  in  vogue,  and  are 
well  known.     The  most  common  is  the  covering  over  of  the  surrounding 
and  nearby  parts  with  thin  sheet-lead  or  several  layers  of  tin-foil,  an  " 
opening  being  made  sufficiently  large  for  the  diseased  area.     If  the  dis- 

1  MacKee  and  Remer  ("The  Single-Dose  X-ray  Method,"  Jour.  Cutan.  Dis.,  1912, 
p.  528)  briefly  review  this  method,  and  advocate  it. 

9 


130  GENERAL   REMARKS   ON  TREATMENT 

ease  is  on  the  face,  a  mask  can  be  made  (pasteboard  or  gauze)  and  covered 
with  four  or  five  layers  of  tin-foil,  except  at  the  part  immediately  over  the 
disease,  which  can  be  cut  out.  These  devices,  however,  consume  time. 
In  my  own  work,  which  is  largely  for  disease  seated  upon  the  face  or  some 
parts  of  it,  I  usually  employ  the  Friedlander  shield  over  the  tube;  the 
size  of  the  opening  used  can  be  readily  regulated.  With  this  or  similar 
shield1  one  could  do  away  with  the  necessity  of  attaching  any  protect- 
ing foil  to  the  patient;  but  it  is  probably  better  to  place  a  narrow  band 
of  foil  around  about  the  diseased  area,  to  protect  the  surrounding  skin 
from  stray  rays;  this  can  be  fastened  with  adhesive  plaster.  Particular 
attention  should  be  given  that  the  scalp,  hair,  eyebrows,  and  eyelashes 
are  protected,  for  exceptionally  a  single  exposure,  especially  if  at  all  pro- 
longed, will  be  followed  by  complete  hair-loss  of  the  part  exposed;  a 
regrowth,  however,  finally  takes  place.  In  long  exposure  the  lips  should 
also  be  protected. 

In  ordinary  therapeutic  work  the  protection,  by  the  above  measure, 
thus  given  the  operator  will  usually  be  sufficient  to  prevent  any  damaging 
action.  In  addition  to  this  an  arrangement  can  readily  be  rigged  so 
that  the  current  is  stopped  before  the  operator  approaches  the  tube. 
An  additional  screen  can  also  be  placed  between  the  tube  and  the  part 
of  the  room  where  the  physician  or  attendant  is  seated  while  the  exposure 
is  going  on. 

Further  data  as  to  the  action  of  the  rays,  both  therapeutically  and 
pathologically,  as  well  as  the  distance  of  the  tube  and  duration  of  ex- 
posure, will  be  found  under  £-ray  Dermatitis  and  in  connection  with  the 
diseases  in  which  the  method  is  employed. 

In  place  of  the  x-ray,  radium  and  other  radio-active  substances  have 
been  variously  extolled.  Radium  has  apparently  about  similar  radio- 
active properties,  and  probably  some  properties  peculiar  to  itself.  While 
not  so  generally  applied,  radium,  in  the  hands  of  those  skilled  in  its  use 
(Wickham,  Abbey,  and  others2),  produces  brilliant  results  in  some  con- 
ditions. For  use  in  cavities,  such  as  the  mouth,  nose,  etc.,  and  for  easy 
application  to  small  cutaneous  lesions,  it  has  some  advantages,  more  espe- 
cially of  convenience.  It  can  be  used  either  in  a  properly  arranged 
applicator,  or,  on  surface  lesions,  the  glass  receptacle  or  aluminum  capsule 
containing  the  radium  can  be  fastened  with  adhesive  plaster.  The  dura- 
tion of  the  first  application  should  not  be,  if  the  preparation  is  a  strong 
one,  more  than  ten  to  twenty  minutes ;  after  several  days  it  is  again  re- 
peated, and  later,  if  necessary,  and  if  there  are  no  reactive  symptoms, 
the  time  of  exposure  can  be  gradually  lengthened.  Duration  and  fre- 
quency depend  upon  the  activity  of  the  preparation — it  should  have 
the  highest  possible  radio-activity ;  with  the  weaker  preparations  the  les- 
sened power  must  be  made  up  by  increased  quantity  and  much  longer 
or  more  frequent  application.  The  weaker,  being  comparatively  inex- 
pensive and  safer,  can  be  entrusted  to  the  patients  with  instructions 
for  exposure  at  short  intervals. 

Actinotherapy. — To  Finsen,  chiefly,  we  owe  the  established  usage 

1  Several  similar  protecting  shields  are  now  on  the  market,  the  lead-glass  shield 
being  an  especially  convenient  one. 

•  Wickham  and  Degrais,  Radiumtherapie,  Paris,  1909. 


of  the  application  of  concentrated  light  deprived  of  its  heat  rays  to  the 
treatment  of  cutaneous  disorders.  His  experimental  studies  with  the 
concentrated  light,  demonstrating  its  destructive  action  upon  bacterial 
life,  led  him  to  apply  it  to  the  treatment  of  lupus  vulgaris.  Since  then 
he  and  others  have  broadened  its  therapeutic  field,  and  it  is  now,  in  some 
of  its  forms  of  application,  also  used  in  lupus  erythematosus,  epithe- 
lioma,  alopecia  areata,  and  some  other  diseases.  While  Finsen  at  first 
resorted  to  sunlight,  applying  it  through  a  properly  shaped  water-con- 
taining lens,  owing  to  the  uncertainty  of  this  source,  he  and  his  asso- 
ciates Forchhammer,  Bang,  and  others,  subsequently  discarded  this 
for  the  carbon  arc-light  of  high  power,  this  being  richer  in  the  acting  rays, 
and  always  available.  The  main  forms  of  apparatus  are:  First  of  all,  the 
Finsen  (so-called  large  Finsen),  and  the  smaller,  similar  (Finsen-Reyn) 
lamps;  in  these  the  principle  of  several  condensing  lenses,  arranged  for 
concentration  in  a  telescope- 
like  tube,  is  the  essential  part. 
This,  it  is  maintained,  and 
doubtless  rightly,  is  necessary 
for  the  deep  penetration  of  the 
rays,  and  in  order  to  get  suffi- 
ciently deep  curative  action. 
It  naturally  necessitates  some 
distance  between  the  actual 
light  and  the  part  being  treated, 
and  requires  more  prolonged  ex- 
posure to  obtain  reaction;  the 
light,  therefore,  is  focused  upon 
the  required  point.  One  of  the 
sections  between  the  lenses  is 
filled  with  distilled  water,  and 
around  this  section  there  is  a 
thin  hollow  jacket,  through 
which  ordinary  water  is  kept 
circulating;  the  heat  rays  are 
thus  filtered  and  overheating 
of  the  apparatus  prevented. 

In  addition,  on  the  part  treated  there  is  firmly  pressed  a  hollow  com- 
pressing lens,  consisting  of  two  quartz  lenses  set  in  a  metal  band, 
through  which  water  is  also  kept  circulating;  besides  still  further 
straining  out  the  heat  rays,  this  compression  lens  also  serves  to  press 
out  the  blood  from  the  tissues,  the  blood  being  a  hindrance  to  the 
deep  penetration  of  the  rays.  The  pressure  is  maintained  by  fastening 
this  hollow  lens  with  straps  or  elastic  bands,  aided  by  the  attendant. 
The  large  Finsen  lamp  requires  with  medium  commercial  voltage  a 
current  of  80  amperes;  the  Finsen-Reyn  lamp  20  amperes.  Lortet  and 
Genoud,  and,  later,  others,  in  order  to  lessen  the  time  of  application, 
as  well  as  to  reduce  the  cost  of  the  apparatus  and  the  amount  of  current 
required,  discarded  the  principle  of  the  telescopically  arranged  condens- 
ing lenses,  and  constructed  an  apparatus  so  as  to  bring  the  light  close  to 


Fig.  23. — Finsen  hollow  compressing  lens 
referred  to  in  the  text;  the  two  tubes  are  for 
ingress  and  egress  of  water.  Cut  is  about 
two-thirds  its  actual  size. 


132 


GENERAL   REMARKS   ON  TREATMENT 


the  part  treated.  This  consists  of  a  basin-  or  bowl-shaped,  thin,  hollow 
metallic  shield,  at  the  projecting  center  of  which  is  set  a  lens,  on  each  side 
of  the  shield;  the  arc  light,  of  carbon  points,  is  brought  up  close  to  the 
inner  lens,  and  against  the  outer  lens  the  patient  presses  the  part  to  be 
treated;  the  apparatus  is  kept  cooled  and  the  heat  rays  strained  out  by 
keeping  water  continually  circulating  through  the  thin  cavity  of  the 
shield  and  lenses.  While  at  first  this  form  of  apparatus,  known  as  the 
French,  or  Lortet  and  Genoud,  lamp,  and  as  the  London  Hospital 
lamp,  was  lauded  as  an  improvement,  further  experience  has  shown  it 
to  be  much  less  penetrating,  and  much  less  effective  in  the  treatment  of 
iupus.  It  usually  brings  about  a  much  more  rapid  surface-action,  but 


Fig.  24. — The  Finsen  hospital  lamp  (showing  the  method  of  employment):  The 
projecting  tubes  can  be  shortened  and  lengthened  so  as  to  permit  the  focusing  of  the 
light  upon  the  diseased  area  being  treated;  the  light  is  directed  through  the  hollow  lens 
(through  which  water  is  circulating),  which  is  kept  pressed  down  upon  the  part  under 
treatment.  It  will  be  noted  that  both  attendants  and  patients  are  provided  with  dark 
glasses  to  protect  the  eyes  from  the  brilliant  dazzling  light. 

fails  in  depth,  even  when  the  time  of  exposure  is  continued  as  long  as 
with  the  Finsen  lamps. 

It  has,  however,  a  field  of  usefulness  in  superficial  dermatoses,  such 
as  superficial  lupus  vulgaris,  alopecia  areata,  and  some  others.  It 
requires  from  5  to  15  amperes.  Bang  and  others,  in  efforts  to  save  time 
in  application,  constructed  a  somewhat  similarly  arranged  pressure  lamp, 
having,  instead  of  carbon,  hollow-iron  electrodes  at  the  arc,  which  were 
kept  cooled  by  water  running  into  their  cavities.  The  arc  of  iron  elec- 
trodes is  rich  in  the  erythema-producing  short  rays,  and  a  decided  surface 
reaction  can  be  brought  about  in  a  few  minutes,  but  it  is  still  less  pene- 
trating than  the  Lortet  and  Genoud  lamp.  It  is,  however,  useful  where 


LOCAL    TREATMENT 


133 


a  quick  superficial  action  is  desired.  Moreover,  it  requires  but  a  few 
amperes  of  current.  Somewhat  similar,  but  still  less  active,  lamps  are 
those  devised  by  Gorl,  Leduc,  Piffard,  and  others,  in  which  the  light 
comes  from  the  electric  spark  between  several,  or  more  closely  contiguous, 
metal  electrodes;  this  light  is  rich  in  the  ultraviolet  rays,  but  its  action  is 
exceedingly  superficial.  Another  lamp  which  Kromayer1  has  brought 
forward  as  a  substitute  for  the  Finsen  lamp  is  that  known  as  the  "quartz 
lamp."  This  is  a  mercury-vacuum  lamp,  made  of  melted  quartz  glass, 
imbedded  in  a  running  water-bath,  whose  casing,  the  size  of  a  fist,  permits 
of  the  exit  of  the  light  through  a  quartz  window,  which,  like  Finsen 's 
compression  lens,  may  be  used  as  a  compressorium.  There  seems  to  be 
no  question  that  in  lupus  vulgaris  the  most  efficient  lamps  are  those 
known  as  the  large  Finsen,  and  the  later  smaller  one  known  as  the 
Finsen-Reyn  lamp,2  and  probably  next  in  value  the  Kromayer  quartz 


Fig.  25.— The  Finsen-Reyn  lamp  in  operation  (Allen). 

mercury- vacuum  lamp.     The  Finsen  method  will  be  further  considered 
in  the  section  on  Treatment  of  Tuberculosis  of  the  Skin. 

In  addition  to  these  several  lamps  intended  for  the  close  or  con- 
centrated treatment  of  a  limited  area,  there  are  others  now  employed 
with  carbon,  carbon-iron,  and  iron  electrodes  by  which  the  actinic 
light  is  projected  by  means  of  a  parabolic  reflector  upon  large  surfaces; 

1  Kromayer,  Jour.  Cutan.  Dis.,  1908,  p.  257  (with  review  and  references). 

2  Finsen,  La  semaine  medicate,  Dec.  22,  1897;  Finsen  and  Forchhammer,  Mil- 
theilungen  aus.    Finsen' s  med.  Lyseninstitut,  Nos.  5  and  6,  Jena,  1904.     (This  covers 
all  work  done  at  the  Finsen  Institute  to  date.)     Bang,  Monatsheflc,  July  i,  1898; 
Valdemar  Bie,  Brit.  Med.  Jour.,  Sept.  30,  1899;  Macleod,  Brit.  Jour.  Derm.,  Sept., 
1899;  Stelwagon,   University  Med.  Mag.,  Phila.,  Dec.,  1900;  Discussion,  Section  Der- 
matol.,  Trans.  Internal.  Cong.,  Paris,  1900;  Discussion,  Brit.  Med.  Assoc.,  Brit.  Jour. 
Derm.,  1901,  p.  381;  Leredde  and  Pautrier,  Annales,  1902,  pp.  327,  etc.;  Hyde,  F. 
H.  Montgomery,  and  Ormsby,  Jour.  Amer.  Med.  Assoc.,  1903,  xl,  p.  i;  F.  H.  Mont- 
gomery, Jour.  Cutan.  Dis.,  1903,  p.  529;  Morris  and  Dore,  Practitioner,  April,  1003. 
Also  the  book  publications  by  Freund,  Williams,  Leredde  and  Pautrier,  Allen,  and 
Others. 


134  GENERAL   REMARKS   ON   TREATMENT 

the  heat  effects  in  some  of  these  latter  are  also  of  therapeutic  value  in 
some  cases.  These  larger  reflecting  lamps  are  found  useful  in  those  dis- 
eases usually  benefited  by  sun  exposure,  as  psoriasis,  some  cases  of 
eczema,  etc. 

The  high-frequency  current  (known  both  as  high-frequency 
and  high-tension  currents)  probably  had  its  first  introduction  in  medi- 
cine by  W.  J.  Morton,  of  New  York,  but  the  experiments  by  Tesla,  with 
modern  apparatus,  and  the  enthusiasm  of  D'Arsonval  led  to  its  present 
position  in  medical  therapeutics ;  it  was  Oudin,  however,  who  gave  it  this 
impetus  in  the  treatment  of  diseases  of  the  skin,  and  whose  enthusiasm 
stamped  it  with  almost  alluring  powers.  Many  of  the  claims  made  for 
it  have  failed  of  corroboration  by  other  writers,  but  that  it  has  value  in 
some  dermatoses,  no  one  who  has  conscientiously  tried  it  can  deny.  It 
is  still,  however,  in  the  experimental  stage,  and  needs  much  more  ex- 
perimentation before  its  proper  status  can  be  known.  The  subject 
has  excited  sufficient  interest  to  lead  to  the  publication  of  some  mono- 
graphs and  to  giving  it  an  important  place  in  works  on  allied  subjects.1 
Variously  shaped  electrodes  have  been  designed  for  its  application,  but 
those  of  greatest  value  and  most  generally  useful  in  dermatology  are  the 
hammer-shaped  vacuum  electrode  and  the  carbon,  and  glass-point, 
electrodes ;  and  where  a  more  prompt  and  decided  limited  circumscribed 
action  is  required,  a  pointed  metallic  electrode.2 

Sundry  other  measures  and  instruments  sometimes  have 
a  use  in  dermatologic  therapeutics,  such  as  poultices  for  removing 
crusts;  roller  bandages  for  supporting  dressings  and  otherwise  aiding 
in  the  treatment,  as  in  eczema  of  the  legs  associated  with  varicose  veins; 
rubber  or  elastic  bandages  and  elastic  stockings  for  similar  purpose, 
but  these  must  be  used  with  caution,  owing  to  possible  irritation.  Coun- 
terirritation  over  the  vasomotor  centers  controlling  the  affected  region — 
a  local  measure  with,  however,  a  constitutional  influence — has  been 
highly  commended  by  Crocker  in  obstinately  recurring  eczema  and 
similar  inflammatory  diseases;  it  may  be  effected  by  sinapisms,  blisters, 
or  with  the  galvanic  electrode,  or  with  the  point  or  roller  electrode  of  the 
static  current.  Massage  or  rubbing  with  oils  or  ointments  is  some- 
times of  service  in  starting  up  the  absorption  of  inflammatory  exudates 
or  induration,  and  is  also  valuable  in  elephantiasis,  scleroderma,  in 
alopecia,  and  some  other  affections.  It  has  long  been  known  that 
"stirring  up  the  skin" — i.  e.,  increasing  and  promoting  temporarily 
active  hyperemia — is  of  benefit  in  certain  cases,  and  especially  in  slug- 
gish and  chronic  areas,  and  we  know  now  that  it  does  so  by  accentuating 
and  imitating  nature's  method.  Some  of  the  measures  already  men- 
tioned doubtless  owe  part  of  their  value  to  this  action.  Bier's  hyperemic 
treatment — the  production  of  active  and  passive  hyperemia  by  means 


1  Denoyes,  Les  Courants  de  Haute  Frequence,  Paris,  1902;  Chisolm  Williams,  High- 
frequency  Currents  in  the  Treatment  of  Some  Diseases,  London,  1903;  Freund's  Radio- 
therapy, and  Allen's  recent  work. 

2  MacKee,  Jour.  Cutan.  Dis.,  1909,  p.  245,  gives  a  favorable  experience  with  this 
last  method  (fulguration,  or  high-frequency  caustic  spark),  and  briefly  reviews  the  work 
of  others,  with  references. 


LOCAL    TREATMENT  135 

of  hot  air,  cupping,  and  bandaging — is  another  method  lately  utilized 
for  this  same  purpose.1 

In  addition  to  the  various  instruments  already  indicated  may  be 
mentioned  the  dental  burr  and  hook  used  in  the  destruction  of  iso- 
lated tubercles  in  lupus  vulgaris;  the  depilating  forceps,  with  easy  spring, 
for  extracting  hairs;  a  hypodermic  syringe,  and  a  slightly  larger  but 
similar  syringe  for  washing  out  acne-abscess  cavities;  an  atomizer  for 
spraying  and  cleansing  purposes;  and  a  small  massage  cup  for  local 
massage  of  the  face,  and  for  favoring  bleeding  and  discharge  in  the  open- 
ing of  acne  lesions,  etc.  In  some  cases  a  glass  pleximeter  to  observe  the 
lesional  appearance  under  pressure,  a  magnifying  glass  for  more  accurate 
inspection  in  occasional  instances,  small  grappling  forceps,  and  some 
other  instruments  usually  contained  in  an  ordinary  pocket  case,  to- 
gether with  other  special  instruments  and  apparatus  mentioned  for 
particular  purposes  in  the  course  of  the  text  will  be  found  of  service  in 
dermatologic  practice. 

1  Sibley  (Lancet,  Feb.  4,  1911,  and  Archives  of  the  Rontgen  Ray,  April,  1911)  records 
favorable  influences  in  various  chronic  dermatoses  from  Bier's  hyperemic  treatment 
(the  suction  cup  method),  especially  when  used  immediately  or  shortly  before  other 
therapeutic  applications. 


CLASSIFICATION 

PROBABLY  in  no  field  of  medicine  has  the  proper  and  rational  classi- 
fication of  diseases  been  fraught  with  so  much  difficulty  as  in  that  of 
dermatology.  In  the  earliest  period,  with  knowledge  lacking  both 
as  to  the  seat  and  character  of  the  histologic  changes  and  the  nature 
of  etiologic  factors,  it  was  natural  that  the  attempts  should  have  been 
based  upon  external  appearances  or  crude  anatomic  forms.  Thus 
arose  the  classification  of  Willan,  which  was  a  development  on  the  lines 
previously  suggested  by  Plenck,  and  inasmuch  as  in  this  plan  papular 
eruptions  were  placed  in  one  group,  vesicular  eruptions  in  another,  and 
so  on,  it  had  some  advantages  for  diagnostic  study,  and  has  evenj-et 
much  to  commend  it.  Although  it  had  the  advantage  of  simplicity, 
it  linked  together  totally  dissimilar  diseases,  and  gave  no  intimation  of 
the  pathologic  process  and  the  cause  of  the  malady,  and  therefore  no 
hint  as  to  therapeutic  management. 

Alibert  endeavored  to  build  up  a  classification  upon  a  somewhat 
similar  but  broader  basis,  according  to  the  clinical  character  and  in- 
herent natural  affinities  of  the  various  diseases,  but,  owing  to  the  many 
contradictions  necessarily  entailed  in  its  elaboration,  it  did  not  gain 
universal  acceptance.  The  French  have,  as  a  rule,  always  favored  the 
emphasizing  of  the  constitutional  etiologic  factors,  as  displayed  in 
Bazin's  classification,  but  the  weakness  of  such  a  foundation  is  the 
assumption  of  data  of  cause  and  effect  that  in  great  measure  are  purely 
hypothetical.  Nor  did  Erasmus  Wilson's  scheme,  grounded  essentially 
upon  the  anatomic  structure  of  the  skin,  meet  with  general  favor. 

The  system  that  has  been  received  with  the  greatest  support  is 
that  elaborated  by  Rokitansky  and  Hebra,  who,  with  the  pathologic 
knowledge  of  the  former  and  the  pathologic  knowledge  and  clinical 
experience  of  the  latter,  formulated  a  classification,  based  principally 
upon  pathologic  histology,  and  yet  with  some,  although  minor,  reference 
to  etiology,  anatomy,  and  physiology.  In  following  this  plan,  however, 
certain  inconsistencies  are  evolved,  but  much  less  strikingly  at  the  time 
of  its  adoption  than  at  the  present  day.  Other  praiseworthy  attempts, 
displaying  much  thought,  dividing  the  diseases  into  natural  classes  and 
subdivisions,  based,  for  the  most  part,  primarily  upon  the  general 
pathologic  factors, — using  the  term  pathologic  in  its  broadest  sense, — 
have  been  made  by  Auspitz  and  Bronson,1  and  although  their  scientific 
elaborations  appeal  to  the  trained  dermatologic  mind,  that  promulgated 
by  Hebra  would  seem  to  be  less  complex  and  to  form  a  better  working 
basis  for  teaching  and  study. 

1  Bronson,  Jour.  Culan.  Dis.,  1887,  pp.  371  and  427;  also  gives  an  analysis  of 
Auspitz's  classification  in  the  same  publication,  1884,  pp.  161  and  202. 
136 


CL  A  SSI  PICA  TION  1 3  / 

Professor  Duhring,1  who,  in  his  former  treatise,  adopted  Hebra's 
system,  with  some  slight  modification,  recently,  urged,  doubtless,  by  the 
changing  views  in  late  years  regarding  the  causes  of  disease,  still  further 
modified  it  by  more  or  less  completely  eliminating  etiology  and  omitting 
an  etiologic  class,  its  foundation  being  essentially  clinical  features,  normal 
and  pathologic  anatomy.  While  it  has  many  advantages,  and  shows 
the  usual  careful  and  profound  throught  of  this  distinguished  derma- 
tologist, the  elimination  of  the  long-recognized  and  accepted  class  of 
"parasitic  diseases"  and  their  transference  to  the  "inflammations" 
constitute  too  great  an  overthrow  of  established  usage  for  the  wisdom 
of  this  plan  to  gain  immediate  recognition,  although,  in  view  of  the 
prevailing  belief  that  many  other  cutaneous  diseases  not  included  there- 
in are  due  to  micro-organisms,  the  abolition  of  such  a  class  would  seem 
to  be  a  necessary  logical  outcome.  It  is  only  too  true  that  a  perfectly 
satisfactory  classification — one  that  is  free  from  criticism — is,  in  the 
present  state  of  our  knowledge,  an  impossibility,  and  the  "alphabetic" 
arrangement  adopted  by  some  American  and  French  authors,  and  for 
the  present  also  in  use  by  the  American  Dermatological  Association,  is 
sufficient  evidence  of  this. 

I  had  long  thought  to  accept  the  latter  plan  as  an  easy  way  out  of 
difficulty,  and  one  that  has  some  advantages;  but  on  mature  considera- 
tion I  feel  that  a  classification,  although  it  may  be  imperfect  and  in- 
consistent in  many  of  its  details,  yet  contains  much  knowledge  and 
information  that  readers  and  students  unconsciously  assimilate.  The 
system  here  adopted  for  this  purpose  is  Hebra's  system,  which,  I  believe, 
with  its  modifications  by  Crocker,  of  placing,  for  more  convenient 
reference,  the  diseases  of  the  appendages  in  one  class,  and  with  the 
further  slight  modifications  by  Morrow,  still  constitutes,  in  spite  of  its 
inconsistencies,  the  most  practical  one.  The  propriety  of  transferring 
some  diseases  from  one  section  to  another  upon  the  basis  of  more  recent 
clinical  observations  and  pathologic  investigation,  has  occurred  to  me, 
and  most  strongly  as  regards  erythema  induratum  scrofulosorum,  lichen 
scrofulosus,  lupus  erythematosus,  etc.,  about  which  there  is  a  growing 
belief,  in  which  I  share,  that  we  have  to  do  with  affections  due  either 
directly  or  indirectly  to  the  tubercle  bacillus,  and  if  so,  properly  classi- 
fiable among  the  tuberculoses  of  the  skin;  but  the  evidence  is  not  yet  suffi- 
ciently conclusive  to  warrant  such  transference  without  some  risk  that  the 
change  may  not  be  a  permanent  one.  Rearrangement,  it  seems  to  me, 
should  be  only  upon  the  basis  of  at  least  tolerably  assured  certainty. 
I  have,  therefore,  made  but  a  few,  and  these  immaterial,  changes,  more 
especially  in  the  grouping  and  order  of  consideration  of  the  diseases  in  a 
few  of  the  classes,  and  have  added  a  supplementary  chapter  for  the 
brief  presentation  of  a  few  diseases  of  the  adjoining  mucous  membranes. 

CLASS  I— HYPEREMIAS 

Essential  Character. 

Erythema  hyperaemicum.  "j 

Erythema  intertrigo.  Y  Active  congestion. 

Erythema  scarlatinoides. 

1  Duhring,  Jour.  Cutan.  Dis.,  1898,  p.  97;  and  Cutaneous  Medicine,  part  ii,  p.223. 


138 


CLASSIFICA  TION 


CLASS  II— INFLAMMATIONS 


Erythema  multiforme. 

Erythema  nodosum. 
Erythema  induratum. 

Erythema  elevatum  diutinum. 
Granuloma  annulate. 
Pellagra. 

Urticaria. 

Urticaria  pigmentosa. 

(Edema  angioneuroticum. 

Pityriasis  rosea. 
Dermatitis  exfoliativa. 
Dermatitis  exfoliativa  epidemica. 
Dermatitis  exfoliativa  neonatorum. 

Prurigo. 

Prurigo  nodularis. 
Lichen  ruber. 
Lichen  planus. 
Lichen  scrofulosus. 

Psoriasis. 

Pityriasis  rubra  pilaris. 

Eczema. 

Dermatitis  seborrhoica. 

Herpes  simplex. 
Herpes  zoster. 

Hydroa  vacciniforme. 
Pompholyx. 

Dermatitis  herpetiformis. 

Pemphigus. 
Dermatitis  repens. 
Impetigo  contagiosa. 
Ecthyma. 

Impetigo  herpetiformis. 

Furunculus. 
Carbunculus. 
Phlegmona  diffusa. 

Dissection  wounds. 
Equinia. 
Malignant  pustule. 

Erysipelas. 
Erysipeloid. 

Sphaceloderrna — 

Dermatitis  gangraenosa  infantum. 
Multiple  gangrene  in  adults 
Diabetic  gangrene. 
Symmetric  gangrene 


Predominant  Clinical  Characters, 
j  Erythematous,     erythematopapular,     or 
\     multiform. 

Erythematonodular. 
Erythematonodular  and  ulcerative. 

>  Erythematous. 

>  Erythematous,  edematous. 


y  Erythematosquamous. 


>•  Papular. 


>  Papulosquamous. 

f  Erythematous,    papular,    vesicular,   pus- 
\      tular,  squamous,  or  multiform. 

(  Erythematosquamous,    erythematopapu- 
\      lar,  or  multiform. 

>  Vesicular  —  grouped. 


f  Vesicular  and  bullous. 

(  Usually  vesicular  and  bullous;  less  fre- 
-<  quently  erythematous,  erythemato- 
(  papular,  pustular,  or  mixed. 

Bullous. 

<  Epidermic  denudation  and  serous  under- 
\  mining. 

Vesicopustular. 

f  Pustular  —  large,  with  markedly  inflam- 
\  matory  base. 

f  Pustular  —  miliary,  grouped,  and  spread- 
\  ing  concentrically. 

>  Phlegmonous. 

[-  Pustular,  papillomatous,  necrotic. 


>•  Erythemato-edematous. 


}•  Necrotic  and  gangrenous. 


CLASSIFICA  TION 


139 


Dermatitis  calorica. 
Dermatitis  traumatica. 
Dermatitis  venenata. 
X-ray  dermatitis. 
Dermatitis  factitia. 
Dermatitis  medicamentosa. 

Exanthemata. 
Scarlatina. 
Rubeola. 
Rotheln. 

Varicella. 
Variola. 


Vaccinal  eruptions. 


^Varied — multiform,  superficial,  or  deep- 
seated. 


>•  Erythematous,  maculopapular. 

Vesicular. 

(  Primarily  papular,  then  vesicular  and  pus- 
\      tular. 

f  Erythematous,  vesicular,  pustular,  multi- 
\     form,  etc. 


Purpura. 


CLASS  III.— HEMORRHAGES 


Essential  Character. 
Blood  extravasation. 


Lentigo. 
Chloasma. 

Naevus  pigmentosus. 

Acanthosis  nigricans. 
Clavus. 


CLASS  IV.— HYPERTROPHIES 

Predominant  Feature. 
Circumscribed  pigmentation. 
Diffused  pigmentation. 

f  Circumscribed  pigmentation  with  variable 
\      tissue  increase. 


Callositas. 

Keratosis  palmaris  et  plantaris.     . 

Keratosis  blenorrhagica. 

Keratosis  senilis. 

Keratosis  pilaris. 
Keratosis  follicularis. 

Verruca. 

Cornu  cutaneum. 

Ichthyosis. 

Porokeratosis. 

Angiokeratoma. 

Scleroderma. 
Sclerema  neonatorum. 

CEdema  neonatorum. 

Elephantiasis. 
Dermatolysis. 


Pigmentation,  with  verrucous  growths. 
Circumscribed  epidermic  thickening. 


[•  Hardened  epidermic  thickening. 

f  Circumscribed  horny  epidermic  thicken- 
\     ing  or  accumulation. 

Epidermic  follicular  papules. 
Pilosebaceous  horny  plugs. 

/  Circumscribed  epidermic  papillary  forma- 
\     tion. 

Projecting  epidermic  horny  formation. 

f  Epidermic  thickening,  with  variable  pap- 
\     illary  elevations. 

(A  spreading  plaque  with  a  dyke-like  epi- 
dermic horny  periphery,  and  usually 
atrophic  center. 

f  Circumscribed   telangiectatic,   epidermic, 
\      wart-like  formation. 

\  Cutaneous    induration    and    infiltration, 
J      with  sometimes  later  atrophic  changes. 

/  Edema,  infiltration,  with  variable  indu- 
\     ration. 

Thickening  and  enlargement. 
Hypertrophy  and  looseness. 


140 


CLASSIFICA  TIOJV 


Albinismus. 

Vitiligo. 

Glossy  skin. 

Atrophia  senilis. 

Striae  et  maculae  atrophicae. 

Diffuse  idiopathic  atrophy. 

Kraurosis  vulvae. 
Ainhum. 

Perforating  ulcer  of  the  foot. 
Morvan's  disease. 


CLASS  V.— ATROPHIES 

Prominent  Characters. 
(  Absence  of  pigment,  congenital — patchy 
\     or  universal. 

f  Patchy  absence  of  pigment  with  periph- 
1  eral  increased  pigmentation;  acquired. 

/  Glossy  thinned  skin,  usually  of  fingers  or 
\  hand. 

f  Thin,  wrinkled  skin,  with  circumscribed 
1  pigmentation  and  often  scurfy  spots. 

/  Linear  and  patchy  thinning;  white 
\  pearly,  or  pinkish. 

( Thinning,  limited  or  general,  with  often 
•j  associated  whiteness  or  pigmentary 
(.  changes  and  wrinkling. 

Thinning,  shriveling,  with  constriction. 

/A  constricting,  contracting  corneous 
\  band. 

( Penetrating     progressive     circumscribed 
ulcer  leading    to    the   formation   of   a 
(     sinus. 

Analgesic  whitlows. 


CLASS  VI —NEW  GROWTHS 


Cicatrix. 

Keloid. 

Dermatitis  papillaris  capillitii. 

Molluscum  contagiosum. 

Multiple  benign  cystic  epithelioma. 

Adenoma  sebaceum. 

Lymphangioma  circumscriptum. 

Xanthoma. 

Xanthoma  diabeticorum. 

Colloid  degeneration  of  the  skin. 

Angioma. 

Naevus  vascularis. 

Telangiectasis. 
Angioma  serpiginosum. 
Granuloma  pyogenicum. 
Fibroma. 
Lipoma. 
Myoma. 
Neuroma. 

Rhinoscleroma. 
Tuberculosis  cutis. 

Tuberculosis  ulcerosa. 

Tuberculosis  disseminata. 

Tuberculosis  verrucosa. 

Scrofuloderma. 

Lupus  vulgaris. 
Lupus  erythematosus. 
Syphilis. 
Aleppo  boil. 
Frambesia. 
Gangosa. 
Verruga. 


General  Character. 


>  Benign. 


Of  possible  malignancy. 


CLASSIFICA  TION 


Carcinoma. 

Paget's  disease. 

Epithelioma. 

Xeroderma  pigmentosum. 
Sarcoma. 

Granuloma  fungoides. 
Leukemias. 
Leprosy. 


*•  Malignant. 


Hyperesthesia. 
Dermatalgia. 

Erythromelalgia. 

Pruritus. 

Anesthesia. 


CLASS  VII.— NEUROSES 

Chief  Symptom. 
>  Increased  or  painful  sensation. 

Pain  and  burning,  with  lividity. 

Itching. 

Decreased  sensation. 


CLASS  VIII —DISEASES  OF  THE  APPENDAGES 

1.  Nails.  Predominant  Process  or  Symptom. 

(  r\-- 

Onychauxis. 


Atrophia  unguium. 
Onychomycosis. 


/  Overgrowth,  with  or  without  malforma- 
\      tion  or  inflammation. 


f  Defective  growth,  degenerative  or  dys- 
\      trophic  changes. 

f  Degenerative,  granular,  and  friable,  due 
\      to  vegetable  parasitic  invasion. 


2.  Hair;  Hair-foUicles. 

Hypertrichosis. 
Atrophia  pilorum  propria. 

Fragilitas  crinium. 

Trichorrhexis  nodosa. 

Monilethrix. 

Piedra. 
Tinea  nodosa. 
Leptothrix. 

Canities. 
Alopecia. 
Alopecia  areata. 

Folliculitis  decalvans. 


Sycosis. 

Conglomerate  suppurative  folliculitis. 


Excessive  growth. 
Atrophic  changes. 
Defective  growth,  fragibility. 
Nodular  swelling  and  bursting. 
Intermittent  thinning  of  hair-shaft. 

[•  Concretions  on  hair-shaft. 

Loss  of  pigment. 

Baldness. 

Baldness  in  patches. 

f  Follicular  inflammation,  with  consequent 
1      atrophy  and  hair  loss. 

/  Follicular  inflammation,  with  papulation 
\     and  pustulation. 


3.  Sebaceous  Glands. 


Seborrhea. 

Milium. 
Steatoma. 

Comedo. 


Acne. 

Acne  varioliformis. 

Acne  rosacea. 


Predominant  Process  or  Symptom. 
Increased  and  altered  secretion. 

\  Retention  cystic  formations. 

/Blocking   up   of   glandular   outlet,   with 
I      retention. 

( Inflammation,    with    papule    or   pustule 
\      formation. 

Inflammation,  with  resulting  scarring. 

(Inflammation,    with    vascular    stasis    or 
dilatation. 


142 


CLASSIFICA  TION 


4.  Sweat-glands. 
Anidrosis. 
Hyperidrosis. 
Bromidrosis. 
Chromidrosis. 
Hematidrosis. 
Uridrosis. 
Phosphoridrosis. 

Sudamen. 
Hydrocystoma. 

Miliaria. 


Disordered  secretion  without  structural 
change. 


"(Disordered     secretion     with     structural 
/     change. 

f  Disordered  secretion  with  inflammatory 
\     structural  change. 


CLASS  IX —PARASITIC  AFFECTIONS 


A.  Vegetable. 
Favus. 

Ringworm. 

Tinea  imbricata. 
Tinea  versicolor. 

Erythrasma 

Dhobie  itch. 

Pinta  disease. 
Myringomycosis. 

Actinomycosis. 
Mycetoma. 

Blastomycosis. 
Sporotrichosis. 


Part  Involved  and  General  Character. 
f  Hair    and    skin;    yellowish,    mortar-like 
\      crusting. 

(Hair  and  skin;  patchy  scurfiness,  usually 
rounded,  ring-like,  with  hair  brittle- 
ness. 

Skin;  concentric,  imbricated  scaly  rings. 

/  Skin;  chiefly  upper  trunk;  fawn-colored 
\     patches. 

(  Skin;   axillary  and  genitocrural  regions; 
\      reddish  or  yellowish-brown  patches. 

/  Skin;  inflammatory;  usually  axillary  and 
\     genito-crural  regions. 

Skin;  variously  colored  patches. 
Skin;  ear  canal;  scurfiness. 

\Skin   and   subcutaneous   tissue;   infiltra- 
j      tion,  nodulation,  and  usually  sinuses. 

\Skin  and  subcutaneous  tissue;  tubercular 
/      and  papillomatous. 


B.  Animal. 

Pediculosis — capitis,  corporis,  pubis. 
Brown-tail  moth. 
Pediculoides  ventricosus. 
Cimex  lecturlarius. 
Pulex  irritans. 

'  Txodes. 
Dermanyssus 

avium. 
Culicidae. 
Similidae. 
.Apidae,  etc. 


Miscellaneous. 


Scabies. 

Leptus  autumnalis. 

Pulex  penetrans. 

Dracunculus. 

Cysticercus  cellulosae. 

Demodex  folliculorum. 

fCEstridae. 
Craw-craw. 
Echinococcus 
cutis,  etc. 


Miscellaneous. 


Living  on  or  attacking  the  skin 


Penetrating  the  skin — either  the  parasites 
or  their  larvae. 


CLASS   I.— HYPEREMIAS 

IN  the  class  of  hyperemias  (hyperasmiae),  or  congestions,  should  be 
included  only  those  cutaneous  conditions  characterized  by  an  abnormal 
flux  of  blood,  unattended  by  ordinary  inflammatory  changes.  This 
class  is  directly  opposed  to  that  known  as  anemias,  sometimes  included 
in  dermatologic  treatises,  in  which  there  is  an  abnormal  diminution  of 
blood  in  the  part,  resulting  in  pallor  of  the  skin.  This  latter  is  merely 
a  passing  condition  without  significance  or  a  more  or  less  permanent 
state  symptomatic  of  systemic  blood  impoverishment;  it  belongs,  there- 
fore, more  properly  to  general  medicine,  and  need  not  be  considered  here. 
Although  hyperemias  are  to  be  considered  as  simple  congestion,  it  is 
not  unusual  to  find  often  a  slight,  although  scarcely  perceptible,  tendency 
to  inflammatory  action.  On  the  other  hand,  instead  of  being  an  active 
phenomenon,  it  may  be  purely  a  passive  congestion,  really  a  stasis,  and 
which  may  be  of  a  dark,  livid  color, — livedo, — and  due  to  local  causes 
or  to  general  circulatory  weakness,  sometimes  resulting  in  a  more  or  less 
general  passive,  livid  congestion  of  the  surface — cyanosis.  The  active 
hyperemias  are  represented  by  the  non-inflammatory  or  non-exudative 
erythemata. 

ERYTHEMA 

When  used  alone,  this  term  is  a  somewhat  indefinite  one,  and  indi- 
cates a  hyperemia  or  redness  of  the  skin  that  may  be  congestive  or  exuda- 
tive. Ordinarily,  however,  it  refers  merely  to  the  simple  hyperemias 
coming  under  the  head  of  erythema  hyperaemicum  seu  simplex,  those 
erythemata  that  are  exudative  coming  under  the  head  of  inflammations. 
The  dividing-line  between  the  erythemata  without  exudation  and  the 
erythemata  with  exudation  and  the  mildest  grades  of  dermatitis  cannot 
always  be  clearly  drawn. 

ERYTHEMA  HYPERAEMICUM 

Synonyms. — Erythema  simplex;  Erythema  congest! vum. 

Definition. — Erythema  hypersemicum  may  be  defined  as  a  hy- 
peremic  disorder,  appearing  in  the  form  of  variously  sized  and  shaped, 
circumscribed  or  diffused,  limited  or  more  or  less  general,  pinkish  or  red, 
non-elevated  patches. 

The  erythemata  are  usually  divided  into  two  general  classes — 
idiopathic  and  symptomatic.  In  the  former  are  included  all  those 
erythemata  due  to  external  agencies.  In  the  latter,  all  those  cases  in 
which  the  erythema  precedes  or  accompanies  systemic  febrile  disease; 
and  those  due  to  disorders  of  the  digestive  tract,  to  the  development 
of  intestinal  toxins,  and  to  the  ingestion  of  certain  drugs. 

143 


144  HYPEREMIAS 

Symptoms.— Of  the  Idiopathic  Class. — The  essential  symptom  is 
redness,  which  may  vary  as  to  degree,  but  is  without  perceptible  eleva- 
tion or  infiltration.  It  disappears  under  pressure,  to  reappear  as  soon 
as  pressure  is  withdrawn.  It  varies  in  extent  in  different  instances, 
dependent  upon  the  amount  of  surface  exposed  to  the  etiologic  factor, 
most  of  the  cases,  naturally  being  of  a  limited  area. 

If  the  cause  continue,  the  condition  may  progress  from  an  erythema 
to  a  dermatitis;  such  cases  will  be  considered  under  the  latter  head. 
If  the  erythema  occurs  repeatedly  in  the  same  location,  there  may  be, 
in  consequence,  more  or  less  pigmentation,  but  this  is  usually  slight  in 
character. 

In  this  class  are  to  be  found  the  erythemata  due  to  heat  and  cold 
— erythema  caloricum.  That  due  to  artificial  heat  is  sometimes  desig- 
nated erythema  ab  igne,  and  that  occurring  from  the  effects  of  the 
sun's  rays,  erythema  solare.  The  former  is  seen  on  the  lower  parts  of 
the  legs  of  those  who  may  be  in  the  habit  of  sitting  close  to  the  fire, 
such  as  cooks,  stokers,  and  engineers.  It  appears  as  ill-defined  red  spots, 
sometimes  reticulated,  and  sometimes  with  a  tendency  to  be  gyrate  and 
annular;  after  cessation  of  the  cause  it  may  give  place  to  moderate  pig- 
mentation.1 The  erythema  due  to  the  sun's  rays  is  well  known,  being, 
according  to  the  duration  of  exposure  and  season,  and  in  a  measure  to 
the  sensitiveness  of  the  individual  skin,  from  a  light  to  a  brilliant  red 
in  appearance.  Although  heat  doubtless  has  an  influence  in  its  produc- 
tion, it  is  now  known  that  the  chemical  or  actinic  rays  of  light  play  the 
important  part.  Prolonged  exposure,  in  those  with  sensitive  skin,  may 
result  in  a  dermatitis,  usually  of  a  vesicular  character.  Repeated  ex- 
posures result  in  gradual  pigmentation  which,  owing  doubtless  to  the  pig- 
ment protecting  the  parts  from  the  actinic  rays,  leads  to  more  or  less 
invulnerability. 

Under  erythema  caloricum  belongs  also  the  erythema  due  to  expo- 
sure to  cold, — erythema  pernio,  chilblains, — more  frequently  met  with 
in  children  and  old  people  with  feeble  circulation.  The  common  sites 
are  the  heel,  toes,  ears,  nose,  and  fingers.  The  affected  part  is  dark 
red,  especially  when  it  is  brought  in  proximity  to  heat  of  any  kind.  It  is 
more  or  less  in  abeyance  in  mild  weather,  and  is  especially  troublesome  in 
winter,  particularly  after  being  out  in  the  cold.  There  is  often  consider- 
able burning  and  sometimes,  also,  itching.  The  condition  is  frequently 
persistent,  and  often  rebellious  to  treatment. 

The  term  erythema  perstans,  while  usually  applied  to  rare  cases 
having  some  of  the  features  of  erythema  multiforme  (q.  ».),  might  also 
be  conveniently  used  to  designate  those  cases  of  persistent  stasic,  more 
or  less  livid,  hyperemia  or  erythema  involving,  usually  symmetrically, 
the  fingers,  often  extending  upward  to  hands  and  lower  part  of  fore- 
arms; and  sometimes  involving  also  the  feet  and  lower  part  of  the  legs. 
The  surface  is  usually  cold,  occasionally  with  an  associated  mild  hyperi- 

1  Hartzell  ("Erythema  ab  Igne,"  Jour.  Cutan.  Dis.,  1912,  p.  462;  with  good  illus- 
tration) reports  4  cases,  in  one  of  which  it  was  on  the  lower  part  of  the  back  and  the 
result  of  the  continued  application  of  a  hot-water  bag;  histologic  examination  of  one 
case  showed  the  affection  to  be  clearly  inflammatory,  the  name  erythema  ab  igne  being 
preferable,  therefore,  to  "ephelis  ab  igne." 


ERYTHEMA   HYPER&MICUM  145 

drosis.  There  are,  as  a  rule,  no  subjective  symptoms.  The  causes  are 
obscure,  doubtless  varied;  among  which  are  probably  cardiac  weakness, 
chilblains,  and  coal-tar  drug  habits;  and  it  may  possibly  be  in  some 
instances  a  benign,  persistent,  stationary,  early  stage  (with  no  disposi- 
tion to  progress)  of  Raynaud's  disease. 

Another  source  of  the  erythemata  of  the  idiopathic  class  is  trauma- 
tism  of  mild  degree — erythema  traumaticum.  This  is  due  to  pressure  or 
friction — as,  for  example,  from  tightly  fitting  garments,  a  truss,  garters, 
tight  bandages,  etc.  It  is  localized,  and  disappears  rapidly  upon  removal 
of  the  cause. 

Erythema  paratrimma  is  a  term,  now  almost  obsolete,  sometimes 
applied  to  erythemata  due  to  pressure,  more  particularly  to  the  ery- 
thema preceding  the  formation  of  a  bed-sore.  Probably  of  pressure 
origin  is  that  erythema  seen  not  infrequently  at  the  back  of  the  neck 
in  infants,  sometimes  extending  up  into  the  hair — erythema  nuchae, 
which  is  usually  transitory. 

Erythema  venenatum  is  a  name  given  to  those  simple  erythemata 
produced  by  the  irritation  of  various  mineral  and  vegetable  substances, 
such  as  mustard,  arnica,  strong  soap,  dye-stuffs,  certain  plants,  and 
the  like. 

Symptoms. — Of  the  Symptomatic  Class. — Redness,  disappearing 
upon  pressure,  is  likewise  the  essential  symptom  characteristic  of  this 
class.  The  erythema  varies  in  extent  in  different  cases,  and  may  consist 
of  but  one  or  two  insignificant  patches,  or  the  general  surface  may  be 
more  or  less  covered.  The  emotional  flushings,  for  instance,  of  which 
repeated  blushing  is  the  mildest  example,  can  doubtless  be  included  under 
this  class.  The  color  of  the  symptomatic  erythemata  varies  usually  from 
a  bright  pink  to  red,  but  it  may  be  of  a  darker  hue,  and  may  even  be 
somewhat  livid.  As  a  rule,  there  are  no  subjective  symptoms,  although 
in  some  cases  slight  burning  and  a  feeling  of  warmth  may  be  experienced. 
Itching  is  rarely  present  to  any  degree,  and  is  usually  entirely  absent. 
Several  varieties  may  be  referred  to. 

Erythema  laeve  may  properly  belong  in  this  class,  although  there 
is  a  local  element  in  its  production,  and  it  is  usually  persistent.  This 
refers  to  the  shiny  and  glistening  redness  of  the  skin  sometimes  ob- 
served in  connection  with  edema  of  the  legs. 

Erythema  fugax,  as  the  term  signifies,  applies  to  those  erythemata, 
of  obscure  origin,  which  appear  in  one  or  more  areas,  and  which  are 
capricious  in  their  appearance  and  disappearance.  Such  an  erythema 
may  appear  suddenly,  most  commonly  on  some  part  of  the  face,  and  disap- 
pear again  in  the  course  of  a  few  minutes  or  several  hours,  to  remain  away 
or  to  reappear.  It  is  possibly  allied  to  urticaria,  although  itching  is 
rarely  present  to  any  degree. 

Erythema  urticans  is  somewhat  similar,  but  usually  evanescent  in 
character  and  quite  itchy.  It  is,  as  in  almost  all  the  cases  of  this  class, 
unattended  by  desquamation. 

In  other  cases  the  erythema,  or  rash,  is  more  or  less  general,  pre- 
senting either  as  areas  or  sheets  of  continuous  redness  or  as  closely 
crowded  or  scattered  red  spots.  Sometimes  the  redness  is  punctate, 

10 


1 46  H  YPEREMIAS 

but  as  a  rule  it  is  uniform.  Roseola  is  a  term  that  has  been  applied 
more  or  less  indiscriminately  to  some  of  the  symptomatic  erythemata, 
and  may  be  regarded  as  a  designation  for  the  more  or  less  general  rashes 
of  this  class;  it  is  applied  more  particularly,  however,  to  those  erythemata 
characterized  by  spots  or  patches,  rather  than  by  diffused  rashes.  The 
symptomatic  erythemata  may  be  seen  sometimes  preceding  or  in  the 
course  of  some  systemic  diseases,  such  as  vaccinia,  diphtheria,  variola, 
etc.,  or  they  may  arise  from  some  stomachic  and  intestinal  diseases  and 
from  intestinal  toxins.  In  the  generalized  rashes  due  to  these  latter 
causes  there  may  be  some  slight  febrile  action,  which,  however,  soon 
subsides.  The  erythema  infectiosum  of  Escherich,  Shaw,1  and  others 
appearing  in  children  in  the  spring  and  summer,  and  characterized  by 
somewhat  generalized  macular  and  patchy  erythema,  more  especially 
on  the  face,  legs,  and  arms,  with  sometimes  slight  systemic  disturbance, 
is  probably  due  to  a  mild  toxemia  of  gastro-intestinal  origin.  . 

The  rash  of  symptomatic  erythemata  may  last  from  several  hours 
to  several  days,  and  exceptionally  may  show  slight  desquamation, 
although  this  is  never  a  striking  feature  except  in  the  types  more  properly 
coming  under  the  head  of  erythema  scarlatinoides,  which  will  be  de- 
scribed separately.  Drugs  are  also  responsible  for  some  of  the  erythe- 
mata of  this  class,  and  these  will  be  referred  to  again  under  dermatitis 
medicamentosa . 

Diagnosis. — The  diagnosis  of  most  of  the  erythemata  of  the  idio- 
pathic  class  is  usually  readily  made.  The  erythemata  of  the  symptom- 
atic group  are  occasionally  somewhat  obscure,  especially  in  those  in 
which  there  may  be  some  febrile  action  and  constitutional  disturbance. 
The  absence  of  the  characteristic  features  of  the  rashes  of  measles, 
scarlatina,  and  of  the  other  symptoms  of  these  diseases  can  be  utilized 
in  questionable  cases.2 

Treatment. — The  treatment  of  the  various  erythemata  described 
is  purely  of  an  expectant  or  symptomatic  character.  In  the  idiopathic 
rashes  a  removal  of  the  cause  is,  as  a  rule,  all  that  is  required.  Dusting- 
powders,  mild  lotions,  such  as  are  advised  in  erythema  intertrigo,  may  be 
prescribed,  if  necessary.  The  calamin-zinc-oxid  lotion  is  admirably 
suited  for  eczema  solare,  and  may  be  used  as  a  preventive  measure. 
For  this  last  purpose  pure  calamin  powder  lightly  dusted  over  the  parts 
will  also  have  a  preventive  influence;  this  property  is  due  to  the  pinkish 
or  reddish  color  of  the  calamin  acting  as  an  obstacle  to  the  action  of  the 
actinic  rays. 

In  chilblain  stimulating  local  remedies  are,  as  a  rule,  required.  An 
occasional  painting,  every  two  or  three  days,  with  tincture  of  iodin, 
pure  or  diluted  with  alcohol,  at  times  acts  well.  Painting  on  several 
coatings  of  collodion,  at  intervals  of  a  few  days,  will,  through  the  pressure 
it  exerts,  also  exercise  a  favorable  effect.  Applications  of  balsam  of  Peru 
have  gained  a  reputation  in  this  affection,  but  like  other  drugs,  it  often 
fails  to  exert  an  influence.  Frictions  with  oil  of  turpentine,  pure  or 

1  Shaw,  Amer.  Jour.  Med.  Sci.,  Jan.,  1905. 

2  Winfield,  "Erythematous  Rashes  Simulating  the  Acute  Exanthemata,"  Brooklyn 
Med.  Jour.,  1902,  vol.  xvi,  p.  349. 


ERYTHEMA   INTERTRIGO  147 

diluted  with  oil,  have  also  cured  some  cases.  The  same  may  be  said  of 
strong  ointments — 3  to  to  per  cent,  strength  of  carbolic  acid  and  creasote. 
Ichthyol  is  to  be  commended  as  a  lotion,  diluted  with  two  or  three  parts 
of  water,  or  as  an  ointment  of  25  per  cent,  strength.  These  various 
applications  should  be  made  once  or  twice  daily,  according  to  circum- 
stances. 

In  obstinate  and  troublesome  cases  the  application  of  a  mild  gal- 
vanic current — two  or  three  milliamperes,  three  or  four  times  weekly 
— will  sometimes  prove  of  value;  the  positive  pole  is  to  be  applied  to  the 
affected  part,  and  the  negative  to  a  neighboring  region,  near  the  truncal 
nerve,  or  it  may  be  held  in  the  hand. 

If  a  case  of  chilblain  comes  under  observation  immediately  after 
its  first  appearance,  mild  applications,  such  as  calamin-and-zinc-oxid 
lotion;  or  a  boric  acid  ointment,  10  per  cent,  strength,  with  one  or  two 
grains  of  menthol  to  the  ounce,  may  be  prescribed. 

In  those  susceptible  to  this  condition  warm  clothing  should  be 
worn,  and,  as  a  rule,  warm  water  should  be  used  in  bathing  the  affected 
part,  which  should  then  be  well  dried  with  a  soft  linen  towel.  As  chil- 
blains are  most  frequent  in  the  weak  and  in  those  of  debilitated  con- 
stitution and  weakened  circulation,  tonics,  such  as  strychnin,  arsenic, 
nitroglycerin,  iron,  and,  in  suitable  cases,  cod-liver  oil,  are  often  of  im- 
portance. 

The  symptomatic  erythemata  require  but  little  treatment,  but  a 
careful  study  of  the  individual  case  and  the  discovery  of  the  cause  will 
indicate  the  appropriate  remedies  to  be  prescribed,  and,  what  is  more 
important,  will  be  of  value  in  guarding  against  recurrences.  In  many  of 
these  cases  there  is  an  absence  of  any  recognizable  factor,  and  in  such  a 
good  plan  is  to  give  a  mild  saline  laxative,  or,  in  children,  as  sufficient  dose 
of  gray  powder,  to  bring  about  free  action  of  the  bowels.  Small  doses  of 
intestinal  antiseptics,  such  as  are  prescribed  in  erythema  multiforme, 
should  also  be  prescribed.  Cases  of  any  severity  should  be  kept  indoors, 
and  if  there  is  febrile  action,  the  patient  should  remain  in  bed.  Local 
treatment  is  rarely  required;  if  this  is  necessary,  the  simple  dusting- 
powders  may  be  used,  or,  in  exceptional  instances  in  which  there  may 
be  burning  and  some  itching,  if  the  dusting-powder  does  not  relieve,  a 
weak  carbolic  acid  lotion,  0.5  to  i  per  cent,  strength,  may  be  prescribed. 


ERYTHEMA  INTERTRIGO 

Synonyms. — Chafing;  Intertrigo. 

Definition. — Erythema  intertrigo  is  a  hyperemic  disorder  occur- 
ring on  parts  where  opposing  surfaces  of  the  skin  come  in  contact,  and  is 
characterized  by  redness,  to  which  may  be  added  an  abraded  surface 
and  maceration  of  the  epidermis. 

Symptoms. — The  skin  of  the  involved  region  gradually  becomes 
hyperemic,  and  may  be  attended  by  a  feeling  of  heat,  tenderness,  or 
soreness.  As  a  rule,  there  is  no  elevation  or  infiltration.  If  the  con- 
dition is  long  continued  and  there  are  increased  warmth  and  perspiration 


148  HYPEREMIAS 

and  resulting  moisture  of  the  parts,  a  variable  amount  of  maceration  of 
the  epidermis  and  a  mucoid  discharge  occur.  If  persistent  or  neglected 
or  if  too  vigorously  treated,  actual  inflammation  of  a  superficial  character 
may  eventually  result,  and  the  mucoid  discharge  may  become  somewhat 
purulent.  In  fact,  in  some  such  instances  the  erythema  gradually  changes 
into  a  true  eczema.  The  disease  may  have  its  seat  about  the  nates  and 
genitalia,  in  the  axillary  region,  folds  of  the  neck,  perineum,  or  beneath  the 
mammae;  in  fact,  it  may  occur  in  any  region  where  opposing  surfaces 
come  together.  In  some  instances  in  persistent  cases  superficial  dermic 
abscesses  or  boils  may  be  superadded.  In  neglected  cases,  from  acci- 
dental infection,  too,  the  simple  erythemas,  especially  when  becoming 
macerated,  may  present  erosions  and  almost  superficial  ulcerations.1 

The  course  is  variable  as  to  duration,  depending  upon  the  conditions 
and  upon  persistence  or  disappearance  of  the  cause. 

Etiology. — The  causes  are  usually  local.  It  is  seen  chiefly  in 
children,  especially  in  fat  subjects,  in  whom  friction  and  moisture  of 
contiguous  parts  of  the  body,  most  commonly  the  buttocks,  genitalia, 
and  region  of  the  neck,  are  the  exciting  factors.  Uncleanliness  or  the 
reverse — the  too  free  use  of  soap  and  water,  especially  soaps  of  irritating 
character — will  often  suffice  to  produce  the  disease.  In  infants  the 
malady,  when  involving  the  genitocrural  and  anal  regions,  is  frequently 
due  to  negligence  in  not  promptly  removing  wet  or  soiled  napkins.  Al- 
though the  exciting  factors  are  usually  external,  the  affection  is  more 
frequently  seen  in  those  with  stomach  and  intestinal  disturbances.  In 
erythema  intertrigo  of  the  genitalia  in  adults  diabetes  mellitus  may  be 
the  predisposing  and  active  factor  (Hardy). 

Diagnosis. — The  disorder  is  rarely  difficult  to  recognize.  It  is  to 
be  distinguished  from  eczema,  and,  when  it  occurs  about  the  genitalia, 
from  the  erythema  of  hereditary  syphilis.  The  difference  between 
erythema  intertrigo  and  eczema  is  really,  so  far  as  the  objective  symp- 
toms are  concerned,  one  of  degree.  The  former  is,  however,  free  from 
any  infiltration  or  thickening,  and  is  rarely  itchy;  the  mucoid  discharge, 
when  present,  does  not  stiffen  linen  (Crocker) ;  and  the  disease  disappears 
promptly  upon  removal  of  the  cause  or  after  some  simple  mild  applica- 
tion. 

The  syphilitic  erythema  about  the  buttocks  and  genitalia  of  some 
infants  with  hereditary  syphilis  (Fournier)  sometimes  resembles  it  very 
closely,  but  this  is  somewhat  dark  in  color;  there  is  a  shade  of  infiltra- 
tion, and  the  color  does  not  disappear  entirely  upon  pressure,  usually 
leaving  a  slight  yellowish  tint.  Moreover,  there  are  generally  other 
evidences  of  cutaneous  syphilis,  more  or  less  characteristic,  upon  other 
parts,  and  other  symptoms  pointing  to  that  disease.  In  doubtful 
cases  a  few  days'  observation  would  serve  to  establish  the  diagnosis — a 
marked  change  for  the  better  would  result  in  erythema  intertrigo,  and 
other  developments  would  probably  show  themselves  in  syphilis. 

1  Some  of  the  more  recent  interesting  papers  on  these  erythemas,  especially  as 
regards  the  less  usual  and  the  accidental  conditions,  are:  Jacquet,  La  Pratique  Derma- 
tologique,  and  Adamson,  "On  Napkin-region  Eruptions  in  Infants,"  Brit.  Jour.  Derm., 
1909,  p.  37  (with  several  illustrations,  review,  and  references);  Ferraud,  Les  Dermites 
des  Nouveau-nes  ("Erythemes  Infantiles")  Etude  Histologique,  Annales,  p.  193,  1908. 


ERYTHEMA   INTERTRIGO  149 

Prognosis. — As  already  intimated,  this  is  always  favorable.  An 
inquiry  into  the  cause,  followed  by  its  correction  or  removal,  will  often 
suffice.  Or  this,  together  with  mild  applications,  will  usually  bring 
about  a  cure  rapidly.  Any  predisposing  constitutional  condition  should 
be  corrected,  otherwise  the  case  may  be  more  or  less  persistent,  tend  to 
frequent  recurrence,  or  develop  into  eczema. 

Treatment. — The  folds,  or  parts  affected  are  to  be  kept  from  con- 
tact by  means  of  lint  or  absorbent  cotton,  these  to  be  frequently  changed; 
or  by  flat  bags  of  thin  cheese-cloth  or  similar  fabric  filled  with  a  dusting- 
powder  (Unna).  Cleanliness  is  absolutely  essential,  but  it  is  to  be  kept 
within  the  bounds  of  common  sense.  The  most  appropriate  applications 
are  dusting-powders  and  lotions;  ointments,  as  a  rule,  are  not  so  satis- 
factory, and,  indeed,  not  infrequently  aggravate.  Of  the  dusting- 
powders,  boric  acid,  zinc  oxid,  talcum,  and  chalk  are  probably  the  most 
frequently  used,  and  may  be  prescribed  separately  or  together.  The 
following  has  been  of  good  service: 

1$.     Pulv.  ac.  borici,  3]   (  4); 

Pulv.  zinci  oxidi,  3ij  (  8); 

Pulv.  talci,  3v  (20). 

In  persistent  cases  in  which  the  epiderm  has  become  macerated 
and  the  discharge  is  somewhat  offensive,  a  few  grains  of  salicylic  acid 
may  be  added  to  the  ounce  of  this  formula.  The  powder  should  be 
applied  freely  two  or  more  times  daily,  depending  upon  circumstances; 
the  parts  previously  bathed  gently  with  tepid  water,  and  mopped  dry, 
occasionally  using  a  minimum  quantity  of  a  mild,  neutral  soap.  The 
various  lotions  advised  and  employed  for  the  treatment  of  the  acute 
types  of  eczema  will  also  be  useful  in  this  disorder.  Of  particular  value 
is  one  composed  of  the  following,  known  commonly  as  the  "calamin-zinc- 
oxid"  lotion: 

1$.     Pulv.  calaminae, 

Pulv.  zinci  oxidi,  aa    3»j  (  i2); 

Glycerin,  njjxv  (     i); 

Alcoholis,  f5ss   (     2); 

Aquae,  q.  s.  ad   Oss    (256). 

Lotions  are  best  applied  by  thoroughly  dabbing  on  several  times  daily; 
or  linen  cloths  may  be  wet  with  them,  and  kept  applied  for  ten  or  fifteen 
minutes,  removed,  and  the  lotion  dabbed  directly  on  the  parts. 

Ointments  may  be  required  in  some  instances,  particularly  in  infants 
who  frequently  soil  the  napkins,  the  layer  of  grease  protecting  the  sur- 
face from  the  irritating  discharges.  For  this  purpose  zinc-oxid  oint- 
ment, cold  cream,  and  Lassar's  paste  are  the  most  acceptable. 

In  some  instances  lotions  applied  during  the  day  and  the  ointment 
at  night  will  bring  about  a  favorable  result  most  quickly. 


150  HYPEREMIAS 

ERYTHEMA  SCARLATINOIDES 

Synonyms. — Erythema  scarlatiniforme  (Hardy);  Roseola  scarlatiniforme  (Bazin); 
Desquamative  exfoliative  erythema;  Erythema  scarlatinoides;  Erythema  scarlatinoides 
recidivans;  Fr.,  Erytheme  scarlatinoide;  Erytheme  scarlatiniforme  desquamatif. 

Definition. — Erythema  scarlatinoides  is  a  term  employed  to  des- 
ignate those  cases  of  more  or  less  diffused  erythema  followed  by  partial 
or  complete  desquamation.1 

Symptoms. — There  are  various  grades  of  this  condition,  from 
those  in  which  but  a  part  of  the  body  is  involved,  to  those  in  which 
the  rash  is  almost  continuous  over  the  entire  surface;  with  insignificant 
or  no  constitutional  disturbance,  to  that  of  severe  degree  with  high 
temperature  (Besnier,  Brocq,  Atkinson,  and  others).  Moreover,  the 
rash  is  occasionally  of  a  morbilliform  character;  by  far  the  majority, 
however,  present  a  scarlatinous  appearance.  This  latter  may  in  some 
instances  be  punctiform  at  first,  but,  as  a  rule,  the  redness  soon  becomes 
uniform.  The  color  may  vary  between  a  bright  pink  or  red  to  a  sluggish 
or  livid  red.  Upon  the  whole,  its  color  and  general  appearance  are 
similar  to  those  of  scarlet  fever.  The  rash  may  be  of  acute  onset,  with 
more  or  less  constitutional  disturbance,  or  it  may  be  somewhat  subacute, 
with  slight  or  no  systemic  symptoms.  As  a  rule,  it  is  ushered  in  with 
the  ordinary  symptoms  of  mild  febrile  disease,  with  a  concomitant  de- 
velopment of  the  skin  redness;  or  this  latter  may  not  appear  for  several 
hours  to  a  day  or  so  later. 

The  constitutional  symptoms,  when  present,  frequently  abate  upon 
the  appearance  of  the  erythema.  In  extreme  cases,  however,  the  sys- 
temic disturbance  may  persist  for  several  days  or  longer;  in  fact,  this 
depends  upon  the  cause  responsible  for  the  eruption.  In  most  instances 
the  rash  begins  to  subside  in  from  twenty -four  hours  to  three  or  four 
days,  with  desquamation,  which  may  be  branny  or  may  take  place  in 
large  thin  sheets.  Exceptionally,  desquamation  is  scarcely  perceptible. 
In  extreme  cases  the  tongue  and  throat  may  share  in  the  eruption,  and 
exceptionally  the  nails  be  shed,  and  even  the  hair  be  lost.  These  cases, 
judged  by  the  reports  of  French  writers  (Vidal,  Besnier,  Brocq),  are  more 
common  in  France  than  with  us  or  in  other  countries. 

Recurrences  are  not  uncommon  in  many  cases  (recurrent  exfoliative 
erythema ;  erythema  scarlatinoides  recidivans) ,  but  the  later  attacks  may 
be  less  severe  (Elliot,  Hartzell,  and  others).  The  course  of  the  eruption 
is  usually  run  in  from  one  to  three  or  four  weeks.  As  a  rule,  there  are 
no  subjective  symptoms. 

1  Some  important  literature:  Brocq,  Jour.  Cutan.  Dis.,  1885,  p.  225,  full  account 
and  bibliography  to  date;  I.  E.  Atkinson,  ibid.,  1886,  p.  295;  Ohmann-Dumesnil,  ibid., 
1890,  p.  293,  with  bibliography;  Besnier,  Annales,  1890,  p.  i,  and  Brocq,  p.  265;  Payne, 
Brit.  Jour.  Derm.,  1894,  p.  129  (unusual  persistent  types);  Ohmann-Dumesnil  (in 
typhoid  fever),  Jour.  Cutan.  Dis.,  1890,  p.  293  (with  some  references),  and  St.  Louis 
Med.  and  Surg.  Jour.,  July,  1893;  Elliot,  New  York  Med.  Jour.,  Jan.  n,  1890;  Blanc, 
International  Clinics,  Oct.,  1891,  and  Jour.  Cutan.  Dis.,  1893,  p.  n;  Sligh  (Case  of 
Annual  Skin -shedding),  Internal.  Med.  Mag.,  June,  1893  (with  illustrations);  Hartzell, 
University  Med.  Mag.,  Aug.,  1895;  Luithlen,  Dermatolog.  Zeitschr.,  vol.  ix.  Heft  i,  1902, 
p.  39,  "Dermatitis  Exfoliativa  und  Erythema  Scarlatiforme"  (review  and  references); 
Kramsztyk,  ibid.,  1902,  H.  3,  and  Jahrbuch  fiir  Kinderheilk.,  vol.  Iv,  1902,  No.  3 
(3  cases);  Gardiner,  Brit.  Jour.  Derm.,  1908,  p.  245. 


The  various  cases  of  shedding  of  the  skin  (skin-shedding,  deciduous 
skin)  are  apparently  related  to  this  malady.  The  erythematous  ele- 
ment is,  however,  seldom  so  pronounced.  In  these  cases  there  is  often 
a  tendency  to  periodicity,  the  most  remarkable  in  this  respect  being 
that  reported  by  Sligh  (loc.  cit.),  in  a  man,  aged  thirty-seven,  who  had 
shed  his  skin  annually  since  birth,  the  beginning  evidences  of  recur- 
rence always  showing  on  the  same  date.  Indeed,  in  these  cases  there 
is  a  suggestive  resemblance  to  "molting"  observed  in  some  animals, 
and  to  the  periodic  shedding  of  the  cuticle  in  serpents.  A  case  recently 
came  to  my  own  notice,  through  Dr.  Harmon,  of  Phillipsburg,  Pa.,  of  a 
boy  of  fifteen  who  had  been  "shedding  his  skin"  twice  yearly — July  and 
December — for  the  past  five  years;  there  was  but  slight  redness,  and  no 


Fig.  26. — Erythema  scarlatinoides  in  a  frail  young  woman  of  thirty  years,  and  of 
generalized  distribution,  the  trunk  showing  branny  exfoliation,  the  extremities  that  of  a 
thin,  flake-like  or  lamellar  character.  There  was  no  infiltration,  the  earliest  stage  being 
a  faint  or  moderately  defined  scarlatiniform  erythema.  An  attack  annually  for  several 
years,  lasting  about  four  or  five  weeks.  No  general  symptoms  except  mild  and  evan- 
escent prodromal  febrile  action  and  slight  malaise. 

subjective  symptoms  except  a  preliminary  feeling  of  dryness  of  the  skin; 
the  process  required  about  two  weeks  to  run  its  course. 

Btiology  and  Pathology. — There  are  doubtless  many  causes 
for  this  form  of  erythema,  which  also  demands,  perhaps,  a  peculiar 
individual  idiosyncrasy.  The  various  toxemias,  general  or  intestinal, 
are  probably  most  frequently  responsible.  Septic  infection  seems  at 
times  causative.  The  condition  is  also  seen  in  association  with  albu- 
minuria,  rheumatism,  gonorrhea,  etc.,  and  may  likewise  result  from 
the  eating  of  certain  foods,  especially  "shell-fish"  and  spoiled  meats,  or 
from  the  ingestion  of  certain  drugs.  External  irritation  may  also  be  the 
starting-point  of  the  erythema— as,  for  instance,  after  operation  and 
from  the  use  of  mercury  and  iodoform.  The  rash  produced  by  this 
latter  is,  however,  usually  more  inflammatory  and  belongs  more  properly 


152  HYPEREMIAS 

under  dermatitis  exfoliativa  (q.  v.).  Other  causes  mentioned  are  sewer- 
gas  poisoning  (Crocker),  digestive  derangements  (McCall- Anderson) 
following  injuries  and  operations  (Atkinson),  obscure  changes  of  tissue 
or  secretion  about  wounds  (Hoffa),  malaria  (Cheadle),  prolapsed  and 
enlarged  ovary  (Elliot),  auto-intoxication  with  ptomains  (Lepine  and 
Moliere).  The  manner  in  which  the  eruptive  phenomena  are  produced 
is  unknown;  this  may  be  from  disturbance  of  the  nerve-centers,  direct 
irritation  on  the  peripheral  blood-vessels  or  nerves,  or  of  reflex  origin. 
Brocq  considers  the  disease  a  mild  form  of  dermatitis  exfoliativa. 

Diagnosis. — At  times  there  is  considerable  difficulty  the  first  day 
or  two  in  reaching  a  positive  opinion.  It  resembles  closely  scarlet 
fever,  but  the  intensity  of  the  constitutional  symptoms  of  this  latter, 
the  peculiar  strawberry  tongue,  and  the  swollen  fauces  are  wanting. 
Moreover,  the  erythema  is  rarely  so  general  in  its  distribution  as  the 
rash  of  scarlatina.  Occasionally,  also,  it  presents  some  resemblance 
to  measles,  but  the  peculiar  associated  symptoms  of  measles  would  be 
absent,  and,  moreover,  the  eruption  of  erythema  rarely  begins  on  the 
face,  and  not  infrequently  spares  this  region.  From  rotheln  it  may  be 
distinguished  by  the  absence  of  the  glandular  enlargement  and  the  lack 
of  a  history  of  contagion.  This  latter  can  also  be  utilized  in  differen- 
tiating from  scarlet  fever  and  measles.  It  must  be  admitted,  however, 
that  in  the  beginning  of  a  tolerably  well-marked  case  of  erythema  scarlat- 
inoides  the  diagnosis  cannot  always  be  made  with  certainty,  and  the 
case  should  be  in  such  instances  isolated;  one  or  two  days'  observation 
will  usually  clear  up  any  doubt. 

Prognosis. — This  is  always  favorable;  in  ten  days  to  three  or 
four  weeks  the  patient  is  usually  entirely  over  the  attack.  It  may, 
however,  recur;  and,  in  exceptional  cases,  recurrences  may  follow  some- 
what rapidly  one  after  another,  partaking  more  of  the  nature  of  derma- 
titis exfoliativa  (q.  v.).  In  one  case  (Tilbury  Fox)  there  had  been  100 
attacks. 

Treatment. — The  systemic  treatment  depends  upon  the  cause 
which  may  have  provoked  the  erythema;  when  this  is  ascertainable, 
the  appropriate  remedies  should  be  advised.  In  many  cases,  however, 
the  treatment  must  necessarily  be  based  upon  general  principles.  A 
saline  laxative,  occasionally  repeated,  along  with  moderate  doses  of 
sodium  salicylate,  quinin,  salol,  charcoal,  and  other  intestinal  anti- 
septics, is  to  be  prescribed.  In  debilitated  subjects  strychnin  is  of  value, 
and  later  other  of  the  well-known  tonics.  To  guard  against  recurrences, 
patients  should  be  carefully  advised  as  to  diet,  avoiding  all  questionable 
foods.  The  possibility  of  certain  drugs  being  at  times  responsible  is  to 
be  borne  in  mind. 

External  treatment  is  rarely  called  for.  If  necessary,  dusting- 
powders  may  be  used;  in  fact,  the  same  applications  as  advised  in  ery- 
thema hyperaemicum. 


CLASS   II.— INFLAMMATIONS 
ERYTHEMA  MULTIFORME 

Synonyms. — Erythema  exsudativum  multiforme;  Fr.,  Erytheme  exsudatif  multi- 
forme;  Erytheme  polymorphe;  Ger.,  Erythema  exsudativum  multiforme. 

Definition. — Erythema  multiforme  may  be  defined  as  an  inflam- 
matory disease  of  an  acute  character,  characterized  by  reddish  or  pur- 
plish red,  often  variegated,  macules,  papules,  and  tubercles,  occasionally 
becoming  vesicular  or  bullous,  and  occurring  as  numerous  scattered  or 
grouped  lesions  of  various  size  and  shape.1 

Symptoms. — The  hands  and  forearms,  especially  the  dorsal  sur- 
faces, the  face,  and  the  legs,  particularly  on  the  tibial  aspects,  are  the 
most  common  sites  invaded,  but  it  may  be  more  or  less  extensive.  Ex- 
ceptionally it  may  be  limited  to  the  trunk  (Pick,  Lewin)  and  to  the  face 
(Jamieson).  It  is  occasionally  of  general  distribution.  The  eruption 
usually  makes  its  appearance  suddenly,  and  may  present  itself  as  ery- 
thematous  patches  of  more  or  less  irregular  outline  and  of  various  forms, 
or  it  may  consist  almost  entirely  of  small  to  large  pea-sized  flattened 
papules  or  tubercles;  or  the  eruption  may  be  of  a  mixed  character.  In 
most  instances,  however,  there  is  a  predominance  of  one  type  of  lesion. 
In  the  first  few  days  the  lesions  are  likely  to  increase  somewhat  in  size, 
and  new  efflorescences  appear.  In  fact,  there  may  be  fresh  outbreaks 
every  day  or  two  for  five  to  ten  days,  when  the  process  begins  to  decline. 
Or  the  eruption  may  consist  of  but  one  moderate  or  extensive  outbreak, 
remain  more  or  less  stationary  for  several  days,  and  then  gradually  fade. 
In  color  the  efflorescences  are  usually  at  first  of  a  somewhat  bright  pink 
or  red,  as  a  rule  becoming  later  violaceous  or  purplish,  especially  in  the 
papular  and  tubercular  forms  of  the  disease. 

1  Some  important  literature:  Lewin  (malignant  and  other  forms),  Berlin,  klin. 
Wochenschr.,  1876,  No.  23,  and  Charite-Annalen,  1878,  vol.  iii,  p.  622,  Berlin;  Schwim- 
mer,  Die  neuropathischen  Dermatonosen,  p.  101;  During,  "Beitrag  zur  Lehre  von  den 
polymorphen  Erythemen,"  Archiv.,  1896,  vol.  xxxv,  pp.  211  and  323  (a  valuable 
exhaustive  paper,  discursive  and  analytic,  bearing  upon  infectious,  epidemic,  and  other 
characters,  with  many  literature  references);  Besnier  (pathogeny),  Annales,  1890,  No.  i; 
Polotebnoff,  "Zur  Lehre  von  den  Erythemen,"  Unna's  dermatolog.  Studien,  1887,  Leip- 
zig; Molenes-Mahon,  "Contribution  a  Petude  des  maladies  infectieuses — De  1'erytheme 
polymorphe,"  These  de  Paris,  1884,  No.  60;  Osier,  "The  Visceral  Manifestations  of 
the  Erythema  Group"  (4  papers),  Amer.  Jour.  Med.  Sci.,  Dec.,  1895,  and  Jan.,  1904; 
and  Brit.  Jour.  Derm.,  1900,  p.  227;  and  Johns  Hopkins  Hosp.  Bull.,  1904,  vol.  xv,  p. 
259;  Schamberg,  "An  Inquiry  into  the  Etiology  and  Nature  of  the  Toxic  Erythemata," 
Jour.  Cutan.  Dis.,  1904,  p.  461;  Panichi,  "Erytheme  exsudatif  polymorphe,"  Giorn. 
ital.,  1903,  pp.  22-179 — resume  by  the  author  in  Annales,  1904,  p.  818  (review,  with 
report  of  16  cases,  with  histologic  examination);  Kreibich,  Archiv.,  1901,  vol.  Iviii, 
p.  125  (histologic);  "Papers  on  the  Toxic  Dermatoses,"  by  Hartzell,  Fordyce,  Johns- 
ton, and  Anthony;  and  discussion  on  same,  Jour.  Cutan.  Dis.,  1912,  pp.  119-167; 
"Discussion  on  Erythema  Multiforme,"  Brit.  Jour.  Derm.,  1912,  p.  427  (paper  by 
Adamson;  discussion  by  Pringle,  Whitfield,  Galloway,  Macleod,  W.  Fox,  Pernet, 
Morris,  and  others). 

153 


1 54  INFLAMMA  TIONS 

The  most  common  type  of  the  eruption  is  that  which  consists  pre- 
dominantly or  entirely  of  papules  (erythema  papulatum).  The  papules 
are  usually  small  to  large  pea-sized,  flattened,  sometimes  with  a  slight 
sinking  in  of  the  central  portion.  They  may  be  discrete  or  crowded 
together.  They  tend  to  increase  somewhat  in  size,  the  central  part 
often  becoming  depressed  and  flat,  so  that  some  or  many  of  these  lesions 
have  an  ill-defined  or  well-marked  ring  appearance.  In  color  they 
are  dark  red  or  violaceous.  The  most  frequent  sites  of  this  type  are 
the  dorsal  surfaces  of  the  hands  and  forearms;  the  legs  and  feet,  and 
not  infrequently  the  face  also,  often  share  in  the  eruption.  The  tuber- 
cular type  (erythema  tuberculatum)  is  similar  to  the  papular,  except 
that  the  lesions  are  somewhat  larger  and  deeper  seated,  these  two  types 
are  commonly  seen  together.  Interspersed  nodose  lesions,  such  as  dis- 
tinguish erythema  nodosum,  are  also  occasionally  associated. 

In  other  instances  the  larger  part  of  the  eruption  consists  of  ery- 
thematous  patches  of  various  sizes  and  shapes.  Often  this  type  is  made 
up  of  distinct  rings,  constituting  the  so-called  erythema  annulare;  or, 
instead  of  single  rings,  the  patches  may  consist  of  several  concentric 
rings,  the  outer  rings  forming  after  the  inner  ones  have  appeared,  and 
necessarily,  therefore,  of  different  tints  of  coloring,  giving  rise  to  the 
term,  sometimes  employed,  of  erythema  iris.  The  erythematous  erup- 
tion may,  too,  present  itself  as  one  or  several  or  more  extensive  spread- 
ing patches,  with  a  sharply  defined  border,  the  older  part  fading  away  as 
the  patches  spread  at  the  other  side — so-called  erythema  marginatum. 
In  some  instances  in  which  the  eruption  consists  of  rings,  these  rings 
may  extend  to  considerable  size  and  coalesce,  the  coalescing  edges  usually 
disappearing;  there  results  an  eruption  of  serpentine  lines  or  bands,  some- 
times found  described  as  erythema  gyratum. 

To  a  rare  and  peculiar  persistent  eruption,  partaking  somewhat  of 
the  nature  of  both  erythema  hyperaemicum  and  erythema  multiforme,  and 
to  a  probably  still  rarer  one,  partaking  largely  of  the  nature  of  a  more  or 
less  general  papular  erythema  multiforme  with  many  of  the  papules 
having  the  aspects  of  urticarial  lesions,  is  given  the  name  erythema  per- 
stans  or  erythema  multiforme  perstans.  The  former  type1  consists 
usually  of  erythematous  spots  or  patches,  which  frequently  assume 
annular,  marginate,  and  gyrate  configuration.  The  latter  type  consists 
of  large  pea-sized  bright  pink  or  reddish  edematous  or  edematous-looking, 
often  urticaria-like,  solid  papules  or  nodules,  often  itchy,  and  with  a 
tendency  to  develop  into  solid  elevated  segments,  gyrate  patches,  and 
rings,  some  of  the  latter  later  breaking  up  into  segments  and  papules 
again;  finally,  after  several  months  or  a  year  or  more,  flattening,  and 
fading  slowly  away.2 

1  G.  W.  Wende,  in  his  paper  (Jour.  Cutan.  Dis.,  1906,  p.  241),  reporting   2  cases, 
gives  a  review,  with  references,  of  other  reported  cases. 

2  One  such  remarkable  instance  of  this  erythema-multiforme-urticaria   type  has 
been  under  my  care  recently,  the  eruption  at  times  quite  itchy  in  character,  having 
already  lasted  a  year,  and  slowly  and  gradually  disappearing.     The  patient  had  an 
exactly  similar  attack  five  years  previously,  which  had  lasted  more  than  a  year.     In 
looking  over  the  literature,  after  seeing  this  case  (Phila.  Derm.  Soc'y  Transact.,  Jour. 
Cutan.  Dis.,  1913),  I  find  that  Dr.  Pringle  (Brit.  Jour.  Derm.,  1912,  p.  275,  case  demon- 
stration) had  recorded  a  similar  instance  under  the  name  of  urticaria  perstans  annulata 


Erythema  muUiforme  of  erythematous  and  papular  type. 


ERYTHEMA   MULTIFORME  155 

In  other  cases,  more  especially  in  the  papular  and  tubercular  types, 
the  inflammatory  process  may  be  sufficiently  intense  as  to  give  rise  to 
true  vesiculation  at  the  central  point  of  the  lesions  and  furnish  the  clinical 
variety,  at  times  designated  erythema  vesiculosum.  In  fact,  the  exu- 
dation may  be  sufficiently  pronounced  to  produce  distinct  blebs — so- 
called  erythema  bullosum.  In  occasional  instances,  instead  of  con- 
centric erythematous  rings,  there  result  concentric  vesicular  or  bullous 
rings,  forming  the  herpes  iris  of  some  authors;  in  this  type  the  several 
concentric  rings  being  of  slightly  different  duration,  the  coloring  is  bril- 
liant in  one,  purplish  in  another,  and  violaceous  in  another,  hence  the 
use  of  the  qualifying  term  iris.  The  vesicular  and  bullous  rings  of  a  patch 
may  coalesce  and  give  rise  to  large  and  distended  blebs  simulating  the 
pemphigus  eruption.  In  cases  of  the  herpetic  type  the  eruption  is  most 
commonly  about  the  hands  and  wrists,  and  not  infrequently  in  the  palms, 
and  on  the  lower  part  of  the  legs.  Vesicular  lesions  are  also  occasionally 
found  on  the  lips  and  in  the  mouth. 

In  some  cases  of  erythema  multiforme  the  eruption  may  be  made 
up  of  an  admixture  of  the  various  types.  In  extensive  cases  of  the 
erythematopapular  type  the  eruption  may  be  more  or  less  general  and 
seemingly  partake  of  the  nature  of  both  this  disease  and  urticaria. 

The  subjective  symptoms  are  rarely  troublesome — frequently  en- 
tirely wanting;  in  some,  slight  burning  and  itching.  In  the  vesicular 
and  bullous  types  the  patches  are  often  painful.  In  occasional  in- 
stances, however,  especially  in  those  cases  having  an  urticarial  element, 
the  subjective  symptoms  of  burning  and  itching  may  be  quite  intense. 

The  constitutional  disturbance  in  erythema  multiforme  is  rarely  of 
any  significance.  During  noted  temperature-elevation  in  31  cases 
out  of  105 ;  my  own  observations  would  place  it  at  even  less.  Accord- 
ing to  Jarisch,  swelling  of  the  lymphatic  glands,  especially  the  cervical 
glands,  is  sometimes  noted.  In  some  cases,  however,  especially  those 
of  a  general  character,  there  may  be  a  good  deal  of  febrile  action,  and 
often  with  accompanying  swelling  and  pain  about  one  or  more  of  the 
joints.  There  may  also  be  some  anorexia,  digestive  disturbance,  and 
malaise.  Endocarditis  has  been  noted  (Gerhardt)  in  rare  instances. 
In  exceptional  cases  of  the  severe  types  the  febrile  action  may  be  quite 
pronounced,  and  continue  for  several  days  or  longer,  or  even  throughout 
the  disease.  In  fact,  in  some  exceptional  cases  such  symptoms  may  exist 

et  gyrata.  In  both  these  cases  the  lesions  had  about  the  same  distribution,  hands 
and  face  being  practically  spared;  but  in  mine  the  papular  or  nodular  lesions  were  not 
quite  so  large,  being  more  the  size  of  a  large  pea  to  possibly  a  dime,  except,  of  course, 
those  which  had  enlarged  by  peripheral  extension,  the  center  clearing;  some  of  the 
rings  were  2  to  5  inches  in  diameter.  I  rather  incline  to  Dr.  Fox's  view  (article  on 
''Urticaria,"  Clifford  Allbutt's  System  of  Medicine,  vol.  ix,  p.  214,  cited  by  Pringle)  that 
"the  persistence  of  a  wheal  is  so  contrary  to  the  usual  temporary  character  that  we 
rightly  assume  a  critical  attitude  in  accepting  an  "urticaria  perstans";  and  for  that 
reason  and  also  for  the  reason  that  distinct  spreading  rings  are  rarely,  if  ever,  seen  in 
true  urticaria,  I  believe  it  more  appropriate  to  class  this  rare  eruption  as  an  "erythema 
multiforme  perstans,"  although  confessedly  such  a  long  persistence  of  the  lesions  of 
erythema  multiforme  is  almost  equally  as  anomalous.  Many  of  the  papular  or  nodular 
lesions  in  these  cases  are  in  their  objective  characters,  however,  very  much  like  the 
wheals  of  urticaria.  Graham  Little  also  describes  (ibid.,  1912,  p.  119 — case  for  diag- 
nosis) a  case  with  some  features  in  common  with  those  just  referred  to. 


156  INFLAMMA  TIONS 

a  few  days  before  the  eruption  appears  (Rigler,  Lipp,  Lewin,  During,  and 
others).  The  observation  has  been  occasionally  made  also  that  in  some 
instances  the  cutaneous  lesions  are  preceded  by  an  inflamed  or  congestive 
or  eruptive  condition  of  the  fauces  (Solstier,  Boeck,  Jamieson,  Fuchs),  or 
less  frequently  a  mild  conjunctivitis  (Fuchs,  During).  Exceptionally, 
too,  the  lips  and  mouth  show  vesicles  or  blebs  before  the  skin  is  involved 
(Pringle,  Crocker).  Grave  cases  of  erythema  multiforme  have  been 
reported  (Lewin,  Gerhardt,  Osier,  and  others),  with  visceral  involve- 
ment or  complications  of  considerable  severity,  and  in  some  of  which 
purpuric  symptoms  presented.  In  these  cases,  among  other  symptoms 
were  noted  throat  complications  (Osier),  diarrhea  and  colic  (Galliard), 
endocarditis  (Gerhardt),  and  laryngeal  symptoms  (Cotte).  It  is  difficult 
to  place  such  cases,  but  they  probably  belong  either  to  a  serious  systemic 
infection  of  which  this  eruption  is  but  a  part,  or  they  (some  of  them) 
belong  to  the  domain  of  purpura.  Other  cases  in  which  the  eruption 
became  rapidly  bullous,  and  continued  more  or  less  as  such,  with  some- 
times a  fatal  termination — being,  I  believe,  more  of  the  nature  of  a  septic 
pemphigus.1  Certain  it  is  that  in  average  cases,  and  especially  those  of 
the  papular  type,  in  which  the  eruption  is  limited  to  the  hands  and  fore- 
arms, face,  and  possibly  the  legs,  there  are  no  perceptible  systemic  symp- 
toms. In  fact,  the  disease  ordinarily  is  benign,  and  runs  an  acute  course. 

Etiology. — The  disease  is  not  uncommon,  constituting  between 
0.5  and  i  per  cent,  of  all  cases.  The  causes  which  lead  to  erythema 
multiforme  are  still  obscure.  My  own  experience  would  give  weight 
to  the  belief  that  the  development  of  intestinal  toxins,  and  probably 
toxins  from  other  sources,  is  an  all-important  factor  in  many  cases.2 
Stale  articles  of  food,  especially  meats,  oysters,  fish,  crabs,  and  lobsters, 
are,  I  believe,  often  causative.  On  the  other  hand,  the  more  severe  and 
rare  grave  types  are  thought  to  be  of  an  infectious  nature  (Lewin, 
Molenes-Mahon,  Vidal,  Leloir,  and  others);  in  support  of  which  are 
quoted  epidemics  (Rigler,  Gaal,  Herxheimer,  During)  and  the  various 
bacteriologic  findings  in  the  blood  (Cordua,  Luzzato,  Manssurrow,  Le- 
grain,  Simon,  Haushalter,  Leloir,  Finger,  and  others).  As  already 
intimated,  in  these  grave  cases  the  erythema  multiforme  is  probably 
only  a  part  or  one  of  a  group  of  symptoms  of  a  general  toxemia  or  infec- 
tion. As  yet,  however,  there  has  been  no  uniformity  in  the  micro- 
organisms found. 

There  are  certain  facts  generally  recognized  in  association  with 
this  disease.  It  is  more  frequently  observed  in  the  spring  and  autumn 
months,  during  which  seasons  atmospheric  conditions  are  somewhat 
variable,  and  the  weather  often  damp  and  rainy.  It  is  apt  to  recur 
for  one  or  two  years.  Moreover,  there  are  not  infrequently  associated 

1  Corlett.  "Erythema  Exudativum  Multiforme,"  Jour.  Cutan.  Dis.,  1908,  p.  7. 
with  a  report  of  a  case  of  erythema  circinatum  bullosum  et  haemorrhagicum,  following 
a  gunshot  wound,  apparently  due  to  streptococcus  infection,  and  terminating  fatally, 
reviews  these  grave  cases  with  full  bibliography. 

2  Thus  is  doubtless  explained  the  cases  seen  occasionally  in  the  course  of  such 
diseases  as  typhoid  fever,  diphtheria,  etc.:  Parker  and  Hazen,  "Erythema  Multiforme 
During  the  Course  of  Typhoid  Fever,"  Johns  Hopkins   Hasp.  Bull,  March,  ion, 
briefly  review  these  cases,  with  references. 


PLATE  II. 


Erythema  multiforme  of  bullous  variety,  in  a  young  woman,  on  the  dorsal  surfaces 
of  the  hands  and  forearms  symmetrically  ;  in  places  a  central  bleb,  surrounded  by  outer 
ring-shaped  bulla — a  tendency  to  "herpes  iris."  Duration,  eight  days. 


Erythema  multiforme  of  erythematovesicular,  circinate,  and  bullous  varieties,  in  a 
young  mulatto  woman,  of  one  week's  duration.  The  bullie  on  arm  have  coalesced, 
forming  serpiginous  tracts.  Eruption  occupies  the  face  and  the  forearms  and  band 
symmetrically. 


ERYTHEMA   MULTIFORME  157 

rheumatic  symptoms.  It  is  common  to  both  sexes,  but  is  somewhat 
more  frequent  in  females;  all  ages  are  liable,  but  it  is  most  frequent 
during  adolescent  and  early  adult  life.  It  is  also  noted  that  newly 
arrived  immigrants  and  young  servants  coming  to  city-living  from  the 
country  (Tilbury  Fox)  are  especially  prone  to  it.  Another  possible 
etiologic  factor  not  to  be  lost  sight  of  is  drug-action;  it  has  followed 
the  administration  of  such  drugs  as  potassium  iodid,  copaiba,  some  of  the 
coal-tar  group,  and  others.  Antitoxin  and  other  serums  are  sometimes 
causative. 


Fig.  27. — Erythema  multiforme  bullosum — herpes  iris. 

In  recent  years  the  suggestion  has  been  advanced  that  this  and  other 
toxic  dermatoses  may  be  due  to  the  absorption,  commonly  from  the 
intestinal  tract,  of  imperfectly  digested  or  improperly  broken  up  proteid— 
in  short,  due  to  anaphylaxis  or  hypersensitiveness  to  a  foreign  albuminoid 
substance  (see  Urticaria). 

Other  factors  also  seem  to  have  an  influence.  Urethral  irritation 
(Kaposi,  Lewin)  and  in  women  uterine  disturbances  have  been  looked 
upon  as  of  etiologic  importance  (Hebra,  Pick,  and  others).  Besnier 
believes  there  must  be  in  all  cases  an  underlying  neurotic  basis.  Urine 
examinations  give  no  insight  into  the  cause. 


158 


INFLAMMA  TIONS 


Pathology. — Erythema  multiforme  is  a  mildly  inflammatory  dis- 
order, somewhat  similar  to  urticaria,  due  doubtless  primarily  to  some 
impression  upon  the  nervous  system,  and  secondarily  upon  the  periph- 
eral circulatory  system;  in  short,  an  angioneurosis  (Landois,  Lewin, 
Auspitz,  Schwimmer).  It  would  seem  probable,  from  the  presence  of 
organisms  in  the  blood  demonstrated  in  several  instances,  already 
referred  to,  and  to  the  fact  that  some  cases  seem  due  to  spoilt  food,  that 
the  vasomotor  disturbance  which  gives  rise  to  the  lesions  must  be  of  toxic 
origin;  in  other  words,  that  the  disease  is  a  toxic  angioneurosis  (Claisse 
and  Legendre);  the  toxin  possibly  of  diverse  character.  It  is  probable 
that  it  may  act  either  centrally  or  peripherally.  The  association  with 
rheumatism  noted  has  led  many  to  believe  that  it  is  due  to  the  same 
underlying  cause  (Bazin,  Boeck).  The  fact  that  extravasations  of 
blood  are  occasionally  observed  in  the  lesions  has  led  to  an  expression  of 
belief  that  it  is  a  form  of  purpura  (Bohn,  Legrand,  Purdon,  and  others) ; 
and  the  grave  cases  reported  (Osier  and  others)  are  strongly  suggestive 

in  this  direction,  as  already  referred 
to.  The  characters  of  the  cutaneous 
lesions  are  determined  by  the  amount 
of  exudation,  which  is  variable.  The 
first  step  is  doubtless  a  simple  hyper- 
emia  due  to  vascular  dilatation,  fol- 
lowed by  a  paresis  of  the  cutaneous 
vessels,  arterioles,  and  capillaries,  with 
cell  proliferation  and  edema. 

The  anatomy  of  the  process  has 
been  clearly  presented  by  the  studies 
of  Leloir,  Lewin,  Villemin,  Unna, 
Jadassohn,  Crocker,  Gilchrist,  Pardee, 
and  others.  As  is  to  be  expected,  the 
epidermic  changes  are  more  marked 
in  the  vesicular  and  bullous  lesions. 
The  papillary  layer  is  the  seat  of 
the  principal  inflammatory  changes, 
consisting  of  dilatation  of  the  vessels, 
around  the  walls  of  which  are  found 
cell  proliferation,  cell  emigration,  and 

edema  of  the  cutis,  and  sometimes  extravasation  of  red  corpuscles  and 
colored  ^blood-serum.  The  epidermis  shares  in  the  edematous  infiltra- 
tion; this  edema  reaches  generally  from  the  subepithelial  vascular  net  to 
the  epidermis,  and  doubles  or  trebles  the  thickness  of  the  papillary  layer 
;Unna).  The  migratory  cells  are  to  be  found  in  more  or  less  abundance 
in  the  upper  rete  layers  (Cornil  and  Renaut).  The  covering  of  the 
vesicles  and  bullae,  as  in  similar  lesions  in  other  diseases,  consists  of  the 
corneous  layer,  sometimes  of  the  entire  epidermis  (Pardee).  Kreibich 
and  Panichi,  from  their  histologic  studies,  believe  the  disease  should  be 
regarded  as  an  inflammatory  dermatitis  rather  than  as  an  angioneurosis. 
Diagnosis — The  diagnosis  of  erythema  multiforme  rarely  gives 
rise  to  serious  difficulty  if  the  multiformity  of  the  eruption,  the  size 


Fig.  28. — Erythema  multiforme  bul- 
losum — herpes  iris. 


PLATE    III. 


Erythema  multiforme — erythema  and  herpes  iris — of  unusually  extensive  development, 
some  of  the  patches  consisting  of  six  rings  and  of  varied  coloring.  (Case  reported  in 
Medical  News,  October  14,  1882.) 


ERYTHEMA   MULTIFORME  159 

of  the  papules,  frequent  tendency  to  ring  shape,  the  frequent  limitation, 
especially  of  the  papular  type,  to  certain  parts,  the  course  of  the  disease, 
and  the  entire  or  relative  absence  of  subjective  symptoms  are  con- 
sidered. It  resembles  urticaria  to  some  extent,  but  the  lesions  of  this 
latter  disease  are  evanescent,  disappearing  and  reappearing  in  the  most 
capricious  manner,  and  are  usually  whitish  in  the  central  portion.  The 
papules  of  erythema  multiforme  persist  for  several  days  at  least,  and 
usually  a  week  or  more.  Moreover,  urticaria,  is  intensely  itchy  and 
the  eruption  is  most  pronounced,  as  a  rule,  upon  covered  portions  of  the 
body,  especially  about  the  buttocks  and  lower  lumbar  region  and  shoul- 
ders. '  The  papules  of  erythema  multiforme  are  usually  somewhat  dark 
colored,  with  a  tendency  to  take  on  a  purplish  or  violaceous  hue,  and 


Fig.  29. — Erythema  multiforme  bullosum — herpes  iris. 

often  with  a  slight  depression  of  the  central  portion.  Those  types  of 
erythema  multiforme  characterized  by  distinct  rings  can  scarcely  be 
confounded  with  any  other  disease;  ordinary  care  would  serve  to  dis- 
tinguish it  from  ringworm,  to  which  it  bears  rough  resemblance.  This 
latter  disease  has  usually  a  scaly  or  papular  border,  and  a  slightly  scaly 
center;  moreover,  rarely  more  than  a  few  patches  are  present. 

In  those  cases  of  vesicular  and  bullous  types  in  which,  from  con- 
fluence of  the  vesicles  and  small  bullae,  distinct  blebs  arise,  may  be 
confused  with  pemphigus,  but  the  distribution  of  the  eruption  and  the 
method  of  formation  of  the  bullae,  and  usually  the  presence  of  some 
characteristic  erythema  multiforme  patches,  will  serve  to  differentiate. 
It  can  scarcely  be  mistaken  for  erythema  nodosum;  in  this  latter  disease 
the  location  of  the  eruption  and  the  size  of  the  lesions  and  color  will 
furnish  sufficient  points  of  difference. 


l6o  INFLAMMATIONS 

Prognosis. — This  is,  as  judged  by  the  observations  of  all  American 
dermatologists,  practically  always  favorable,  in  average  cases  the  erup- 
tion disappearing  in  from  ten  days  to  several  weeks,  and  without  per- 
manent trace.  The  graver  cases  are  apparently  more  frequent  in 
Europe.  In  some  instances,  however,  new  crops  may  appear  from 
time  to  time  for  a  month  or  more,  and  the  course  of  the  disease  be  pro- 
longed. One  or  more  recurrences  in  succeeding  years  are  not  uncommon. 
In  exceptional  cases,  especially  of  the  vesicular  and  vesicobullous  type, 
in  which  the  mouth  and  lips  are  sometimes  involved,  frequent  and 
closely  connected  recurrences  may  give  the  disease  almost  a  chronic 
aspect;  and  it  may,  in  fact,  last  for  months  and  years  (Bazin,  Kaposi, 
Hutchinson,  Polotebnoff,  Colcott  Fox,  Payne,  and  others).  These  cases, 
in  which  there  may  be  troublesome  itching,  more  properly  belong,  how- 
ever, to  dermatitis  herpetiformis. 

In  those  rare  and  grave  cases  referred  to  in  which  the  eruption  is 
doubtless  a  part  of  a  general  systemic  disease,  or  distinctly  infectious, 
the  prognosis  would  depend  upon  the  character  and  gravity  of  the 
constitutional  involvement.  I  have  never  met  writh  this  grave  type, 
except  in  one  or  two  instances  when  the  eruption  was  simply  a  comani- 
festation  of  septicemia;  others  (Uffelmann,  Vidal,  Leloir,  and  others) 
have,  however,  recorded  deaths,  usually  from  visceral  involvement  or 
complication. 

Treatment. — It  is  difficult  to  state  how  far  treatment  influences 
the  course  of  the  disease,  but  that  it  has  no  effect  whatsoever,  as  many 
contend,  is  not  in  accord  with  my  own  observations.  As  it  is  probable 
that  the  development  of  intestinal  toxins  plays  an  important  role  in  many 
of  these  cases,  the  treatment  most  commonly  to  be  prescribed,  and  which 
in  my  experience  is  the  most  satisfactory,  should  consist  of  such  remedies 
as  sodium  salicylate,  salol,  thymol,  and  sodium  benzoate,  in  fairly  full 
dosage.  Conjointly  with  one  or  more  of  these  an  occasional  laxative 
dose  of  calcined  magnesia  should  be  given.  In  fact,  saline  laxatives  alone 
are  often  sufficient.  Of  these,  magnesium  sulphate  and  sodium  phos- 
phate are  the  most  satisfactory;  or  the  well-known  laxative  mineral 
waters  may  be  substituted.  In  the  more  stubborn  cases  large  repeated 
doses  of  quinin  sometimes  prove  of  benefit.  Probably  the  remedies 
most  frequently  to  be  prescribed  in  this  disease  are  .salol  or  sodium 
salicylate,  with  small  doses  of  charcoal  and  an  occasional  laxative  dose  of 
calcined  magnesia,  or  they  may  be  prescribed  in  combination  as  follows: 

fy     Pulv.  salol.,  gr.  xx  (1.35); 

Pulv.  magnesia  calcinat., 

Pulv.  carb.  ligni,  aa  gr.  xl   (2.65). 

To  be  divided  into  20  parts  and  put  in  capsules.     Of  these,  one  is  to  be 
taken  every  three  or  four  hours — about  four  daily. 

In  those  cases  in  which  rheumatic  swellings  and  pains  are  present, 
sodium  salicylate  in  full  doses,  with  an  occasional  saline  purge,  will 
give  the  most  prompt  relief.  In  those  constantly  recurring  cases  in 
which  the  lips  and  mouth  are  coinvolved  particular  attention  should 
be  given  to  the  condition  of  the  digestion,  and  intestinal  antiseptics, 
along  with  arsenic,  should  be  administered,  with  other  remedies  which 


ERYTHEMA    NODOSUM  l6l 

might  be  called  for  by  some  special  condition  of  the  patient;  continued 
doses  of  quinin,  arsenic,  iron,  and  strychnin,  and,  in  some  cases,  cod- 
liver  oil,  will  prove  of  service.  Among  other  remedies  advised  may  be 
mentioned  salicin  (Jamieson),  potassium  iodid,  30  grains  daily  (Villemin, 
Elliot),  more  especially  in  the  vesicular  and  bullous  types  (Elliot); 
for  the  relapsing  and  frequently  recurring  forms,  quinin  (Duhring,  Pelon, 
Payne)  and  ergotin  (Schwimmer). 

As  a  rule,  external  treatment  is,  in  the  simple  erythematous  and 
papular  manifestations,  rarely  required.  In  the  more  or  less  generalized 
cases,  however,  especially  those  in  which  the  disease  presents  an  urticarial 
aspect,  with  burning  and  itching,  antipruritic  applications,  such  as  are 
employed  in  urticaria,  may  be  advisable. 

The  larger  vesicular  and  bullous  lesions  should  be  punctured,  and 
the  contents  gently  pressed  out.  In  these  latter  cases  the  "calamin- 
zinc-oxid"  lotion,  named  under  the  head  of  Eczema,  may  also  be  em- 
ployed with  advantage,  or  one  of  the  mild  soothing  ointments  can  be 
applied,  spread  on  lint.  In  those  patients  in  whom  erythema  multi- 
forme  tends  to  recur  yearly  a  course  of  intestinal  antiseptics  and  occa- 
sional purgation,  previous  to  the  usual  time  of  the  outbreak,  together  with 
the  avoidance  of  dietary  indiscretions,  will,  I  believe,  sometimes  ward  off 
the  attack. 

ERYTHEMA  NODOSUM 

Synonyms. — Dermatitis  contusiformis;  Fr.,  Erytheme  noueux;  Ger.,  Erythema 
nodosum. 

Definition. — Erythema  nodosum  is  an  inflammatory  affection 
of  an  acute  type,  characterized  by  the  formation  of  variously  sized, 
roundish,  more  or  less  elevated,  erythematous  nodes  or  swellings,  at- 
tended with  a  variable  degree  of  systemic  disturbance.1 

Symptoms. — Erythema  nodosum  is  usually  ushered  in  with  febrile 
disturbance,  gastric  uneasiness,  malaise,  and,  not  infrequently,  with 
rheumatic  swellings  and  pains  about  the  joints.  These  constitutional 
symptoms  may  be  of  a  mild  and  scarcely  noticeable  character,  or  they 
may  be  severe.  The  cutaneous  eruption  makes  its  appearance  sud- 
denly, either  concomitantly  with  the  foregoing  systemic  symptoms, 
or  some  hours  or  a  day  after  their  onset.  The  lesions  are  seen  for  the 
most  part  upon  the  tibial  surfaces,  and  may  often  be  limited  to  these 
regions;  not  infrequently,  however,  other  regions  may  be  involved,  more 
especially  the  arms  and  forearms.  The  lesions  may  also  occur,  though 
only  exceptionally,  on  the  mucous  surfaces  of  the  mouth  and  throat 
(Duhring,  Pospelow,  Kaposi,  Rasumow).  They  are  rarely  present  in 

1  Some  important  literature:  S.  Mackenzie  (analysis  of  108  cases  and  relation  to 
rheumatism),  London  Clin.  Soc.  Trans.,  1886,  vol.  xix,  p.  215;  Schulthess  (analytic 
study),  Correspondenzbl.  f.  Schweiz.  Aerzte,  1895,  No.  3;  Numa  Bes  (association  with 
diseases  of  genito-urinary  organs),  These  de  Paris,  1872;  Amiaud,  L'  Erythemenoueiix; 
ses  Complications  viscerates,  1879,  Paris-  Uffelmann  (associated  with  tuberculosis), 
Archiv,  1874,  p.  174;  1877,  p.  230;  and  also  Oehme,  ibid.,  1878,  p.  324;  Knipe  (cases 
simultaneously  in  same  family),  Brit.  Med.  Jour.,  1882,  vol.  ii,  p.  974,  and  also  Demme, 
Fortschritte  der  Med.,  1888,  No.  7;  Duhring,  loc.  tit.;  Harrison,  Brit.  Jour.  Derm.,  1900, 
p.  250  (analytic  remarks  concerning  80  cases);  E.  Hoffmann  (etiology  and  patho- 
genesis),  Deutsch.  med.  Wochenschr.,  1904,  vol.  xxx,  p.  1877. 
11 


j  62  INFLAMMA  TIONS 

great  number,  the  eruption  usually  being  made  up  of  from  several  to 
twenty  or  thirty  nodes.  They  begin,  as  a  rule,  as  deep-seated  nodules, 
rapidly  growing  larger  and  becoming  elevated.  They  are  from  a  cherry 
to  a  hen-egg  or  even  larger  in  size,  are  rounded  or  oval,  tender  and  pain- 
ful, and  have  a  glistening  and  tense  look,  and  are  of  a  bright  red,  erysipela- 
tous  color  that  merges  gradually  into  the  sound  skin.  They  are  not 
sharply  circumscribed.  Later  the  color  grows  of  a  darker  hue  and  be- 
comes purplish  or  violaceous,  and,  in  disappearing,  gradually  undergoes 
the  various  color  changes  of  a  bruise — bluish,  bluish-yellow,  and  greenish, 
muddy  yellow.  In  occasional  instances  they  are  distinctly  hemorrhagic. 
When  first  appearing  they  are  quite  firm,  but  gradually,  after  reaching 
their  full  development,  in  the  course  of  several  days  or  one  or  two  weeks, 
they  soften,  become  semifluctuating,  and  appear  as  if  about  to  break 
down,  but  suppurative  or  destructive  changes,  however,  never  occur, 
absorption  invariably  taking  place;  there  are  several  recorded  exceptions 
(Demme,  Uffelmann,  Hardy,  Purdon,  Haisolt),  but  which  must  have 
been  due,  I  believe,  to  some  accidental  factor  or  complication.  There 
may  be,  in  some  cases,  associated  lesions  of  erythema  multiforme.  The 
subjective  symptoms  are  rarely  severe,  although  occasionally  trouble- 
some, consisting  of  tenderness,  pain,  and  sometimes  throbbings. 

The  course  of  the  disease  varies  somewhat  in  different  cases.  As 
a  rule,  the  nodes  do  not  all  come  out  at  one  time,  but  there  is,  at  first, 
an  appearance  of  three  or  four,  and  these  are  soon  followed  by  others. 
After  some  days  or  a  few  weeks  new  lesions  cease  to  appear,  and  the 
process  gradually  declines,  the  oldest  fading  away  first,  going  through 
the  various  color  changes  referred  to.  In  the  course  of  several  weeks 
or  a  few  months  all  traces  of  the  eruption  will  have  entirely  disappeared. 

The  constitutional  symptoms  usually  abate  in  average  cases  after 
the  first  several  days.  In  extreme  instances,  however,  there  may  be 
continuous  febrile  action,  similar  to  that  observed  in  fevers,  and  ex- 
ceptionally it  seems  to  partake  of  the  nature  of  a  prolonged  febrile 
disease  (Hutchinson,  Baumler).  Cases  of  this  disease  have  also  been 
reported  from  time  to  time  in  which  there  were  signs  pointing  to  visceral 
involvement  and  even  cerebral  invasion,  these  graver  symptoms  some- 
times markedly  ameliorating  or  abating  upon  the  appearance  of  the 
eruption  upon  the  skin.  Endocarditis  is  occasionally  noted;  in  Macken- 
zie's cases  (108),  in  5  cases  heart  murmurs  developed  during  the  attack, 
apparently  due  to  this  disease. 

Etiology. — The  disease  is  met  with  most  usually  in  those  under 
the  age  of  thirty.  Mackenzie's  statistics  of  108  cases  give:  14  cases 
under  the  age  of  ten;  69  cases  between  the  ages  of  ten  and  thirty;  15 
between  thirty  and  forty ;  and  10  in  those  over  forty  years  of  age.  Females 
are  much  more  frequently  affected  than  males — by  one  analysis  (Mac- 
kenzie), 5  to  i;  by  others  (Schulthess  and  Harrison) ,  3  to  i.  It  is  more 
common  in  cold  and  damp  seasons  (Duhring).  While  it  may  occur  in 
those  seemingly  in  good  health,  its  most  frequent  subjects  are  among  the 
weak  and  anemic.  The  frequently  associated  rheumatic  symptoms  ob- 
served would  indicate  some  connection  with  this  disease  (Garrod,  Mac- 
kenzie, Begbie,  Durian,  Legrand,  Besnier,  Boeck,  and  others),  but  whether 


ERYTHEMA   NODOSUM  163 

causative  or  simply  as  a  manifestation  of  the  same  underlying  factor  is 
not  known.  The  urine  discloses  practically  nothing,  although  Cursch- 
mann  states  that  in  25  cases  he  met  with  hemorrhagic  nephritis  5  times. 
Among  other  factors  which  have  been  variously  thought  to  be  of  influence 
may  be  mentioned  malaria  (Boicesco,  Moncorvo),  digestive  disorders, 
auto-intoxication,  defective  sanitation  (Moore),  drugs,  etc.  It  is  not  a 
common  disease. 

Pathology.— The  nature  of  the  disease  is  not  clear,  The  febrile 
action  and  the  occasional  visceral  involvement  or  complications  would, 
I  believe,  point  rather  strongly  to  a  specific  infection,  and  this  is  the 
present  trend  of  opinion.1  The  simultaneous  occurrence  of  the  disease 
in  two  or  more  members  of  the  same  family  (Knipe,  Demme),  or  one 
after  another  (Nash,  Little),  would  lend  support  to  this  belief,  but  such 
cases  are  extremely  rare.  Doubtless  in  the  grave  cases  reported  the  dis- 
ease may  be  due  to  septic  infection.  The  reported  cases  (Amiaud, 
Uffelmann,  Oehme,  Lailler,  Goldschneider,  Talamon,  Buisine)  of  asso- 
ciated or  subsequent  tuberculosis,  usually  grave  in  character,  would 
indicate  simply  the  presence  of  a  predisposing  factor,  and  must  be  con- 
sidered rare  or  purely  accidental.2  Its  occurrence  in  the  course  of 
syphilis  (Despres,  Leloir,  Mauriac,  Testut,  Jackson)  seems  too  rare  to 
be  viewed  more  than  as  a  coincidence.3 

Its  relation  to  erythema  multiforme  is  certainly  a  close  one,  and 
many  (E.  Wilson,  Lewin,  Auspitz,  Polotebnoff,  Kaposi,  Besnier,  Brocq, 
Boeck,  Crocker,  Hyde,  and  others)  believe  it  to  be  a  manifestation  of 
this  disease,  and  cases  are  occasionally  reported,  among  which  recently 
those  by  Gibb,4  Gliick,5  and  Schein,6  in  which  lesions  of  both  erythema 
multiforme  and  erythema  nodosum  are  alleged  to  have  been  present. 
In  a  few  cases  under  my  own  observation  the  eruption  seemed  of  mixed 
character.  Nevertheless,  the  distinct  individuality  of  erythema  nodo- 
sum is  strenuously  maintained  by  many  leading  clinicians  and  pathol- 
ogists  (Hebra,  Neumann,  During,  Vidal,  Leloir,  Duhring,  Schulthess, 
Veiel,  Unna,  Jadassohn,  Jarisch,  and  others).  During,  in  105  cases  of 
erythema  multiforme,  never  saw  an  erythema  nodosum  lesion. 

There  is  some  difference  of  opinion  as  to  how  the  lesions  are  pro- 
duced— whether  the  disease  is  an  angioneurosis  (Lewin),  the  cutaneous 
phenomena  resulting,  as  in  erythema  multiforme,  or  an  inflammation 
of  the  lymphatics  (Hebra),  or  due  to  embolism  (Bohn,  Panum). 

From  anatomic  investigations  made  (Lewin,  Kaposi,  Campana, 
Phillipson,  Jadassohn),  the  inflammatory  character  of  the  process  is 

1  Lendon,   in   his   recent  work,  "Nodal   Fever;    Synonyms — Erythema  Nodosum, 
Erythema  Multiforme,"  London,  1905,  holds  this  view  strongly,  but  one  must  confess 
that  as  yet  the  evidence  is  not  conclusive. 

2  Marfan,  La  Presse  Medicale,  June  26,  1909,  p.  457  (abstract  in  Brit.  Jour.  Derm., 
1909,  p.  372),  reiterates  the  belief  in  some  relationship,  briefly  reviews  the  subject,  and 
details  some  experimental  observations  (with  references  to  important  papers). 

3Leviseur,  "Erythema  Nodosum  Syphiliticum,"  Jour.  Cutan.  Dis.,  1911,  p.  597, 
reviews  the  literature,  and  thinks  it  indicates  that  there  is  conclusive  evidence  of 
there  being  a  syphilitic  eruption  resembling  clinically  both  erythema  nodosum  and 
erythema  induratum. 

4  Gibb,  Lancet,  April  23,  1898. 

6  Gliick,  abstract  in  Monatshefte,  1898,  vol.  xxvii,  p.  467- 

6  Schein,  ibid.,  vol.  xxviii,  1899,  p.  411. 


1 64  IN  FLA  MM  A  TIONS 

disclosed.  Dilatation  of  the  blood-vessels  and  closely  crowded  cells 
are  to  be  noted  in  the  corium  and  papillary  layer,  and  in  some  instances 
extravasations  of  blood  or  transudation  of  blood  coloring-matter.  Granu- 
ular  cell  infiltration  of  connective-tissue  bundles  and  cell  collections  pack- 
ing the  lymphatic  vessels  are  also  at  times  observed.  In  the  blood- 
vessels, particularly  the  veins,  the  leukocytes  are  sometimes  so  massed 
that  they  have  the  aspect  of  white  thrombi  (Unna).  Hoffmann  found 
phlebitis  of  the  larger  subcutaneous  veins.  In  addition  there  is  marked 
serous  infiltration  in  the  cutaneous,  and  usually  subcutaneous,  tissues. 
The  epidermis  rarely  shares  in  the  morbid  process. 

Diagnosis. — Erythema  nodosum  should  not  be  confounded  with 
bruises,  abscesses,  gummata,  and  the  lesions  of  erythema  induratum, 
to  which  it  may,  at  times  during  its  course,  bear  resemblance.  If  the 
beginning  bright  red,  rosy  tint,  with  the  later  color  changes,  the  appar- 
ently violent  character  of  the  process,  the  number,  the  situation,  and 
course  of  the  lesions,  are  borne  in  mind,  an  error  in  diagnosis  is  not 
likely  to  occur.  Bruises,  abscesses,  and  gummata  are  rarely  present 
to  a  greater  number  than  one  or  two  or  three.  The  course  of  the  latter 
two  diseases  is  entirely  different — the  nodes  of  erythema  nodosum 
never  break  down,  and  the  disease  is  frequently  accompanied  by  rheu- 
matic pains  and  swellings  about  the  joints.  The  lesions  of  erythema 
induratum  are  slower  in  their  course,  are  usually  dark  in  color  in  the 
very  beginning,  soon  show  evidences  of  breaking  down  and  of  ulceration, 
and  are  unaccompanied  by  any  febrile  and  rheumatic  symptoms.  More- 
over, this  latter  disease  is  usually  seen  in  subjects  with  tuberculous  tend- 
encies. 

Prognosis. — This  is  favorable,  the  disease  usually  running  its 
course  in  several  weeks  to  one  or  two  months.  A  few  grave  and  fatal 
cases  have  been  reported  (Demme,  Schmitz,  Lewin,  and  others) ,  but  there 
always  arises  a  question  that  these  are  examples  of  a  general  systemic 
septic  infection,  of  which  the  erythema  nodosum  is  simply  a  symptom  and 
a  part  of  an  accidental  complication.  At  all  events,  as  met  with  in  this 
country,  the  disease,  while  in  exceptional  instances  severe  and  even 
temporarily  alarming,  as  a  rule  gives  rise  to  no  anxiety,  and  always 
ends  in  recovery.  .  The  condition  of  the  heart  should,  however,  be  in- 
vestigated, especially  in  cases  associated  with  rheumatic  symptoms. 

Treatment. — For  the  most  part  the  treatment  of  this  disease  is 
symptomatic  and  expectant.  Rest,  relative  or  absolute,  depending 
upon  the  severity  of  the  cases,  should  be  enjoined.  The  diet  should 
be  plain  and  unstimulating.  A  saline  laxative  and  intestinal  anti- 
septics and  alkalis  are  most  commonly  prescribed.  Full  doses  of 
quinin  are  useful  in  some  cases.  Duhring  especially  indorses  the  value 
of  sodium  salicylate  and  quinin.  As  a  rule,  an  occasional  saline  laxative, 
with  sodium  salicylate  or  sodium  benzoate,  and  moderate  doses  of  quinin, 
constitute  the  essence  of  the  treatment. 

In  some  instances  the  tender  and  painful  character  of  the  cutaneous 
lesions  will  demand  external  treatment.  Lead-water  and  laudanum, 
and  3  to  10  per  cent,  ichthyol  ointments,  may  be  used  for  this 
purpose. 


ERYTHEMA   INDURATUM  ^5 

The  rheumatic  swellings  and  pains  often  about  the  joints  will  also 
require  at  times  similar  soothing  applications;  the  parts  may  also  be 
enveloped  with  cotton  batting. 


ERYTHEMA  INDURATUM1 

Synonyms. — Erythema  induratum  scrofulosorum;  Erytheme  indure  des  scrof- 
uleux  (Bazin);  Erytheme  noueux  chronique  des  membres  inferieurs  (Besnier). 

Definition.— A  sluggish  chronic  disease,  usually  of  the  leg,  char- 
acterized by  the  more  or  less  continuous  formation  of  subcutaneous 
nodules,  which  enlarge  to  variable  size,  become  purplish  or  purplish  red 
in  color,  and  terminate  after  long  duration  in  absorption  or  necrosis. 

Symptoms.— The  disease,  first  clearly  described  by  Bazin,  and 
later  by  Besnier,  Feulard,  Colcott  Fox,  J.  C.  White,  and  others,  is 
usually  slow  and  insidious  in  its  appearance,  presenting  a  symptoma- 
tology resembling  both  erythema  nodosum  and  syphilitic  gummata. 
Several  or  more  nodules  are  usually  found  about  the  legs,  and,  most 
frequently,  on  the  lower  calf  region,  and,  as  a  rule,  at  the  sides  and 
slightly  posteriorly.  They  have  been,  however,  observed  on  the  entire 
leg  region,  and  also  on  the  lower  part  of  the  thigh.  The  lesions  are  first 
not  perceptible  to  the  eye,  but  are  felt  on  palpation  as  deep-seated,  hard, 
indurated,  pea-sized  nodules.  Gradually  in  the  course  of  days  or  weeks 
enlargement  ensues,  and  they  reach  the  size  of  a  small  or  large  cherry  or 

1  Literature:  Bazin,  Lefons  sur  la  scrofule,  second  edit.,  1861,  p.  146;  Besnier, 
Annales,  1889,  p.  25  (case  demonstration);  Feulard,  ibid.,  p.  206;  Colcott  Fox,  West- 
minster Hasp.  Reps.,  1888,  p.  144;  and  Brit.  Jour.  Derm.,  1893,  pp.  225  and  293  (with 
colored  plate  and  report  of  9  cases — a  clear  clinical  presentation  and  review  and  refer- 
ences to  literature  of  the  disease);  also  ibid.,  1896,  p.  178  (case  with  associated  angio- 
keratoma);  Patteson,  ibid.,  p.  338;  Hutchinson  (a  number  of  suggestive  cases),  Archives 
of  Surgery,  1893-94,  vol.  v,  pp.  31  and  98;  Crocker,  Diseases  of  Skin,  second  edit.,  1893, 
p.  107  (refers  to  cases  with  arm  lesions);  J.  C.  White,  Jour.  Cutan.  Dis.,  1894,  p.  471 
(4  cases,  i  a  boy  aged  twelve);  Thibierge,  Semaine  Med.,  1895,  p.  545;  Pringle,  Brit. 
Jour.  Derm.,  1896,  p.  96  (male  subject);  Meneau,  Jour,  de  Med.  de  Bordeaux,  1896, 
vol.  xxvi,  p.  105  (case  demonstration);  Truchi,  These,  Toulouse,  1898,  brief  abstract  in 
Annales,  1898,  p.  1034  (histologic  examination);  Mackenzie  (case  demonstration), 
Brit.  Jour.  Derm.,  1897,  p.  79;  Audry,  Annales,  1898,  p.  209  (histologic  examination, 
and  animal  inoculation — negative);  Leredde,  ibid.,  p.  893  (histologic  examination); 
Dade,  Jour.  Cutan.  Dis.,  1899,  p.  306  (full  clinical  report  of  a  case,  with  histologic  ex- 
amination by  Ewing);  Johnston,  ibid.,  p.  312  (with  associated  necrotic  granulomata; 
histologic  examination;  review  of  subject  and  allied  cases,  with  bibliography);  also 
Philadelphia  Monthly  Med.  Jour.,  Feb.,  1899;  Bronson,  Jour.  Cutan.  Dis.,  1899,  p. 
240  (case  demonstration);  Abraham,  Brit.  Jour.  Derm.,  1899,  p.  206  (demonstration — 
doubtful  case— with  discussion) ;  Thibierge  and  Ravaut,  "Etude  sur  les  lesions  et  la 
nature  de  1'erytheme  indure,"  Annales,  1899,  p.  513  (report  of  3  cases,  with  4  colored 
histologic  cuts;  review  of  the  subject  and  references) ;  see  also  a  suggestive  paper  by 
Macleod  and  Ormsby,  "Report  on  the  Histopathology  of  Two  Cases  of  Cutaneous 
Tuberculides,  in  One  of  which  Tubercle  Bacilli  were  Found,"  Brit.  Jour.  Derm., 
1901,  p.  367  (with  2  histologic  cuts,  review,  and  references);  Whitfield's  (Brit.  Jour. 
Derm.,  1901,  p.  386,  and  1905,  p.  241,  and  on  "Multiple  Inflammatory  Nodules  of 
the  Hypoderm,"  ibid.,  1909,  p.  i,  with  several  case  and  histologic  illustrations  and 
review  of  the  subject)  investigations  led  him  to  conclude  that  there  are  two  types — 
one  being  of  a  tuberculous  nature,  occurring  almost  entirely  in  young  girls;  the  other 
occurring  in  middle-aged  women  of  poor  circulation,  having  nothing  to  do  with  the 
tuberculous  process,  and  which  might  be  called  by  Philippson's  name  of  "phlebitis 
nodularis  necrotisans" ;  Thibierge  and  Gastonel,  Annales,  1909,  p.  310  (reaction  and 
improvement  from  tuberculin  injections);  Thibierge  and  Weissenbach,  Bull,  et  Mem. 
d.  I.  Soc.  med.  des  Hop.  (seance  des  March  u,  1911). 


1 66  I  NFL  A  AIM  A  TIONS 

even  as  large  as  a  walnut;  the  skin  during  this  enlargement  becomes  at 
first  a  pale  purplish  red,  later  darker  in  tinge,  and  finally  a  dull  viola- 
ceous. The  formations  are  still  noted  to  be  -somewhat  hard  or  slightly 
doughy,  but  when  of  large  size  lose  their  well-defined  character  and  seem 
to  fuse  with  surrounding  infiltrated  tissue.  They  may  continue  at  this 
stage  for  some  time,  and  then  gradually  soften  and  disappear  by  absorp- 
tion, with  slight  desquamation  and  sometimes  atrophy,  or  undergo 
necrosis  and  result  in  a  punched-out,  somewhat  deep,  sluggish-looking, 
irregular  ulcer.  Exceptionally,  as  in  the  cases  of  Burns1  and  W.  Pick,2 
there  is  very  little  or  no  disposition  to  ulceration,  and  the  condition 
is  suggestive  of  a  chronic  erythema  nodosum,  under  which  title  Pick 
places  his  case.  Both  terminations  are  usual  in  an  average  case,  a  few 
lesions  disappearing,  the  larger  number  breaking  down.  Some  lesions 
remain  small  and  scarcely  recognizable,  except  by  palpation.  There  is 
never  distinct  abscess  formation,  but  slight  softening  takes  place,  the 
skin  becomes  necrotic  at  one  point,  and  there  may  be  a  slight,  sero- 
purulent  discharge,  followed  by  gradual  necrosis  of  the  whole  nodule; 
or  this  latter  takes  place  en  masse,  without  previous  spot  necrosis. 
Occasionally  the  nodule  necroses  first  at  several  points,  and  then  rapidly 
or  gradually  in  its  whole  mass,  the  surface  breaking  down  at  first,  and 
the  deeper  parts,  quickly  or  slowly  afterward.  In  some  cases  several 
nodes  may  be  in  close  proximity,  and  as  they  grow  practically  fuse 
together,  although  to  the  sight  and  to  touch  there  usually  remains  an  ill- 
defined  outline  of  the  several  lesions  composing  the  mass.  In  these  cases 
there  may  be  a  noticeable  surrounding  sluggishly  inflammatory  infiltra- 
tion. 

The  ulcers,  the  maturing  nodes,  and  the  atrophic  depressed  areas 
left  from  absorbed  lesions  are  surrounded  by  deep,  dark  red,  or  purplish 
areola.  This  dark  color  remains  for  some  time  subsequently  to  healing. 
Some  of  the  ulcers  may  gradually  heal,  others  remain  open  and  sluggish, 
with  a  slight  seropurulent  or  watery  discharge;  if  several  are  in  close 
proximity,  there  may  result  an  irregular,  ulcerated  area,  with  here  and 
there  a  "bridge"  of  purplish  colored  infiltrated  skin  and  tissue;  in  such 
cases  the  consequent  scarring  is  usually  pronounced.  A  variable  de- 
gree of  edema  of  a  doughy  or  inelastic  character  is  sometimes  noted, 
which  is  occasionally  followed  by  slight  tissue  hypertrophy. 

The  disease  is  almost  invariably  limited  to  the  parts  named,  al- 
though Bazin,  Crocker,  Pringle,  and  Colcott  Fox  have  exceptionally 
observed  lesions  elsewhere  as  well,  more  especially,  however,  on  the 
arms.  Johnston  and  DuCastel  have  each  observed  a  case  with  char- 
acteristic nodes  upon  the  legs  and  suggestive  necrotic  tuberculous  look- 
ing lesions  on  other  parts.  It  is  slow  and  persistent,  and  more  pro- 
nounced in  its  expression  in  the  cold  season.  As  a  rule,  the  lesions  are 
not  painful  except  upon  pressure — certainly  not  painful  to  a  marked 
degree. 

Etiology  and  Pathology.— The  disease  is  met  with  almost 
exclusively  in  girls  and  women  between  the  ages  of  twelve  and  thirty, 

1  Burns,  Boston  Derm.  Soc.  Trans.,  Jour.  Cutan.  Dis.,  1905,  p.  177. 

2  Pick,  Archill,  1904,  vol.  Ixxii,  p.  360  (i  plate). 


ERYTHEMA   INDURATUM  167 

and  especially  among  those  whose  occupation  keeps  them  on  their  feet.1 
It  is  a  rare  malady,  and  particularly  among  the  well-to-do  classes. 

The  nature  of  the  disease  is  obscure.  It  is  not  a  thrombosis  nor  a 
phlebitis,  as  the  characteristic  symptoms  of  these  conditions  are  lacking; 
nor  is  it  connected  with  syphilis  in  any  way,  although  the  clinical  picture 
is  extremely  suggestive.  There  are  often  associated  symptoms,  past  or 
present,  of  a  scrofulous  diathesis;  this  has  been  noticeably  so  in  the  cases 
under  my  observation.  In  fact,  its  tuberculous  origin  is  more  in  accord 
with  the  clinical  data.2 

Histologic  and  bacteriologic  investigations  led  Audry  and  Truchi 
to  conclude  that  it  is  not  tuberculous,  but  a  manifestation  of  a  nature 
similar  to  erythema  nodosum.  Johnston,  although  believing  that  it  is 
an  expression  of  tuberculous  disease,  could  not  corroborate  it  by  histo- 
logic  findings.  On  the  other  hand,  Thibierge  and  Ravaut's  studies 
place  it  among  the  cutaneous  manifestations  of  tuberculous  infection. 
They  found  in  all  three  cases  examined  by  them  that  the  vascular  chan- 
nels were  chiefly  affected  with  inflammatory  and  degenerative  changes, 
and  there  was  a  large  number  of  giant-cells;  moreover,  they  succeeded, 
by  experimental  animal  inoculation,  in  producing  a  general  tuberculosis. 
Leredde,  who  also  examined  a  case  histologically,  compares  the  lesion 
to  a  necrotic  tuberculid.  The  bacillus  has,  however,  never  been  found, 
although  as  yet  the  examinations  have  been  meager.  It  is  not  improb- 
able, as  contended  by  Whitfield,  that  there  are  two  classes  of  cases 
scarcely,  if  at  all,  positively  clinically  distinguishable,  one  of  which  be- 
longs under  tuberculosis;  the  other,  more  acutely  inflammatory,  but  of 
obscure  origin  and  nature. 

Diagnosis. — Erythema  nodosum  and  syphilitic  gummata  are  to 
be  excluded.  The  acute  character  of  the  former,  its  surface  involve- 
ment in  the  very  earliest  stage,  some  lesions  remaining  small  and  surface 
lesions  throughout;  the  bright  pink  or  red  color,  with  the  gradual  change 
of  color  often  observed;  the  painful  and  tender  character  of  the  nodes, 
and  its  usually  occupying  preferably  the  tibial  surface;  the  absence  of 
tendency  to  break  down,  and  its  course — are  all  different  from  the 
symptoms  of  erythema  induratum.  The  nodes  in  erythema  nodosum, 
it  is  true,  are  often  suggestive  of  softening,  but  this  never  ensues,  a  few 
cases  of  ulcerative  ending  are  on  record,  but  one  may  ask,  in  view  of  its 
resemblance  to  erythema  induratum,  whether  it  was  not  confused  with 
this  latter  disease. 

1  Hirsch,  Arch.  Derm.,  1905,  vol.  Ixxv,  pp.  56  and  181,  shows  in  a  review-summary  of 
80  collected  cases  that  only  n  were  males;  as  to  age,  there  were  18  under  twenty,  18 
between  twenty  and  thirty,  n  between  thirty  and  forty,  5  between  forty  and  fifty,  i 
between  fifty  and  sixty,  and  i  at  sixty-eight;  in  30  of  the  cases  there  were  other  evi- 
dences of  tuberculosis. 

2Harttung  and  Alexander's  case,  Archiv,  April,  1902,  vol.  Ix,  p.  39  (c  mical  and 
histologic,  with  2  colored  histologic  plates,  and  full  bibliography),  died  of  pleuropnei 
monia — the  autopsy  showed  pulmonary  tuberculosis;  second  paper,  ibid.,  1905,  vol. 
Ixxi,  p.  385  (5  cases,  i  doubtful):  there  were  histologically  two  groups— those  showing 
tuberculous  changes  and  those  showing  inflammatory  changes;  Thomas,  Rev.  gen.  ae 
din.  et  ther.,  Jan.  24,  1903,  p.  49,  case  with  scrofulous  symptoms  and  pleuropneumoma; 
Sollner,  Monatshefte,  1903,  vol.  xxxvii,  p.  545,  has  reported  a  case  in  which  there  was 
an  association  with  both  lichen  scrofulosorum  and  pulmonary  tuberculosis;  Alexander, 
Berlin,  klin.  Woch.,  1904,  vol.  Ixi,  p.  897,  an  association  with  folliclis. 


1 68  INFLAMMATIONS 

The  clinical  expression  of  the  ulcers  is  strikingly  like  syphilis,  but 
gummata  are  usually  rapid,  remain  rather  sharply  circumscribed,  are 
generally  more  painful  and  inflammatory  and  suppurate,  and  are  mark- 
edly purulent;  in  erythema  induratum  the  destruction  of  tissue  results 
from  necrosis  rather  than  from  suppuration.  Moreover,  syphilitic 
gummata  are  rarely  numerous,  and  rarely  on  both  legs.  Further, 
syphilitic  lesions  yield  rapidly,  as  a  rule,  to  antisyphilitic  remedies — 
erythema  induratum,  on  the  contrary,  not  only  is  uninfluenced  but 
often  aggravated  by  such  treatment. 

Prognosis  and  Treatment.— The  disease  is  persistent  and 
obstinate,  but  with  the  patient's  co-operation  the  results  are  satisfac- 
tory. The  constitutional  treatment  of  most  value  is  that  based  upon 
the  assumption  that  the  disease  is  scrofulous.  Cod-liver  oil,  iron, 
quinin,  strychnin,  and  phosphorus,  with  full  nutritious  diet,  are  the 
remedies  indicated,  cod-liver  oil  being  the  most  useful.  Rest,  with  the 
leg  in  a  recumbent  or  supported  posture,  is  of  great  importance.  Anti- 
septic applications  of  boric  acid,  hydrogen  dioxid,  and  resorcin  are  espe- 
cially valuable.  An  ointment  of  resorcin,  5  to  10  per  cent,  strength, 
made  up  with  Lassar's  paste  (see  Eczema),  is  a  useful  application.  The 
plan  I  have  found  most  satisfactory  when  patients  cannot  give  the  time 
to  absolute  or  even  relative  rest  is  to  wash  daily  the  ulcers,  and  also  the 
general  leg  surface,  with  a  saturated  solution  of  boric  acid  containing  3 
to  10  grains  (0.2-0.65  8m-)  °f  resorcin  to  the  ounce  (32  gm.),  dressing 
the  ulcers  with  a  powder  of  boric  acid  or  with  the  foregoing  paste,  and 
putting  on  a  roller-bandage.  As  soon  as  a  clean  condition  of  the  ulcers 
is  established  and  they  are  looking  less  active,  which  usually  ensue  in 
from  ten  days  to  a  few  weeks,  this  treatment,  provided  the  ulcers  are 
not  numerous,  is  somewhat  changed;  the  preliminary  washing  of  the 
entire  leg  is  the  same,  but  the  ulcers  are  sprayed  with  hydrogen  dioxid, 
and  then  a  gelatin  dressing  of  zinc  oxid  and  ichthyol  (see  Eczema  for 
formula)  is  put  on,  leaving  a  "window"  over  each  ulcer.  The  ulcers 
are  then  dressed  with  the  powder  or  ointment  as  above  and  changed 
daily.  The  gelatin  dressing  is  renewed  every  three  or  four  days.  If 
the  ulcers  are  numerous,  this  gelatin  bandage  treatment  is  not  feasible 
until  the  smaller  have  been  healed  and  but  several  remain.  Whitfield 
and  Thibierge  have  both  had  a  good  result  from  treatment  with  injections 
of  tuberculin. 


ERYTHEMA  ELEVATUM  DIUTINUM 

Under  this  title  Crocker  and  Williams1  have  called  attention  to  a 
rare  malady,  of  unknown  nature,  characterized  by  persistent,  raised, 
pinkish  to  purplish,  flattened  nodules  or  patches,  with  sharply  defined 
edges,  and  usually  free  from  any  subjective  symptoms.  These  writers 
also  refer  to  somewhat  analogous  or  allied  cases  by  Bury,2  Hutchin- 

1  Crocker  and  Williams,  Brit.  Jour.  Derm.,  1894,  pp.  i  and  33  (with  colored  plate 
and  references  to  similar  or  allied  cases). 

2  Bury,  Illust.  Med.  News,  May  18,  1889,  p.  145  (with  colored  plate). 


ERYTHEMA   ELEVATUM  DIUTINUM  169 

son,1  and  Boeck,  and  present  abstracts  of  the  same.  The  features  of 
the  several  cases,  while  in  many  respects  similar,  differed  in  some  minor 
particulars.2  The  common  features  were  the  purplish  hue,  marked 
elevation  with  abrupt  edges,  the  rather  solid  or  firm  character  of  the 
efflorescence,  their  persistence  for  months,  years,  or  indefinitely,  and 
their  occurrence  in  subjects  of  gouty  or  rheumatic  nature  or  history. 
In  some  cases,  in  one  or  more  patches,  there  was  dilatation  of  a  few  sur- 
face capillaries.  The  eruption  was  scanty  in  a  few  cases,  consisting  of 
one  to  several  areas,  and  in  others,  while  scarcely  abundant,  patches 
were  to  be  seen  over  a  number  of  places,  sometimes  widely  scattered. 
I  have  met  with  4  cases  with  some  of  the  features  here  described — 3 
women  and  i  man — all  past  the  age  of  forty,  one  past  fifty.  The  erup- 
tion in  2  of  these  cases  consisted  of  but  a  single  patch  on  the  nose,  and  in 
the  third  a  patch  on  each  cheek.  In  the  fourth  case  (a  recent  one)  there 
were  several  small  areas  scattered  over  the  face.x 

Microscopic  study  of  the  Crocker  and  Williams'  case  showed  the 
seat  of  the  morbid  changes  to  be  between  the  epidermis  and  deep  por- 
tion of  the  corium,  immediately  adjacent  to  the  coil  glands,  and  to 
be  fibrocellular  in  character,  the  process  being  of  a  chronic  inflammatory 
nature. 

The  reported  cases  were  apparently  not  materially  influenced  by  the 
treatment  variously  employed.  In  my  cases  the  cheek  case  recovered 
spontaneously  or,  possibly,  from  a  mild  astringent  protective  applica- 
tion employed;  the  nose  case  (male)  was  treated  with  applications  of 
Vleminckx's  solution,  and  eventually  recovered;  and  in  the  third  patient 
(female  nose  case)  it  finally  yielded  to  the  continuous  application  of 
mercurial  plaster. 

1Hutchinson,  Illust.  Clin.  Surg.,  1878,  vol.  i,  p.  39  (with  colored  plate);  Brit. 
Jour.  Derm.,  1888-90,  vol.  i,  p.  10;  Arch.  Surg.,  1889-90,  vol.  i,  p.  372;  ibid.,  vol. 
ii,  1890-91,  plate  Ixi  (this  last  is  Bury's  case).  Gilchrist,  Trans.  Amer.  Derm.  Assoc. 
for  1900,  p.  221,  also  recorded  a  case  presenting  some  resemblance  to  the  disease  under 
consideration,  occurring  on  the  extremities,  in  a  child,  but  exhibiting  a  ringed  nodular 
appearance.  F.  J.  Smith  also  reports  a  case,  Brit.  Jour.  Derm.,  1894,  p.  144-  Accord- 
ing to  Crocker,  Brit.  Jour.  Derm.,  1894,  p.  148,  model  1599  (Quinquaud's  case,  child's 
hand),  in  the  Museum  of  the  Hopital  St.  Louis,  Paris,  labeled  "fibr6mes  multiples  nodu- 
laires  des  extremites,  histologiquement  fibrdmes  fascules,"  is  a  case  of  this  disease. 

2  In  the  Bury  and  Crocker  and  Williams  cases  the  lesions  were  situated  over  the 
articulations  and  on  the  palmar  surfaces;  began  as  nodules,  becoming  confluent,  result- 
ing in  a  flattened  patch,  disclosing,  however,  its  nodular  origin;  the  lesions  were  at  first 
erythematous  and  later  purplish;  all  were  persistent,  some  indefinitely  so;  others  finally 
undergoing  involution;  no  tendency  to  spread  over  large  areas;  the  subjects  (3  cases) 
were  young  females.     In  the  Hutchinson  type  there  was  no  special  localization  shown, 
but  usually  over  flat  bony  surfaces;  the  lesions  began  as  flattish  nodules,  if  close  together 
coalesced,  and  lost  their  nodular  character,  forming  elevated,  flattened  patches;  they 
were  purplish  from  the  beginning,  and  were  persistent,  with  no  involution  tendency, 
and  disposed  to  spread  widely;  the  subjects  (4  cases)  were  males  and  somewhat  ad- 
vanced in  years.     The  lesions  were  somewhat  less  firm  than  the  Bury  type;  the  ele- 
vation  could  be  almost  removed  by  long-continued  pressure,  being  apparently  chiefly 
due  to  edematous  infiltration. 

3  Darier's  Sarcoid;  Boeck's  Sarcoid— Urban,  Brit.  Jour.  Derm.,  1910,  p.  331. 


!  70  INFLAMMA  TIONS 

GRANULOMA  ANNULARE 

Synonyms. — Ringed  eruption  on  the  fingers  (Colcott  Fox);  Lichen  annularis, 
Ringed  eruption  of  the  extremities  (Galloway);  Sarcoid  tumors  (Rasch,  Galewski); 
Eruption  chronique  circinee  de  la  main  (Dubreuilh);  Neoplasie  nodulaire  et  circinee 
(Brocq);  Erythematosclerosis  circinee  du  dos  des  mains  (Audry). 

Granuloma  annulare  is  a  rare  chronic  dermatosis  observed  more 
commonly  in  children,  and  most  frequently  on  the  dorsal  aspect  of  the 
hands,  especially  over  the  joints;  and  consisting  usually  of  several  some- 
what deep-seated  and  projecting  whitish  or  pinkish  nodules  and  con- 
tinuous or  broken  whitish  nodular  rings.  This  peculiar  and  interesting 
malady  has  been  given  established  recognition  through  the  observations 
of  Colcott  Fox,  Dubreuilh,  Galloway,  Crocker,  Brocq,  Graham  Little, 
and  others.1 

Symptoms. — The  malady  may  present  itself  somewhat  suddenly, 
but  usually  gradually  and  slowly;  and  it  may  begin  as  one  or  several 

literature:  Colcott  Fox,  "Ringed  Eruption  on  the  Fingers,"  Brit.  Jour.  Derm., 
1895,  p.  91  (case  demonstration),  and  "Ringed  Nodular  Eruption,"  ibid.,  1896,  p.  15 
(case  demonstration);  Dubreuilh,  "Sur  un  cas  d'Eruption  circinee  chronique  de  la 
main,"  Annales,  1895,  p.  355  (with  histologic  examination),  and  ibid.,  1905,  p.  65 
(3  additional  cases);  Galloway,  "Lichen  Annularis:  A  Ringed  Eruption  of  the  Ex- 
tremities," Brit.  Jour.  Derm.,  1899,  p.  221  (with  excellent  colored  plate,  two  histologic 
cuts,  and  review  of  similar  and  allied  cases,  with  references) ;  Crocker,  "Granuloma 
Annulare,"  ibid.,  1902,  p.  i  (6  cases:  4  personal,  i  Pringle's,  i  Pernet's;  colored  plate, 
showing  3  cases  and  histologic  cuts);  Brocq,  Annales,  1904,  p.  1089,  "Neoplasie  nodu- 
laire et  circinee  des  extremites,"  and  "Traite  elementaire  de  dermatologie  pratique," 
vol.  ii,  p.  275  (2  case  illustrations);  Galewski,  Iconographia  Dermatologica^Fa&c.  iii 
(colored  plate);  Graham  Little,  "Granuloma  Annulare,"  Brit.  Jour.  Derm.,  1908,  pp. 
213,  248,  281,  and  317,  in  his  excellent  and  exhaustive  paper,  gives  a  resume  and 
references  of  the  above  and  all  other  published  cases,  and  of  a  number  of  communi- 
cated (unpublished)  cases,  with  illustrations  of  the  Galloway,  Sequeira,  Leslie  Roberts, 
Hyde  and  Montgomery,  Macleod,  Colcott  Fox,  and  his  own  cases;  and  histologic  cuts 
of  the  Fernet,  Pringle,  Whitfield,  Savill,  Jadassohn,  Adamson,  and  his  own  cases;  and 
an  analytic  tabulation  of  49  cases;  discussion  of  this  paper  by  Crocker,  Galloway, 
Fernet,  Colcott  Fox,  and  Adamson,  ibid.,  p.  327;  Crocker,  Jour.  Cutan.  Dis.,  1894,  p.  5 
(reported  as  a  case  of  lupus  erythematosus  resembling  lichen  planus) ;  Fernet,  case  of 
granuloma  annulare  (celluloma  annulare,  Fernet)  (with  illustrations),  Proceedings  of 
tlie  Royal  Society  of  Medicine,  London,  1908;  G.  W.  Wende,  "A  Nodular,  Terminating 
in  a  Ring,  Eruption  (Granuloma  Annulare),"  Jour.  Cutan.  Dis.,  1909,  p.  388  (case 
illustrated  and  histologic  cuts);  dalla  Favera,  Dermatolog.  Zeitschr.,  1909,  vol.  xvi,  p.  73 
(case  and  histologic  illustrations;  first  Italian  case);  Halle  (Lesser's  clinic),  Archiv, 
1909,  vol.  xcix,  p.  51  (report  of  a  case,  with  review,  case  and  histologic  illustrations 
[colored]);  Hartzell,  Jour.  Cutan.  Dis.,  1910,  p.  302  (case  demonstration;  .r-ray 
exposures  had  already  flattened  the  lesions  considerably;  Pellier,  "Stereo-phlogose 
nodulaire  et  circinee  (Granuloma  annulare  de  Crocker"),  Annales,  1910,  p.  28;  on 
hand;  Graham  Little,  Brit.  Jour.  Derm.,  1910,  p.  390  (case  demonstration);  Varney 
and  Jamieson,  Jour.  Cutan.  Dis.,  IQII,  p.  22,  illustration,  male  patient,  aged  fifty-eight, 
lesions  on  wrist  and  hand,  gradually  disappeared  under  arsenic;  MacLeod,  Brit.  Jour. 
Derm.,  1911,  p.  409  (case  demonstration),  girl  aged  four;  on  back  of  both  thighs  and 
calves;  Bunch,  Brit.  Jour.  Derm.,  1911,  p.  357  (case  demonstration),  boy  aged  two 
and  one-half  years,  on  dorsum  of  right  foot;  Chipman,  Brit.  Jour.  Derm.,  Nov.,  1911, 
P-  349)  b°y  aged  fourteen;  on  pinna  of  each  ear  and  back  of  each  hand  (case  and  histo- 
logic illustrations);  C.  J.  White,  Boston  Med.  and  Surg.  Jour.,  May  4,  1911;  girl  aged 
eight,  index  fingers;  gradually  disappeared  under  .v-ray  exposures  (histologic  ex- 
amination); Vignolo-Lutati,  Dermatolog.  Wochenschr.,  Jan.  20  and  27, 191 2,  pp.  77  and 
114;  girl  aged  thirteen,  on  dorsum  of  hand — disappeared  on  administration  of  sodium 
salicylate,  leaving  a  small  atrophic  scar;  histologic  study;  careful  review  of  the  litera- 
ture; Piccardi,  "Erythema  Elevatum  et  diutinum,"  Dermatolog.  Wochfnschr.,  Sept.  7, 
1912,  vol.  Iv,  p.  1115,  review  and  bibliography;  discussion  of  the  two  conditions— 
erythema  elevatum  and  granuloma  annulare. 


GRANULOMA   ANNULARE  \J\ 

discrete  nodules,  as  a  more  or  less  ringed  or  crescentic  group  of  nod- 
ules, or  possibly  (?)  as  a  distinct  continuous  ring.  The  formation  is 
seemingly  semi  translucent,  has  a  smooth  surface,  is  whitish  or  ivory- 
like,  often  shining  and  glistening  in  appearance ;  sometimes  with  a  bluish- 
red  or  purplish-red  tinge  which  is  occasionally  quite  pronounced  and 
somewhat  deep  in  hue.  It  is  a  solid  formation,  either  firm  or  slightly 
doughy  to  the  touch;  deeply  seated  as  well  as  projecting  above  the 
skin  level,  with,  as  a  rule,  a  narrow  areolar  pinkish  or  reddish  zone.  It 
is  usually  a  trifle  flattened  or  it  may  be  distinctly  so.  A  beginning 
nodule  increases  in  size  to  that  of  a  small  to  large  pea,  and  may  remain 
as  such;  but  it  may  increase  peripherally  in  area  and  with  a  partial  or 
complete  disappearance  of  the  central  part,  finally  presenting  as  a  per- 
fectly or  imperfectly  formed  elevated  ring-like  or  crescentic  plaque,  the 
band  being  yT  to  f  inch,  or  occasionally  more  in  width.  When  begin- 
ning as  a  ringed  or  crescentic  group  of  nodules,  these  enlarge,  crowd 
together  more  or  less  closely  at  the  contiguous  sides,  with  a  resulting 


Fig.  30. — Granuloma  annulare. 

ring-like  plaque.  A  plaque  may  be  artistically  ring-like,  or  it  may  only 
be  irregularly  and  unevenly  circular  or  crescentic  in  outline;  not  infre- 
quently a  small  or  even  large  portion  of  the  ring  missing,  the  resulting 
plaque  being  a  crescent  or  a  segment  of  a  ring.  The  ring,  though  upon 
casual  inspection  occasionally  appearing  solid  and  continuous,  is  rarely 
unbroken,  but  is  made  up  of  contiguous  or  closely  set,  sometimes  fused, 
nodules. 

The  size  of  the  ring-like  formation  varies  from  a  fraction  of  an  inch 
to  i  or  2  inches  or  more  in  diameter.  The  skin  of  the  inclosed  area 
seems  normal,  but  upon  inspection  with  a  lens  slight  atrophy  may  be 
observed  in  some  instances;  it  may  be  the  normal  skin  color  or  pinkish 
or  reddish.  Its  course  is  usually  persistent,  after  an  uncertain  develop- 
ment, often  remaining  stationary  for  some  time  or  almost  indefinitely,1 
sometimes  one  or  more  of  the  lesions  partly  disappearing  or  entirely 

1  Colcott  Fox  (discussion  on  Dr.  Bunch's  case,  loc.  cii.)  mentioned  a  case  in  a 
woman  he  saw  twenty  years  ago,  and  in  whom  it  still  continues. 


1 7  2  I  NFL  A  MM  A  TIONS 

* 

disappearing,  with  now  and  then  a  new  nodule  or  ring  presenting. 
Doubtless,  in  most  instances,  after  an  uncertain  period  of  several  months 
or  years,  it  undergoes  spontaneous  involution  and  cure,  slight  stains 
marking  the  sites  for  a  time.1  There  are  no  subjective  symptoms,  only 
rarely  is  slight  evanescent  burning,  itching,  or  tenderness  complained  of. 
The  eruption  is  seldom  abundant,  usually  consisting  of  not  more  than 
several  nodules  and  rings;  most  cases  are  only  seen  after  the  ring  forma- 
tion or  grouping  is  more  or  less  fully  developed.  The  most  common  site 
for  the  malady  is  the  dorsal  surface  of  the  hands,  especially  over  the 
joints;  next  in  frequency,  in  the  order  named,  are  wrists,  feet,  ankles, 
neck,  elbows,  knees,  and  buttocks;  face  and  scalp  are  rarely  affected 
(Graham  Little). 

Etiology  and  Pathology.— The  cause  of  the  disease  is  not 
knowTi;  it  is  thought  to  occur  more  frequently  in  those  of  tuberculous 
antecedents.  It  is  more  commonly  observed  in  children  and  early 
youth,  and  about  equally  in  the  two  sexes.  In  a  number  of  instances 
it  first  presented  in  summer  time.  The  histologic  conditions,  studied 
by  most  observers  named,  do  not  justify  the  term  "granuloma."  Gallo- 
way found  the  process  to  be  an  inflammatory  one,  consisting  chiefly  of 
cell  infiltration  of  the  type  seen  in  certain  chronic  inflammatory  processes 
in  the  cutis,  especially  the  lichen  group.  Graham  Little  concludes  that 
we  have  to  do  with  a  deep  hypodermic  inflammation  gradually  spread- 
ing toward  the  surface,  and  situated  around  vessels;  the  cell  masses,  con- 
sisting of  large  mononuclear  cells,  numerous  spindle-shaped,  or  oblong, 
or  pear-shaped  cells,  with  an  elongated  nucleus,  indistinguishable  from 
connective-tissue  corpuscles;  and  a  few  large  epithelioid  cells  inter- 
spersed in  the  cell  mass;  in  many  of  the  foci  of  cells  there  appeared  to  be 
central  destruction;  there  were  no  plasma  cells,  and  only  occasionally 
mast  cells  in  abnormal  numbers. 

Diagnosis. — The  peculiar  whitish  or  ivory-colored  nodule,  ele- 
vated band-like  or  nodular  rings,  segments  or  crescents,  its  sluggish 
course,  and  the  absence  of  subjective  symptoms  are  so  distinctive  that 
the  malady  can  scarcely  be  confounded  with  anything  else.  Lichen 
planus  annularis  bears  slight  resemblance,  and  some  observers  claim 
relationship  with  erythema  elevatum  diutinum.  Exceptionally  it  has 
some  keloidal  suggestion. 

Prognosis  and  Treatment — The  malady  is  benign,  finally,  after 
a  variable  period  of  months  or  years,  probably  disappearing  sponta- 
neously. Sodium  salicylate  (Vignolo-Lutati)  and  arsenic  (Varney  and 
Jamieson)  have  been  credited  with  favorable  influences.  As  a  rule,  the 
lesions  will  yield  more  or  less  rapidly  to  applications  which  tend  to  pro- 
duce desiccation  and  exfoliation;  salicylic  acid  and  resorcin  ointments, 
pastes,  lotions  or  paints,  such  as  are  employed  in  acne,  callosity,  and 
senile  keratoses.  X-ra.y  has  been  favorably  spoken  of  (Hartzell,  C.  J. 
White). 

1  Graham  Little,  Brit.  Jour.  Derm.,  1912,  p.  22  (case  demonstration),  notes  a  recur- 
rence in  patient  previously  under  his  care,  after  a  few  years'  freedom. 


PELLAGRA  iy? 

PELLAGRA1 

Synonyms.—  Lombardian  leprosy;  Erythema  endemicum;  Fr.,  Pellagre-  Mai  de 
misere;  L'erytheme  pellagreux;  Ital.,  Mai  Rosso;  Risipola  Lombarda;  Mai  del  Sole- 
Scorbuto  alpino. 

Definition.—  Pellagra  is  an  endemic  systemic  disease,  character- 
ized by  cutaneous  manifestations  of  an  erythematosquamous  and  pig- 
mentary character,  and  associated  with  disturbances  of  the  cerebro- 
spinal  system  and  the  digestive  tract.  It  is  of  endemic  occurrence 
in  certain  regions  of  Italy  (Lombardy,  Venetia,  ^Emilia)  and  Spain; 
also  in  the  Tyrol,  Bukovina,  and  Roumania.  Its  first  occurrence  in 
Spain  is  referred  to  the  year  1735.  In  recent  years  sporadic  cases 


important  literature  of  pellagra.  Foreign:  Tuke,  Klinische  imd  Ana- 
tomische  Studien  uber  die  Pellagra,  Berlin,  1893;  Lombroso,  Die  Lehre  wn  der  Pellagra, 
Berlin,  1898  (an  exhaustive  monograph  with  histologic  cuts);  Sandwith,  "Pellagra  in 
Egypt,"  Brit.  Jour.  Derm.,  1898,  p.  395;  Raymond,  "Les  alterations  cutanees  de  la 
pellagre,"  Annales,  1889,  p.  627;  Nicolas  and  Jambon,  "Contributions  a  1'etude  de  la 
pellagre  et  du  syndrome  pellagreux  Annales,"  1908,  pp.  385  and  480  (review  with  full 
bibliography);  Sambon,  Brit.  Med.  Jour.,  1905,  ii,  p.  1272  (geographic  and  etiologic); 
Manson,  "Tropical  Diseases";  Lavinder  and  Babcock's  Translation  of  Marie's  French 
Monograph. 

American:  Searcy,  "An  Epidemic  of  Acute  Pellagra,"  Jour.  Amer.  Med.  Assoc., 
1907,  vol.  xlix,  p.  37,  and  "Pellagra  in  the  Southern  States,"  New  Orleans  Med.  Jour., 
Oct.,  1908,  p.  413;  Wood,  "The  Appearance  of  Pellagra  in  the  United  States,"  Jour. 
Amer.  Med.  Assoc.,  1908,  vol.  liii,  p.  274  (illustrated;  a  good  review  of  the  subject); 
Babcock,  "What  are  Pellagra  and  Pellagrous  Insanity?  Does  Such  a  Disease  Exist  in 
North  Carolina,  and  What  are  Its  Causes?"  Report  of  Board  of  Health,  South  Carolina, 
1907;  Jour.  South  Carolina  Med.  Assoc.,  Nov.,  1908;  Amer.  Jour.  Insanity,  April,  1908 
vol.  Ixiv;  Lavinder,  "Pellagra:  A  Precis,"  Public  Health  and  Marine  Hospital  Service, 
Washington,  D.  C.,  1908;  "The  Prevalence  of  Pellagra  in  the  United  States,"  ibid., 
1909;  "Notes  on  the  Prognosis  and  Treatment  of  Pellagra,"  ibid.,  "Prophylaxis  of 
Pellagra,"  ibid.,  and  "Etiology  of  Pellagra,"  New  York  Med.  Jour.,  July  10,  1909;  Wat- 
son, "Etiology  of  Pellagra.  The  Italian  Maize  Theory  or  the  Theory  of  Lombroso," 
Jour.  South  Carolina  Med.  Assoc.,  Nov.,  1908;  and  "Pellagra:  Observations  on  the  Dis- 
ease as  a  Result  of  Study  of  One  Hundred  Cases  hi  South  Carolina  and  Italy,"  New 
York  Med.  Jour.,  May  18,  1909,  p.  936  (good  review  of  the  subject);  Egan,  "Pellagra 
in  Illinois:  History,  Etiology,  and  Symptomatology,"  Bull.  Illinois  State  Board  of 
Health,  Pellagra  number,  Aug.,  1909  (review  and  references,  and  a  number  of  illus- 
trations); "Transactions  of  Conference  on  Pellagra,"  held  in  Columbia,  S.  C.,  Nov. 
3-4,  1909,  Jour.  Amer.  Med.  Assoc.,  1909,  vol.  liii,  p.  1659;  Hyde,  "Pellagra  and 
Some  of  the  Problems,"  Amer.  Jour.  Med.  Sci.,  Jan.,  1910  (2  colored  illustrations, 
review  and  bibliography);  Dyer,  New  York  Med.  Jour.,  1909,  p.  997  (cutaneous  symp- 
toms); Howard  Fox,  New  York  Med.  Record,  Feb.  5,  1910  (cutaneous  symptoms); 
Siler  and  Nichols,  "Observations  on  Pellagra  at  the  Peoria  State  Hospital,  111.,"  New 
York  Med.  Record,  Jan.  15,  1910  (a  study  and  an  exposition  of  the  disease  in  all  its 
phases;  175  cases  among  2150  inmates  in  1909;  examinations  of  fecal  matter  disclosed 
in  84.8  per  cent,  of  the]cases  protozoal  infection  [amebae,  flagellate,  and  encysted  forms])  ; 
Reed,  New  York  Med.  Record,  Jan.  22,  1910  (etiologic;  calls  attention  to  the  fact  that 
the  fungus  diplodia  has  lately  become  sufficiently  prevalent  in  America  to  attract  the 
attention  of  those  engaged  in  growing  maize,  and  its  prevalence  almost  simultaneous 
with  the  appearance  of  pellagra);  King,  "The  Etiologic  Controversy  Regarding  Pel- 
lagra," Jour.  Amer.  Med.  Assoc.,  March  12,  1910,  p.  859  (gives  a  good  review  of  the 
conflicting  opinions  with  references);  Sambon,  "Nature,"  Oct.  17,  1910—  abstract  in 
Jour.  Amer.  Med.  Assoc.,  July  23,  1910,  p.  361  —  believes  from  his  investigations  that  the 
maize  is  not  the  cause,  but  that  evidence  points  to  its  transmission  to  the  individual  by 
an  infected  sand-fly;  Albright,  "Pellagra  in  Tennessee,"  Southern  Med.  Jour.,  March, 
1912,  p.  69,  states  (Special  Commission  Report)  that  investigations  in  64  out  of  96 
counties  disclosed  316  cases;  Knight,  Jour.  Amer.  Med.  Assoc.,  June  22,  1912,  p.  1940, 
reports  10  cases  in  one  family  —  whole  family  —  parents  and  eight  children;  specimen  of 
cornmeal  examined  and  found  to  be  unfit  for  human  consumption.  See  also  recent 
book  publications  by  Lavinder  and  Babcock,  Niles,  Roberts,  and  Edward  Jenner 
Wood. 


174 


INFLAMMA  TIONS 


and  small  epidemics  have  been  observed  in  other  parts  of  the  world; 
and  its  appearance  and  development  in  the  United  States,  more  espe- 
cially in  the  Southern  part,  have  been  recently  brought  to  notice  by 
Merrill,  Searcy,  Babcock,  Zeller,  Bellamy,  Moore,  Lavinder,  Egan, 
Siler,  Wood,  Watson,  Thayer,  and  others. 

Symptoms.— There  are  two  types  of  the  disease:  the  acute  (ty- 
phoid type  of  Lombroso)  and  the  chronic.  This  latter  is  the  common 
one,  and  that  which  is  usually  described  by  the  Italian  writers.1  In  the 
recrudescences  in  the  chronic  cases  the  type  may  change  to  that  of  acute. 

The  disease  usually  appears  in  the  spring,  is  frequently  preceded 
for  several  weeks  or  longer  by  lassitude,  great  fatigue,  vertigo,  headache, 
anorexia,  pain  in  the  epigastrium,  and  diarrhea;  sometimes  associated 
with  sensations  of  weakness,  especially  in  the  lower  extremities,  and  not 


Fig.  31. — Pellagra:  Showing  involve- 
ment, with  pigmentation,  of  hands,  lower 
forearms,  and,  to  a  slighter  extent,  the  face 
(courtesy  of  Dr.  J.  J.  Watson). 


Fig.  32. — Pellagra:  Showing  eruption 
and  pigmentation  on  hands  and  face  (one 
of  Lombroso's  cases;  courtesy  of  Dr.  J.  J. 
Watson) . 


infrequently  with  a  feeling  of  dryness  and  burning  in  the  mouth,  and  heat 
in  the  stomach.  Later  in  the  course  of  the  disease  there  may  be  an 
associated  stomatitis,  with  more  or  less  salivation. 

The  cutaneous  phenomena  are,  as  a  rule,  the  last  to  appear,  and 
these  can  be  divided  roughly  into  three  stages:  the  first,  congestion 
or  erythema;  the  second,  with  added  scaliness,  thickening,  and  pigmen- 
tation; and  the  third,  a  tendency  to  atrophic  thinning.  When  first 
presenting,  therefore,  the  eruption  is  erythematous  in  character  and 
primarily  dark  red  in  color,  which  later  becomes  dark  brown;  and  is 
fairly  symmetrical.  It  appears  on  uncovered  portions,  those  which 

1  Most  Italian  writers  allege  that  the  acute  type  is  never  primary,  but  is  always  a 
profound  exacerbation  of  the  chronic  form.  Wood  and  others  state,  on  the  contrary, 
from  their  study  of  the  cases  in  our  Southern  States  that  at  least  50  per  cent,  are  of  the 
acute  form. 


:•  PELLAGRA  175 

are  commonly  exposed  to  the  sun,  as  the  back  of  the  hand  and  lower 
part  of  the  forearms,  face;  and  in  persons  who  go  barefooted,  on  the 
lower  part  of  the  legs  and  dorsal  surface  of  the  feet.  Raymond  and 
others  have,  however,  observed  it  on  the  feet  of  those  who  are  foot-clad, 
and  Wood  and  others  have  noted  it  on  the  sternum  and  the  labia  pudendi. 
The  skin,  which  assumes  a  reddish  color,  soon  develops  a  variable  degree 
of  thickening,  and  to  these  changes  are  added  burning  and  itchy  sensa- 
tions, and,  later  on,  there  may  be  loss  of  sensibility.  The  inflammation 
may  have  its  seat  in  the  superficial  or  deeper  layers.  The  epidermis, 
especially  the  horny  layer,  seems  to  shrivel  up,  more  conspicuously  at 
the  border,  and  slowly  desquamates,  the  amount  of  scaliness  varying 
somewhat  in  different  cases  and  in  different  attacks;  the  underlying 
surface  appears  red,  and  not  infrequently  is  fissured.  Occasionally  the 
gross  appearances  are  those  of  a  superficial  burn  in  its  middle  and  disap- 
pearing stages.  Vesicles,  bullas,  and  petechiae  -are  also  not  uncommon 


Fig.  33. — Pellagra:    Showing  the  constant  involvement,  with  pigmentation,  of  hands 
and  wrists  (courtesy  of  Dr.  J.  A.  Egan). 

associated  manifestations.  Pigmentation  takes  place  during  and  after 
the  attacks,  the  parts  remaining  more  or  less  thickened.  These  latter 
features  become  more  pronounced  with  succeeding  attacks.  At  the  ad- 
vent of  winter  the  cutaneous  phenomena  show  signs  of  improvement,  and 
the  disease  gradually  abates  and,  exceptionally,  may  disappear.  Usu- 
ally, however,  as  late  spring  approaches,  it  recurs,  and  the  disease  may 
thus  repeat  itself  for  several  or  more  years,  and,  in  addition  to  the 
cutaneous  changes,  brings  in  its  course  muscular  weakness  and  mental 
despondency.  These  apparently  free  intervals  are,  as  a  rule,  mere  remis- 
sions in  the  malady,  and  not  a  disappearance  with  subsequent  recurrence. 
After  repeated  attacks  the  skin  becomes  wrinkled,  thinned,  lax,  and  takes 
on  a  senile  appearance,  and  presents  a  bluish-red  or  dark-brown  color,  and 
tends  to  exfoliate  in  large  flakes.  The  fingers  become  more  or  less  fixed 
in  a  semiflexed  position.  Gradually  the  patient  becomes  debilitated  and 
greatly  emaciated,  owing  to  digestive  weakness  and  to  frequent  coexistent 
diarrhea,  and  also,  doubtless,  as  a  result  of  the  changes  brought  about 


176  INFLAMMATIONS 

by  the  involvement  of  the  cerebrospinal  system.  Later,  as  the  pulse 
becomes  weak  and  the  muscular  weakness  increases,  pains  in  the  head 
and  spinal  cord  and  convulsions  present,  stupor  and  melancholia  develop, 
and  quite  frequently  insanity  results;  sooner  or  later  a  fatal  termination 
ensues.  These  last-mentioned  symptoms  may  exceptionally  be  among 
the  earliest  manifestations. 

In  the  acute  form  of  the  malady  the  onset  is  more  rapid  and  more 
violent,  with  the  typhoid  symptoms  usually  pronounced.  The  toxemic 
characters  are  predominant,  while  the  skin  and  other  phenomena  may 
or  may  not  be  more  or  less  striking;  exceptionally,  the  patient  succumb- 
ing before  the  cutaneous  changes  are  fully  developed.  While  pellagra 
is  often  considered  an  afebrile  disease,  during  the  active  period  there  is 
often  a  rise  in  temperature,  usually  slight. 

Etiology  and  Pathology.— The  disease  develops  at  almost  all 
ages,  but  most  frequently  in  those  of  mature  adult  age.  In  Italy  il  seems 
confined  to  the  poor  and  peasant  class,  but  in  our  Southern  States,  while 
more  prevalent  with  these  classes,  the  upper  classes  are  also  affected. 
It  is  not  contagious,  nor  is  it  now  believed  to  be  hereditary.  It  is  met 
with  in  almost  all  the  European  countries,  being,  however,  peculiarly 
frequent  in  Italy  and  Roumania.  In  our  country  it  was  scarcely  known 
until  a  few  years  ago,  when  its  appearance  in  our  Southern  States,  and 
especially  in  institutions  for  the  insane,  in  considerable  numbers,  was, 
as  already  stated,  noted.  It  has  been  attributed  to  the  eating  of  damaged 
maize.  According  to  Neusser,  the  poisonous  principle  is  developed  in 
diseased  or  fermented  maize  under  the  influence  of  the  bacteridium 
maidis.  Paltauf  and  Heider,  Macjocchi,  Babes,  Tizzoni  and  Panichi, 
Wood,  and  others  have  also  found  various  organisms,  some  similar,  but 
most  of  them  different,  to  which  they  incline  to  attribute  the  disease. 
Lombroso's  investigations1  seem  to  attribute  it  to  the  causative  action 
of  fermented  maize  toxins,  and  he  claimed  to  have  experimentally  pro- 
duced symptoms  apparently  similar.  On  the  other  hand,  Kaposi, 
Scheiber,  Manson,  and  others  have  observed  the  malady  in  those  who 
have  never  used  this  food,  and  Hardy  also  stated  that  he  had  had  cases 
in  the  Hospital  Saint-Louis  in  which  maize  had  played  no  role.  These 
and  other  observers  have  also  called  attention  to  the  fact  that  there  are 
regions  where  maize  is  extensively  cultivated  and  much  eaten  in  which 
pellagra  is  absolutely  unknown.  Alcoholic  excess,  poverty,  poor  hy- 
gienic surroundings,  and  exposure  to  the  sun  are  predisposing  factors,  the 
last  considered  by  many  as  being  almost  essential,  but  some  exceptions 
to  this  are  now  known.  It  is  not  impossible  that  the  peculiar  distribu- 
tion of  the  eruption  could  also  be  ascribed  to  the  circulatory  weakness 
and  nerve  influence.2  Blood  investigations  show  a  secondary  anemia, 

1  Lombroso's  theory  is  that  certain  fungi  and  aspergilli  form  on  maize  if  it  is  exposed 
to  moisture,  these  producing  a  toxin,  which  taken  up  into  the  system,  causes  pellagra. 

2  Neusser  has  recorded  that  in  Roumania  the  gypsy  children  who  run  about  entirely 
naked  show  the  usual  distribution  of  the  eruption.     In  some  of  the  American  cases  it  is 
not  uncommon  for  covered  parts  to  be  co-involved;  more  especially  parts  of  the  body 
which  are  subject  to  pressure  (Watson).     Some  of  the  Illinois  suspected  patients  were 
made  to  wear  fenestrated  gloves,  the  developing  eruption  being  largely  limited  to  the 
exposed  areas;  on  the  other  hand,  patients  not  exposed  to  the  sun,  and  bedridden  patients 
developed  the  eruption  on  the  characteristic  situations  (Ormsby). 


PELLAGRA 


177 


rarely  a  marked  leucocytosis;  blood  is  uniformly  sterile  and  not  infective 
for  ordinary  laboratory  animals  (Lavinder). 

The  post-mortem  findings  are  pachymeningitis,  sclerosis  of  the 
brain  and  cord,  and  anemic  and  atrophic  conditions  of  internal  organs, 
fatty  degeneration,  and  pigmentary  changes.1  The  cutaneous  changes, 
according  to  Raymond,  are  essentially  those  of  a  mild  congestion  and 
irritation,  and  more  especially  a  hyperkeratinization  with  atrophy  of 
the  rete. 

One  may,  I  believe,  be  justified  in  saying  that  as  yet  the  aggregate 
observations  and  experimental  investigations  are  still  lacking  in  con- 
clusiveness  as  to  the  true  and  essential  cause  of  the  disease.  It  seems 
not  unlikely,  from  its  ensemble  of  symptoms  and  its  analogy  to  other 
protozoal  infections,  that  its  cause  may  be  found  in  protozoal  organ- 
isms, a  view  suggested  several  years  ago  by  Sambon,  later  by  Terni, 
and  recently  by  several  American  observers,  especially  Siler  and  Nichols.2 

Diagnosis. — Outside  of  the  usual  districts  for  the  disease,  some 
difficulty  might  well  arise  in  the  diagnosis  in  the  earlier  period.  The 
most  prominent  characteristic  signs  are  the  parts  affected  (backs  of 
hands,  lower  forearms,  face,  and  often  dorsal  surface  of  feet)  and  the 
character  of  the  eruptive  phenomena — dermatitis,  usually  of  a  mild 
grade,  often  simulating  the  appearance  of  a  burn — with,  especially 
later,  thickening  and  pigmentation;  the  frequently  observed  shriveling 
of  the  horny  layer,  and  occasionally  almost  the  entire  epidermis  (usually 
more  marked  at  the  borders),  just  before  desquamating  is  to  be  con- 
sidered more  or  less  suggestive.3  These  symptoms  and  the  associated 
and  sometimes  precursory  general  disturbances  of  digestion,  frequent 
diarrhea,  nervous  involvement,  melancholy,  and  other  evidences  of 
mental  despondency,  will  usually  prevent  error.  If  to  these,  say  many 
observers,  is  added  the  knowledge  that  the  patient  has  lived  largely  on 
maize,  the  diagnosis  becomes  more  certain.  It  should  not  be  confused 
with  another  rare  condition — pseudopellagra — observed  in  alcoholics 
with  peripheral  neuritis. 

Prognosis  and  Treatment.— In  regions  where  the  disease  has 

1  Spiller  (Anderson  and  Spiller,  Amer.  Jour.  Med.  Sci.,  Jan.,  1911)  in  a  pathologic 
report  on  material  from  2  cases,  and  from  a  pathologic  review  of  the  subject  (with 
references)  found  "that  the  degeneration  is  caused  by  some  toxic  or  infectious  sub- 
stance affecting  all  parts  of  the  cerebrospinal  axis,  producing  cellular  degeneration  and 
diffuse  degeneration  of  nerve-fibers  in  the  posterior  and  anterolateral  columns;   the 
cortical  degeneration  of  the  brain  is  responsible  for  the  mental  symptoms";  Corlett 
and  Schultz  (Jour.  Cutan.  Dis.,  1911,  p.  193)  noted  first  changes  in  the  nervous  system, 
structural  changes  in  the  nerve-cells  and  fibers  leading  to  loss  of  ganglion  cells  and  the 
disappearance  of  the  axis  cylinder  in  the  peripheral  nerves  supplying  affected  skin  areas 
and  in  those  of  the  gastric  mucosa;  The  Illinois  Pellagra  Commission  (Dr.  Ormsby, 
Sec'y)  found  the  post-mortem  findings  to  be  those  of  a  generalized  intoxication. 

2  Ormsby  (Report  of  Illinois  Pellagra  Commission,  Jour.  Cutan.  Dis.,  1912,  p. 
589)  states  the  Commission  concluded  that  the  disease  appears  to  be  due  to  infection 
with  some  living  organism;   Sambon  and  Chambers'  (review  of  preliminary  report 
on  the  work  done  by  Sambon  and  Chambers,  in  Egypt,  Italy,  Spain,  Austria,  Rou- 
mania,  France,  and  Hungary,  on  question  of  etiology,  editorial  in  Jour.  Trap.  Med. 
and  Hyg.,  Sept.  2,  1912,  p.  262)  investigations  seem  to  exclude  the  maize  theory,  direct 
contagion,  house  infection,  and  hereditary  transmission,  and  to  point  conclusively  to 
the  insect-carried  infection  of  pellagra. 

3  Menage,  Southern  Med.  Journal.,  March,  1912,  p.  88,  looks  upon  this  shriveling 
appearance  as  almost  pathognomonic. 

12 


1 7  8  INFLAMMA  TIONS 

long  been  endemic,  the  outlook,  in  slight  attacks,  is  favorable,  pro- 
vided the  proper  food  can  be  given  and  the  surroundings  improved. 
Severe  cases  are  prone  to  prove  fatal;  the  average  duration  is  five  years, 
although  it  may  continue  for  ten  or  fifteen.  In  communities  where 
the  disease  is  new,  as,  for  example,  our  Southern  States,  the  prognosis 
is  grave,  the  majority  of  cases  proving  fatal,  and  the  acute  type  prob- 
ably invariably  so;  the  average  duration  is  also  less. 

There  are  no  specific  remedies,  the  essential  management  consist- 
ing in  placing  the  patient  in  good  hygienic  surroundings,  and  improv- 
ing the  general  health  by  good  nourishing  food  and  such  tonics  as  may 
seem  indicated.  Arsenic  and  iron  preparations,  especially  the  former, 
and  usually  in  the  form  of  Fowler's  solution,  are  the  remedies  upon  which 
most  support  has  been  placed,  and  which  sometimes  influence  the  disease 
favorably;  atoxyl  has  been  lauded  by  a  few,  but  Babcock,  Lavinder, 
Thayer,  Wood,  and  others  could  not  corroborate  its  alleged  promptly 
favorable  action.  Salvarsan  has  also  been  credited  with  some  recoveries.1 
In  one  recorded  instance  (Thayer)  thyroid  proved  of  promising  value; 
and  in  several  instances  (Cole  and  Winthrop)  transfusion  of  blood  cured 
the  patient.  According  to  Siler  and  Nichols  (Peoria  State  Hospital 
observations)  "mild  cases  recovered  without  therapeutic  aid;  severe 
cases  were  not  much  benefited  by  Fowler's  solution,  atoxyl,  or  thyroid 
tablets." 

Acrodynia. — Synonyms. — Erythema  epidemicum;  Cheiropodalgia;  Fr.,  Acrodynie; 
Mai  des  pieds  et  des  mains;  Maladie  de  Paris;  Ger.,  Acrodynie. 

This  title  was  given  by  Chardon  to  a  disease  first  observed  in  Paris 
and  in  other  parts  of  France  from  1828  to  1830,  occurring  as  an  acute 
epidemic  and  having  some  resemblance  to  both  ergotism  and  pellagra. 
Occasional  cases  are  observed  from  time  to  time  among  soldiers  and 
prisoners,  and  exceptionally  in  others.2  Most  cases  have  occurred  in 
Eastern  countries.  The  malady  is  ushered  in  with  constitutional  symp- 
toms consisting  of  anorexia,  nausea,  vomiting,  and  diarrhea;  and  the 
face,  hands,  and  feet  are  noted  to  be  swollen,  and  the  conjunctivas  in- 
jected. It  is  accompanied  by  disorders  of  the  nervous  system,  char- 
acterized by  pricking  and  burning  sensations;  at  first  there  is  marked 
hyperesthesia  of  the  extremities,  which  in  turn  is  followed  by  anesthesia; 
severe  pains  in  the  extremities  are  one  of  the  characteristic  features  of 
the  disease.  Early  in  the  course  of  the  malady  the  eruptive  phenomena, 
make  their  appearance,  and  present  as  erythematous  spots  primarily  on 
the  hands  and  feet,  especially  on  the  palms  and  soles,  and  spreading  up- 
ward on  the  arms  and  legs,  and  sometimes  involving  the  trunk.  The 
affected  portions  of  the  skin  desquamate  and  are  thickened  and  brownish ; 
black  pigmentation  may  supervene.  The  disease  is  afebrile  and  usually 
runs  its  course  in  a  fortnight  to  four  weeks.  In  aggravated  cases  paresis, 
edema  of  the  limbs,  and  toxic  spasms  may  ensue. 

1  Nice,  McLester  and  Torrance,  "Pellagra  Treated  with  Salvarsan,"  Jour.  Amer. 
Med.  Assoc.,  1911,  No.  12,  Ivi  (successful  in  3  cases). 

2  Tholozan,  "De  1'acrodynie,"  Gaz.  Med.  de  Paris,  1861,  pp.  647,  661,  689,  724, 
and  821,  has  reported  20  cases  and  described  the  malady  fully. 


URTICARIA 


179 


The  nature  of  the  disease  is  obscure.  Some  observers  attribute  it 
to  a  toxic  agent  affecting  the  nerve-centers,  developed  in  damaged  grain; 
others  recognize  its  analogy  to  pellagra  and  ergotism,  and  Marquez1 
remarks  upon  the  similarity  of  the  general  and  local  symptoms  to  those 
resulting  from  chronic  arsenical  poisoning.  In  several  of  the  fatal  cases 
inflammation  of  the  spinal  arachnoid  has  been  noted. 

The  malady  usually,  however,  except  in  those  greatly  debilitated 
or  in  advanced  years,  runs  a  favorable  course,  recovery  ensuing  within 
one  or  two  months.  Treatment  is  upon  general  principles.  Counter- 
irritation  over  the  spine  has  been  employed,  and  is  generally  advised. 

URTICARIA 

Synonyms. — Hives;    Nettlerash;    Fr.,    Urtiraire;   Ger.,    Nesselsucht;    Nesselaus- 


Definition. — Urticaria  is  an  inflammatory  affection  characterized 
by  evanescent  whitish,  pinkish,  or  reddish  elevations  or  wheals,  some- 
what  variable  as  to  size  and  shape,  and  attended  by  itching,  stinging, 
and  pricking  sensations. 

Symptoms. — The  eruption  in  urticaria  usually  comes  out  sud- 
denly, occasionally  being  preceded  by  burning  or  itching  of  variable 
intensity.  It  is  erythematous  in  character  and  consists  of  scanty  or 
profuse  pea-  to  bean-sized  elevations,  linear  streaks,  or  small  or  large 
irregular  patches,  or  an  admixture  of  these  forms.  It  may  be  limited 
in  extent  and  distribution,  or  more  or  less  general  and  abundant.  While 
no  part  of  the  body  is  exempt  from  possible  manifestations,  covered 
parts,  especially  the  lower  trunk,  buttocks,  and  upper  outer  chest,  around 
about  the  axillary  regions,  are  favorite  localities.  The  outbreak  may 
be  preceded  and  accompanied  by  symptoms  of  gastric  derangement,  and 
exceptionally  and  in  extensive  and  markedly  acute  cases  by  some  febrile 
action.  In  many  cases,  however,  the  cutaneous  eruption  is  unaccom- 
panied by  any  other  recognizable  symptoms.  The  lesions  are  fugacious 
in  character,  disappearing  and  reappearing  in  the  most  capricious  manner. 
They  are  somewhat  firm,  with  an  average  size  in  the  typical  wheal  of  a 
flattened  large  pea.  They  may  vary  in  tint  in  different  cases,  and  in 
different  lesions  in  the  same  case.  They  are  pinkish  or  reddish,  with 
usually  a  whitish  central  portion.  At  times  they  are  almost  entirely 
whitish,  with  a  narrow,  pinkish  areola.  The  subjective  symptoms  are, 
as  a  rule,  quite  marked,  consisting  of  stinging,  intense  burning  or  itching, 
or  a  combination  of  these  symptoms.  Rubbing  or  scratching  the  parts 
to  obtain  relief  will  ordinarily  provoke  a  new  outcropping  in  such  regions. 
The  lesions  are  distinctly  evanescent,  lasting  from  several  minutes  to  a 
fractional  part  of  a  day,  the  average  being  about  an  hour  or  two.  The 
intervening  skin  is  perfectly  normal  in  appearance,  new  lesions  present- 
ing rapidly  from  time  to  time.  In  exceptional  cases  the  individual 
lesions  may  persist  for  several  days  or  a  week  or  longer— urticaria  per- 
stans.  In  some  instances,  with  or  without  a  few  or  more  wheals  on  other 
parts,  the  disease  presents  itself  as  an  ill-defined  puffiness  of  the  hands 
1  Marquez,  Gaz.  hebdom.,  1889,  p.  91. 


!  go  INFLAMMA  TIONS 

and  fingers  and  feet,  accompanied  with  intense  subjective  symptoms  of 
burning  and  itching. 

During  an  outbreak  of  urticaria,  and  in  exceptional  instances  with- 
out actual  outbreak,  and  even  in  the  interim  of  attacks,  it  is  possible  in 
some  persons  to  bring  out  linear  wheals  by  simply  rubbing  the  finger  or 
drawing  a  lead-pencil  somewhat  firmly  over  the  surface.  In  this  manner 
letters,  symbols,  and  words  may  be  produced  at  will  and  last  for  minutes 
or  hours.  This,  or  a  phase  of  it,  constitutes  the  so-called  urticaria 
factitia,  dermatographism,  autographism. 


Fig.  34. — Dermatographism.  Tracing  done  with  the  blunt  end  of  a  lead  pencil, 
making  slight  pressure,  the  "welts"  reaching  full  and  prominent  development  in 
several  minutes  (courtesy  of  Dr.  C.  N.  Davis). 

Barthelemy1  has  thoroughly  studied  this  peculiar  condition,  and 
finds  that  while  it  is  commonly  associated  with  urticarial  attacks  at 
short  or  long  intervals,  it  not  infrequently  may  exist  independently,  and 
the  subject  learn  of  its  existence  only  accidentally.  One  such  instance 
as  the  last  named  has  come  under  my  notice.  The  lines  or  figures 
brought  out  at  will  in  these  cases  last  a  variable  time — from  twenty  or 
thirty  minutes  up  to  twenty-four  hours.  The  tendency  in  some  in- 
stances, according  to  Barthelemy,  occasionally  disappears  temporarily. 

The  eruption  in  urticaria  is  not  always  confined  to  the  external 
surface.  The  mucous  membranes  of  the  mouth,  throat,  larynx,  and 

1  Barthelemy,  Etude  sur  le  Dermographisme  ou  Dermoneurose  Toxivasomotrice, 
Paris,  1893  (an  admirable  and  complete  monograph  with  a  review  bibliography  of  the 
literature  and  notes  of  many  cases  and  17  illustrations). 


URTICARIA  l8l 

possibly  the  intestinal  mucous  surfaces,  may  exceptionally  be  the  seat 
of  wheals  and  edematous  swellings,  a  number  of  instances  of  which  have 
been  recorded,  more  especially  in  recent  years  (Delbrel,  Madison  Taylor, 
Hinsdale,  Merx,  and  others).1  Occurring  about  the  throat  and  larynx, 
the  symptoms  are  sometimes  alarming. 

Urticaria  may  be  acute  or  chronic;  in  most  instances  the  former, 
the  outbreak  coming  on  rapidly,  with  slight  variations  as  to  the  intensity 
of  the  attack.  The  lesions  may  continue  to  appear  and  disappear  in  the 
most  capricious  manner,  for  several  hours  to  two  or  three  days,  and  then 
disappear  entirely;  or  there  may  be  one  more  or  less  extensive  outcropping 
of  wheals,  reaching  its  acme  in  an  hour  or  so,  and  then  gradually  fading 
away.  The  duration  of  an  acute  attack  is  from  several  hours  to  several 
days,  the  average  being  twenty-four  to  forty-eight  hours.  It  may 
recur  in  some  instances  from  time  to  time  at  intervals  of  weeks  or  months 
upon  exposure  to  the  necessary  etiologic  factor  or  factors.  In  exceptional 
cases  of  urticaria,  but  more  particularly  in  the  hemorrhagic  form,  pig- 
mentation results  which  may  last  for  some  months  or  longer. 

Chronic  urticaria,  fortunately,  is  not  very  common.  In  these  cases 
the  lesions  are  usually  evanescent,  as  in  the  acute  type,  and  very  often 
somewhat  scanty,  but  fresh  efflorescences  continue  to  appear  from  day  to 
day  and  from  week  to  week  almost  indefinitely,  the  patient's  general 
health  often  suffering  from  the  constant  worry  and  discomfort  produced 
by  the  itching  and  burning.2  Very  exceptionally  the  lesions,  or  some  of 
them,  instead  of  being  evanescent,  are  somewhat  persistent,  lasting  days 
or  weeks — urticaria  perstans  (Pick);  some  cases  of  which  are  doubtless 
examples  of  prurigo  nodularis.  Other  instances  of  persistence  of  the 
lesions,  some  assuming  annular  and  gyrate  forms,  have  been  described 
as  urticaria  perstans  annulata  et  gyrata,  but  these  cases  seem  to  belong 
more  properly  to  erythema  multiforme  (q.  v.*). 

Instead  of  the  characteristic  lesions  of  the  disease,  the  eruption 
may  be  atypical,  thus  arising  the  types  known  as  giant  urticaria,  papular 
urticaria  (urticaria  papulosa),  hemorrhagic  urticaria  (urticaria  haemor- 
rhagica,  purpura  urticans)  bullous  urticaria  (urticaria  bullosa). 

The  conditions  variously  described  as  giant  urticaria,  urticaria 
tuberosa,  urticaria  cedematosa,  and  acute  circumscribed  edema  are 
closely  allied  or  identical,  varying  usually  as  to  degree,  and  presenting  the 
cutaneous  symptoms  of  tumor-like  swellings  of  evanescent  character. 

1  Delbrel,  "Contribution  a  1'etude  de  1'urticaire  des  voies  respiratoires,"  Thlse  de 
Bordeaux,  1896  (reviews  25  cases  from  literature  and  adds  2  of  his  own);  Madison  Tay- 
lor (larynx  and  skin),  Philadelphia  Med,  Jour.,  April  2,  1898;  Hinsdale,  Philadelphia 
Polydinic,  July  30,  1898;  Freudenthal  (recurrent  and  chronic  of  larynx  and  skin),  New 

York  Med.  Jour.,  Dec.  31,  1898;  Chittenden  (buccal,  pharyngeal,  and  nasal  mucous 
membrane  and  skin,  chronic  in  character,  with  recurrent  hematemesis) ,  Brit.  Jour. 
Derm.,  1898,  p.  158;  Goodale  and  Hughes  (chronic  and  of  tongue  only,  controlled  by 
salol),  Amer.  Jour.  Med.  Sci.,  April,  1899;  Merx  (recurrent,  tongue,  throat,  and  skin; 
with  bibliography),  Mimch.  med.  Wochenschr.,  1899,  p.  n74i  F.  A.  Packard  Soc y 
Trans.,  Philadelphia  Med.  Jour.,  July  22,  1899,  and  Archives  of  Pediatrics,  1899,  P- 
729  (showing  apparent  connection  between  respiratory  disturbances  and  urticanal 
eruptions).  . 

2  Under  the  name  "urtica  solitaria"  Vorner  (Dermatolog.  Zeitschr.,  Jan.,  1913,  p.  IJ 
records  several  (4)  cases  where  general  recurrent  urticarial  attacks  finally  gave  place 
to  an  occasional  appearance  of  a  single  lesion,  and  usually  when  recurring  this  lesion 
always  appeared  in  the  same  place. 


1 82  INFLAMMA  TIONS 

They  are  frequently  a  part  of  a  more  or  less  general  urticaria  in  which 
most  of  the  symptoms  are  of  the  ordinary  wheal  type,  presenting  the 
edematous  swellings  here  and  there,  more  especially  about  the  eye- 
lids, mouth,  and  ears.  Occasionally,  however,  acute  circumscribed 
edema  seems  to  be  entirely  or  sufficiently  independent  of  urticarial 
manifestations,  and  free  from  subjective  symptoms,  to  be  entitled  to 
separate  description  (q.  v.~). 

Urticaria  papulosa,  also  known  as  lichen  urticatus,  consists  essen- 
tially of  an  urticaria  in  which  the  lesions  are  discrete  and  scattered 
and  usually  upon  the  limbs.  They  may  appear  as  small,  more  or  less 
typical  wheals,  which  disappear,  leaving  behind  persistent  eczema-like 
papules,  though  somewhat  larger  than  the  papules  in  the  latter  disease. 
Or  the  lesions  may,  for  the  most  part,  appear  as  papules  from  the  start, 
with  here  and  there  a  scattered  typical  wheal.  In  addition  to  the  serous 
exudation  of  the  ordinary  wheal,  there  seems  to  be  in  this  type  a  mark- 
edly inflammatory  element.  These  papules  usually  itch  intensely,  and 
as  a  result  the  summits  of  many  of  them  are  scratched  and  covered  with 
minute  blood-crusts.  They  disappear  but  slowly,  new  papules  coming 
out  from  time  to  time.  This  type  may  last  from  one  to  several  months 
or  longer,  and  tends  to  recur.  It  is  almost  entirely  confined  to  young 
children  and  to  those  in  a  depraved  state  of  health.  It  is  rather  rare  in 
this  country. x  It  is  possible  that  this  form,  instead  of  being  a  true  urti- 
caria, may  be  an  example  of  mild  prurigo,  a  disease  which  is  not  uncom- 
mon in  Austria  and  other  European  countries. 

Urticaria  haemorrhagica  seu  purpura  urticans  is  characterized  by 
efflorescences  similar  in  size  and  shape  to  those  of  ordinary  urticaria 
except  that  there  is  a  variable  amount  of  hemorrhage  into  the  wheals. 
It  is  probable  that  in  the  majority  of  these  cases  the  purpuric  condition 
is  the  primary  one,  and  the  wheal  formation  secondary;  in  fact,  in  some 
cases  the  purpuric  element  may  be  of  a  somewhat  grave  character,  with 
hemorrhages  from  the  mucous  membranes. 

Urticaria  bullosa,  or  bullous  urticaria,  is  that  form  of  urticaria  in 
which  the  lesions  become  capped  with  a  vesicle  or  bleb  or  in  which 
the  wheals  are  rapidly  displaced  by  blebs.  This  anomaly  is  seen  most 
frequently  upon  the  extremities,  although  this  lesion  may  in  excep- 
tional instances  constitute  the  larger  part  of  the  eruption — so  much 
so  as  to  suggest  pemphigus,  dermatitis  herpetiformis,  or  bullous  ery- 
thema multiforme.  Apparently  the  inflammatory  action  has  been 
sufficiently  great  to  give  rise  to  considerable  fluid  effusion,  in  this  manner 
the  wheals  resulting  in  the  formation  of  bulla;. 

Etiology. — Urticaria  may  occur  at  all  ages  and  in  both  sexes, 
and  in  all  countries.  It  is  much  more  frequent,  however,  between 
the  ages  of  early  childhood  and  middle  adult  age,  and  is  possibly  some- 
what more  common  in  the  female  sex.  The  papular  type  is  more  fre- 
quent in  England2  than  elsewhere,  and  is  almost  exclusively  seen  in 

1  ChSpman,  California  State  Jour,  of  Med.,  June,  1910,  states  that  it  is  not  uncom- 
mon in  San  Francisco,  and  thinks  the  flea  is  frequently  a  factor  there  in  its  pro- 
duction. 

2  Colcott  Fox,  "On  Urticaria  in  Infancy  and  Childhood,"  Brit.  Jour.  Derm.,  1890, 
pp.  133  and  176. 


URTICARIA 


183 


children.  There  are  many  causes,  but  there  is  some  peculiar  individual 
predisposition  necessary,  inasmuch  as  the  same  cause  may  not  produce 
the  eruption  in  different  subjects.  In  some  instances  a  hereditary  in- 
fluence or  predisposition  is  observed,  especially  in  the  cases  associated  with 
giant  lesions  and  edematous  swellings.  The  etiologic  factors  may  be 
considered  under  the  heads  of  external  and  internal  causes,  or  direct  and 
indirect. 

As  exemplifying  the  external  causes  may  be  mentioned  the  bites 
or  irritation  produced  by  jelly-fish,  mosquitos,  fleas,  stinging  nettle. 
certain  kinds  of  caterpillars,  bedbugs,  etc.  Constant  scratching  or  any 
persistent  skin  irritation,  as  in  scabies  and  pediculosis,  will  at  times 
also  be  provocative.  While,  as  a  rule,  in  urticaria  produced  by  this  class 
of  etiologic  factors  the  urticarial  lesions  appear  only  at  the  points  or  im- 
mediate neighborhood  of  the  irritation,  yet  this  is  not  always  the  case,  as 
in  particularly  susceptible  individuals  a  general  outbreak  may  result. 

The  internal  or  indirect  causes  are  numerous,  here  again  the  indi- 
vidual peculiarity  having  a  potent  contributory  influence.     Most  of  this 
class  act  through  the  stomach  and  intestinal  tract.     Among  the  more      I 
^v     common  factors  in  this  class  may  be  mentioned  oysters,  clams,  crabs,  ^y 

r  lobsters,   shrimps,   mussels,   fish,   pork,   more  especially  sausages  and  .i** 
scrapple,    veal,    nuts,    mushrooms,    strawberries,    and   cucumbers.     In   i^r 
addition  to  the  articles  of  food  named,  others  may  be  causative  in  special     3 
instances,  owing  to  some  striking  idiosyncrasy,  such,  for  instance,  as    Q  4 
oatmeal  and  butter.     The  irritation  from  intestinal  worms  may  also  be 
the  cause  in  the  urticarias  of  children.     The  malady  is  not  infrequent  in 
immigrants  during  their  first  several  months'  stay  in  our  country,  doubt- 
less due  to  the  complete  change  of  diet  and  mode  of  living.     An  attack 
may  also  result  from  the  ingestion  of  certain  medicinal  substances,  more 
especially   copaiba,    cubebs,    chloral,    turpentine,    qujnin,    opium,    the 
iodids,  and  many  of  the  coal-tar  products.     The  use  of  antitoxins  has 
added  another  cause  occasionally  provocative. 

Emotional  or  psychic  causes,  such  as  anger,  fright,  or  sudden  grief, 
will  sometimes  excite  an  outbreak,  more  especially  if  occurring  during 
or  directly  after  a  meal,  the  process  of  digestion  being  apparently  inter- 
fered with,  possibly  permitting  the  development  of  toxins.  Urticaria 
is  at  times  observed  in  association  with  malaria,  jaundice,  albuminuria, 
and  diabetes  mellitus.  The  not  infrequent  occurrence  of  the  disease  in 
rheumatic  and  gouty  individuals  would  point  to  these  constitutional  con- 
ditions as  likewise  predisposing.  Functional  and  organic  diseases  of  the 
uterus  may  also  be  found  to  be  the  important  underlying  etiologic  factors, 
especially  in  the  recurrent  and  chronic  cases.  Surgical  operations,  more 
particularly  upon  the  abdominal  cavity,  exceptionally  appear  to  be  of 
causative  influence.  In  fact,  whatever  gives  rise  to  profound  nervous 
disturbance  must  be  looked  upon  as  of  some  import.  My  own  impres- 
sion has  been  that  these  various  factors  act  principally  by  the  disturbing 
influence  they  may  have  upon  the  act  of  digestion.  Beyond  question, 
toxins  from  without  or  within— auto-intoxication— must  in  this,  as  in  some 
other  diseases  of  the  skin,  especially  erythema  multiforme,  be  considered 
as  the  most  common  cause  of  the  outbreak.  The  action  of  nervous 


1 84 


influence,  direct  or  indirect,  is  shown  by  a  case  reported  by  Oliver,1 
where  the  eruption  was  due  to  eye-strain,  persisting  or  recurring  when 
a  change  in  lenses  was  necessary.  Ravitch2  believes  disturbances  of  the 
thyroid  to  be  a  factor  of  importance  in  chronic  urticaria. 

In  the  past  several  years  biologic  investigations  have  been  thought 
to  point  out  as  probably  first  indicated  by  Wolff-Eisner  that  urticaria 
(and  other  toxic  dermatoses)  may  be  due  to  a  hypersensitiveness  to  a 
foreign  albuminoid  substance — the  albumin  not  being  sufficiently  split 
up  by  the  intestinal  juices,  such  products  being  absorbed  into  the  cir- 
culation, and  provoking  an  outbreak.  A  hypersensitive  or  anaphylactic 
condition  may  be  thus  brought  about  which  makes  the  individual  acutely 
responsive  to  even  the  smallest  quantity  of  such  toxic  substances.  The 
faulty  or  imperfect  preparation  of  this  protein  for  safe  absorption  might 
be  directly  or  indirectly  due  to  any  of  the  various  etiologic  factors  named. 


.Fig.  35.— Urticaria — section  of  a  wheal:  e,  Epidermis,  practically  no  alteration;  c, 
corium,  showing  acute  inflammatory  changes,  swollen  and  infiltrated  with  serous  exuda- 
tion, with  the  blood-vessels  (v,  v,  v),  especially  those  accompanying  the  sweat-ducts 
(j, ./,  s,  s)  dilated  and  surrounded  by  and  containing  numerous  polynuclear  leukocytes; 
lymphatic  vessels  (I,  I)  and  spaces  also  enlarged,  containing  granular  matter;  numerous 
mast-cells  (m,  m)  scattered  through  the  corium  (courtesy  of  Dr.  T.  C.  Gilchrist). 

Pathology. — The  pathology  of  urticaria  is  closely  similar  to  that 
of  erythema  multiforme.  The  disease  is  an  angioneurosis,  the  lesions 
being,  primarily  at  least,  due  to  vasomotor  disturbance,  which  may  be 
of  diverse  origin,  but  doubtless  most  commonly  toxinic ;  the  angioneurotic 
view  has,  however,  some  distinguished  opponents.  Barthelemy  believes 
dermatographism  to  be  due  to  a  toxic  vasomotor  dermatoneurosis. 
In  urticarial  lesions  dilatation  following  spasm  of  the  vessels  results  in 
effusion,  and  in  consequence  the  overfilled  vessels  of  the  central  por- 
tion are  emptied  by  pressure  of  the  exudation,  and  the  pink  or  reddish 
color  gives  place  to  central  paleness,  while  the  pressed  back  blood  ac- 

1  Oliver,  Philadelphia  Med.  Jour.,  January  14,  1899. 

2  Ravitch,  "The  Thyroid  as  a  Factor  in  Urticaria  Chronica,"  Jour.  Cutan.  Dis., 
1907,  p.  512;  also  Leopold-Levi  and  de  Rothschild,  Compt.  rend.  Soc.  de  Biol.,  Nov., 
1906. 


URTICARIA  185 

centuates  the  bright  red  tint  of  the  periphery.  Philippson,1  from  animal 
experiments,  believes,  with  Heidenhain,  that  the  secretion  of  lymph  is 
not  a  passive  process  due  to  intravascular  pressure,  as  contended  by 
most  dermatologists,  but  that  a  secretory  action  of  the  vascular  endo- 
thelium  is  involved;  and  that  the  edema  of  urticaria  is  similarly  pro- 
duced by  direct  action  of  poisonous  substances  upon  the  vessels  in  the 
neighborhood.  Torok  and  Hari's2  experimental  studies  are  also  in 
accord  with  this  view.  Gilchrist's3  experimental  observations  led  him 
to  a  somewhat  similar  conclusion:  that  a  true  wheal  is  an  acute,  inflam- 
matory edematous  swelling,  due  either  to  local  inoculation  of  irritating 
substances,  as  insect  bites,  etc.,  or  to  drugs  or  to  some  toxin  probably 
originating  in  the  alimentary  canal,  the  irritating  agent  producing  death 
of  cells,  which  is  followed  by  acute  inflammatory  changes.  Wright  and 
Paramore4  believe  that  an  attack  of  urticaria  may  be  directly  due  to  a 
diminution  of  the  lime  salts  in  the  blood,  with  consequent  associated  de- 
fective blood  coagulability — is  of  the  nature  of  a  serous  hemorrhage. 

The  pathologic  anatomy  of  a  wheal,  studied  by  various  observers 
(Vidal,  Unna,  Gilchrist,  and  others),  shows  it  to  be  a  more  or  less  firm 
elevation  of  a  circumscribed  or  somewhat  diffused  collection  of  semi- 
fluid material,  more  especially  in  the  upper  layers  of  the  skin.  While  it 
has  its  usual  seat  in  the  derma  proper,  in  intense  cases  the  subcutaneous 
tissue  may  also  be  involved  in  the  process.  Gilchrist  found  the  epi- 
dermis unaltered,  but  the  whole  corium  the  seat  of  acute  inflammatory 
changes;  the  blood-vessels,  especially  those  accompanying  the  sweat- 
ducts,  enlarged,  containing  and  surrounded  by  a  large  number  of  poly- 
nuclear  leukocytes;  the  lymphatic  vessels  and  the  juice-spaces  were 
also  much  enlarged,  containing  only  granular  material;  large  numbers 
of  polynuclear  cells  were  found  to  pervade  the  whole  region,  even  into 
the  papillae,  but  only  a  few  had  found  their  way  into  the  epidermis. 
There  were  numerous  mast-cells  throughout  the  corium,  and  the  latter 
was  much  swollen  and  infiltrated  with  serous  exudation. 

Diagnosis. — This  rarely  gives  any  difficulty.  In  fact,  the  disease 
is  so  common  and  well  known  that  the  diagnosis  is  usually  made  by  the 
patient.  The  character  of  the  lesions,  their  evanescent  nature,  the 
irregular  and  general  distribution,  usually  abundant  upon  covered  parts, 
and  the  accompanying  intense  itching,  will  afford  sufficient  basis  for  its 
recognition.  These  points  will  serve  to  differentiate  it  from  erythema 
multiforme,  to  which  it  bears  some  resemblance.  Urticaria  bullosa 
might,  upon  first  and  careless  inspection,  lead  to  a  confusion  with  pem- 
phigus or  dermatitis  herpetiformis,  but  the  usually  preceding  wheal 
upon  which  the  bleb  arises,  and  the  presence  here  and  there  of  the  ordi- 
nary type  of  the  eruption,  together  with  the  history  and  course,  will 
prevent  error. 

1  Philippson,  Giorn.  ital.,  1899,  Fasc.  vi,  p.  675,  abstract  in  Brit.  Jour.  Derm.,  1900, 

2  Torok  and  Hari,  "Experimentelle  Untersuchungen  iiber  die  Pathogenese  der  Urti- 
caria," Archiv.,  1903,  vol.  Ixv,  p.  21.  . 

3  Gilchrist,  "Some  Experimental  Observations  on  the  Histopathology  of  Urticaria 
Factitia,"  Jour.  Cutan.  Dis.,  1908,  p.  122. 

4  Paramore  (experimental  study),  Brit.  Jour.  Derm.,  1906,  pp.  239  and  248. 


i86 


Chronic  urticaria  has  essentially  the  same  features  as  the  acute 
disease,  except  the  eruption  is  usually  less  abundant.  It  is  not  to  be 
forgotten  that  both  pediculosis  and  scabies,  as  well  as  the  irritation  of 
other  animal  parasites,  may  occasionally  be  responsible  for  scattered 
wheals,  but  the  other  eruptive  features  of  such  maladies  (q.  v.)  are  usu- 
ally sufficiently  distinctive  to  prevent  confusion. 

Prognosis.— The  acute  disease  is  of  short  duration,  disappearing 
spontaneously  or  as  the  result  of  treatment  in  several  hours  or  a  few 
days;  it  may  recur  upon  exposure  to  the  exciting  cause.  Patients 
with  urticarial  tendency  should  give  special  attention  to  the  dietary, 
and  avoid  those  articles  which  may  cause  indigestion  or  which  expe- 
rience has  taught  them  may,  owing  to  some  idiosyncrasy,  provoke 
the  disease.  The  prognosis  of  chronic  urticaria  is  to  be  guarded,  and 
will  depend  upon  the  ability  to  discover  and  remove  or  modify  the 
etiologic  factor.  Recurrences  are  not  uncommon. 

Treatment. — Acute  urticaria,  the  most  common  expression  of 
the  disease,  is  usually  due  to  stomach  or  digestive  disturbance  of  acute 
character.  If  the  case  is  urgent  and  seen  early,  an  emetic,  to  rid  the 
stomach  quickly  of  the  offending  material,  may  be  given;  this  is,  however, 
rarely  required.  The  usual  plan  is  to  give  a  purge.  For  this  purpose 
there  is  nothing  better  than  the  antacid  magnesia,  although  any  of  the 
various  salines  will  usually  act  satisfactorily.  In  addition  to  the  purga- 
tive, an  antacid  should  be  administered  at  several  hours'  interval,  such 
as  sodium  salicylate  or  sodium  bicarbonate  or  benzoate;  of  the  salicylate, 
5  to  10  grains  (0.35-0.65)  three  or  four  times  daily,  and  of  the  others, 
10  to  20  grains  (0.65-1.35)  at  a  dose;  in  children  the  doses  should  be 
smaller.  The  diet  for  the  time  should  be  plain.  In  the  vast  majority 
of  the  acute  cases  this  simple  plan  of  treatment  will  prove  sufficient 
to  end  the  attack.  If  the  attack  should  be  somewhat  persistent,  the 
alkali  should  be  continued,  and,  in  addition,  small  doses  of  salol  and  a 
few  grains  of  charcoal  added  to  each  dose.  The  calcined  magnesia,  too, 
should  be  administered  about  every  other  night  until  the  disease  has 
yielded. 

It  is,  however,  the  chronic  cases  of  urticaria  which  often  tax  our 
therapeutic  resources.  Such  cases  require  the  most  rigorous  and  care- 
ful examination,  in  order  to  discover,  if  possible,  the  underlying  etiologic 
factor  or  factors.  The  possibility  of  diabetes,  albuminuria,  disease  of 
the  liver,  and  utero-ovarian  disease  being  the  influential  cause  should  be 
eliminated.  The  urine  should  be  carefully  and  repeatedly  examined, 
for  this  sometimes  gives  the  clue  to  the  acting  factor.  Particular  atten- 
tion should  be  given  to  the  digestive  apparatus,  for  probably  this,  as  in 
the  acute  cases,  is  the  most  common  source  of  the  disease.  The  patient's 
habits  as  regards  the  use  of  alcohol  and  the  use  of  drugs  should  also  be 
inquired  into,  as  having  a  possible  bearing. 

There  are  many  cases,  it  is  true,  of  chronic  urticaria  in  which  the 
etiology  remains  obscure,  even  after  the  most  careful  investigation, 
and  such  cases  must  be  treated  empirically.  Experience  has  taught 
that  the  remedies  most  frequently  successfully  used  in  such  cases  are 
quinin,  sodium  salicylate,  atropin  (Schwimmer  and  many  others), 


URTICARIA  187 

pilocarpin  (Pick),  ergot,  potassium  bromid,  salol,  strophanthus  (RifEat), 
ichthyol,  strychnin,  calcium  chlorid  (Wright),  along  with  saline^ laxa- 
tives. Arsenic  may  also  be  tried  in  resistant  cases,  although,  Except 
indirectly,  in  small  doses  as  a  tonic,  it  is  usually  disappointing.  --The 
most  efficient  of  these  in  a  given  number  of  cases  are  atropin  and  sodium 
salicylate. 

Frequent  and  repeated  doses  of  saline  laxatives  sometimes  cure^ 
when  all  the  ordinary  remedies  have  failed  to  make  a  permanent  im- 
pression. For  this  purpose  calcined  magnesia,  taken  every  second  q? 
third  night,  or  Carlsbad  salts,  magnesium  sulphate,  sodium  sulphate, 
Hunyadi  Janos  water,  or  Friedrichshall  water,  taken  every  morning 
or  every  second  morning,  can  be  prescribed.  The  dose  should  be  suffi- 
cient to  produce  free  and  prompt  action,  but  not  sufficiently  large  to  bring 
about  a  condition  of  diarrhea.  The  following  also  has  given  me  satis- 
faction: 

TV     Sodii  sulphat.  granulat.,  5ij  (64.); 

Sodii  chlorid.,  Siiss  (10.); 

Sodii  bicarbonat.,  3vss  (22.). 

This  should  be  kept  in  a  closely  stoppered,  wide-mouthed  bottle,  * 
and  one  to  two  teaspoonfuls  taken  dissolved  in  a  half  to  a  tumblerful 
of  hot  water  twenty  or  thirty  minutes  before  breakfast;  or  in  some  ^ 
cases  it  seems  to  act  better  when  taken  in  smaller  doses— a  half  to  one 
teaspoonful — before  each  meal.  In  obstinate  cases  spinal  galvaniza- 
tion, static  insulation,  and  the  static  current  with  the  roller  electrode 
applied  along  the  spine  should  be  tried.  Ravitch,  in  the  belief  that  the 
thyroid  gland  is  a  factor,  has  prescribed  in  atrophy  and  functional  inac- 
tivity desiccated  thyroid  gland  in  chronic  cases  with  alleged  favorable 
results;  while  in  enlarged  glands  and  hypersecretion  such  remedies  as 
thyroidectin,  strophanthus,  bromids,  atropin,  and  #-ray. 

It  is  understood  that  in  all  these  cases  the  diet  is  to  be  carefully  regu- 
lated, and  all  indigestible  foods  interdicted,  and  especially  those  articles 
which  experience  has  taught  are  not  infrequently  causative  factors. 
Coffee  and  tea  in  excess  should  also  be  avoided;  in  fact,  these  drinks 
should  be,  in  rebellious  cases,  forbidden  absolutely.  Resorting  for  a  J. 
time  to  an  exclusively  milk  diet  will  sometimes  prove  curative,  or  at 
least  remove  the  disease  for  a  time.  In  persistent  cases  of  the  disease 
which  have  proved  rebellious  to  all  plans,  especially  those  dependent 
upon  neurasthenic  conditions,  change  of  scene  and  climate  will  some- 
times give  temporary,  and  not  infrequently  permanent,  freedom. 

If  the  eruption  is  extensive  the  itching  is  likely  to  be  so  trouble- 
some a  feature  that  the  patient  loses  much  sleep,  and  in  such  instances, 
occasionally,  recourse  must  be  had  to  potassium  bromid,  chloral,  sul- 
phonal,  acetanilid,  phenacetin,  and  the  like.  In  a  few  instances  two  or 
three  daily  doses  of  acetanilid  or  phenacetin  in  moderate  quantity  have, 
as  already  intimated,  afforded  more  or  less  permanent  relief.  Opiates 
are  usually  to  be  avoided,  inasmuch  as  they  often  increase  the  subjective 
symptoms. 

In  most  cases  of  urticaria  it  is  found  necessary  to  resort  to  local 
applications  to  give  some  relief  to  the  intense  itching  and  burning  which 


1 8  8  INFLAMMA  TIONS 

usually  characterize  the  malady.  The  most  efficient  are  those  remedies 
wjiichrare  known  to  have  an  antipruritic  action.  Carbolic  acid  in 
lotion  form  is  one  of  the  most  valuable  antipruritics  in  our  possession. 
It  may  be  prescribed  as  in  the  following: 

1$.    Acid,  carbolici,  3ss-3j  (2-4-)', 

Glycerini,  5ss  (2.); 

Alcoholis,  oj  (32.); 

Aquae,  q.  s.  ad  oviij  (256.). 

Liquor   carbonis   detergens   is   another   valuable   preparation,    and 
,  may  be  used  in  the  strength  of  i  to  2  or  3  ounces  (32.  to  96.)  to  the 
pint  (500.)  of  water.     A  lotion  of  thymol,  such  as  the  following,  will  like- 
wise be  found  of  value: 

1$.     Thymolis,  gr.  viiss-xv  (0.5-1.); 

Glycerini,  3ij  (8.); 

Alcoholis,  oij  (64.); 

Liquor  potassae,  5  j  (4.) ; 

Aquae,  q.  s.  ad  Sviij  (256.). 

Alkaline  baths  are  also  of  great  benefit  in  some  cases.  These  may 
be  made  with  borax,  sodium  carbonate,  sodium  bicarbonate,  i  to  4 
ounces  (32.  to  128.)  to  the  bath  of  about  30  gallons;  ammonium  muriate, 
i  to  2  ounces  (32.  to  64.)  to  the  bath,  is  also  useful.  The  patient  should 
remain  in  the  bath  from  several  minutes  to  ten  or  fifteen  minutes,  and 
the  temperature  should  be  sufficiently  warm  that  chilliness  does  not  occur. 

In  mild  cases,  and  even  in  some  of  the  more  severe  cases,  the  use  of  a 
dusting-powder  on  the  affected  surfaces  will  be  sufficiently  soothing,  and 
has  the  advantage  of  cleanliness  and  ease  of  application.  For  this  pur- 
pose any  of  the  ordinary  dusting-powders,  such  as  zinc  oxid,  rice  flour, 
talc,  and  boric  acid,  can  be  used. 

Ointments  are  rarely  of  service  in  the  ordinary  type  of  this  disease, 
but  in  the  types  described  as  the  vesicular  and  bullous  varieties  they 
may  be  demanded  for  their  soothing  and  protective  influence.  For 
this  purpose  the  plain  zinc  oxid  ointment,  with  5  or  10  grains  (0.35  or 
0.65)  of  resorcin  or  carbolic  acid  to  the  ounce  (32.),  will  prove  satis- 
factory. A  boric  acid  ointment — i  dram  (4.)  of  boric  acid  to  the  ounce 
(32.)  of  cold  cream — may  also  be  of  use.  If  there  is  a  good  deal  of 
irritation,  the  calamin-zinc-oxid  lotion  may  likewise  be  employed  in 
these  cases. 

URTICARIA  PIGMENTOSA1 

Synonyms. — Xanthelasmoidea;  Urticaria  perstans  pigmentosa. 

Definition. — An  urticaria-like  eruption,  in  which  the  lesions  are 
usually  persistent  and  show  accompanying  or  subsequent  pigment 
deposit,  with,  in  some,  a  new  growth  element. 

1  Literature:  For  cases,  etc.,  antedating  1883  (Nettleship,  Morrant  Baker,  Tilbury 
Fox,  Barlow,  Sangster,  Morrow,  Goodhart,  Mackenzie,  Cavafy)  see  paper  by  Colcott 
Fox,  Trans.  Med.-Chir.  Soc'y,  London,  1883,  p.  329;  also  Crocker's  paper,  Trans. 
Clin.  Soc'y,  London,  1885,  p.  12;  also  Raymond,  "Urticaire  pigmentee,"  These  de 
Paris,  1888  (giving  a  complete  review  of  the  subject — referring  to  29  cases).  Among  the 
many  cases  reported  since  may  be  mentioned:  Elliot,  Jour.  Cutan.  Dis.,  1891,  p.  296; 


URTICARIA    PIGMENTOSA 


189 


Symptoms. — The  eruption,  which,  with  rare  exceptions,  makes  its 
appearance  in  the  first  several  months  of  life,  is,  as  a  rule,  scarcely 
distinguishable  in  its  beginning  from  ordinary  urticaria;  but  the  lesions, 


Fig.  36. — Urticaria  pigmentosa  in  a  female  child  eleven  months  old.  Began  in  the 
fourth  month,  at  first  on  the  legs,  and  gradually  invaded  the  entire  surface,  including  the 
scalp.  The  lesions  present  as  ordinary  wheals,  but  are  persistent,  subsiding  somewhat, 
becoming  yellowish,  later  with  a  violaceous  tinge;  after  continuing  for  several  months 
or  longer  they  disappear,  leaving  purplish  and  bluish-yellow  stains.  Some  of  the  lesions 
have  a  slight  resemblance  to  xanthoma.  Itching  was,  as  a  rule,  moderate,  only  occa- 
sionally troublesome.  Several  years  later  the  malady  was  much  less  active,  and  the 
lesions  relatively  sparse.  General  health  excellent. 

or  the  most  of  them,  instead  of  disappearing  quickly,  are  persistent, 
and  after  some  days  or  a  few  weeks  show  pigment  deposit.  An  individual 

Hallopeau  (leaving  white  cicatrices),  Annales,  1892,  p.  628;  Bronson  (soc'y  discus- 
sion), Jour.  Culan.  Dis.,  1894,  p.  260;  Morrow,  ibid.,  1895,  p.  445  (leaving  in  places 
tabs  of  loose  skin — this  case  was  over  twenty  years'  duration) ;  Jadassohn,  Verhandl. 
d.  IV.  Deutsch.  derm.  Cong.,  Vienna,  1894;  Fabry,  Archiv,  1896,  vol.  xxxvi,  p.  21; 
Gilchrist,  Johns  Hopkins  Hasp.  Bull.,  1896,  vol.  vii,  p.  140;  Dubrisay  et  Thibi£rge, 
Annales,  1896,  p.  1303;  Colcott  Fox,  Brit.  Jour.  Derm.,  1898,  p.  411  (especially  bear- 
ing upon  urticaria  pigmentosa  and  true  urticaria,  leaving  pigmentation) ;  Brongersma, 
Brit.  Jour.  Derm.,  1899,  p.  179  (a  good  resume  of  the  pathology);  Woldert,  Jour. 
Amer.  Med.  Assoc.,  Oct.  21,  1899,  p.  1022;  Stelwagon  (3  cases),  Jour.  Cutan.  Dis., 
1898,  p.  576;  Duhring's  Cutaneous  Medicine,  Part  ii,  p.  300;  Graham  Little  (an  admi- 
rable paper — clinical,  histologic,  experimental  and  review,  with  tabulation  of  reported 
•cases),  Brit.  Jour.  Derm.,  1905,  pp.  355,  393,  427,  and  1906,  p.  16. 


190 


INFLAMMA  TIONS 


lesion  may  continue  for  weeks,  months,  or  at  times  longer,  gradually 
flatten  down,  and  leave  behind  slight  or  pronounced  stain.  This  stain 
may  be  at  first  quite  purplish  and  later  become  less  pronounced,  and 
finally,  sometimes  only  after  years,  entirely  disappear.  Quite  com- 
monly rubbing  the  affected  region  will  bring  up  wheals  at  the  sites  of 
the  stains  of  disappearing  lesions.  Instead  of  the  purplish  or  bluish 
tinge,  the  lesion  may  be  of  a  yellow  or  salmon  color.  These  latter  bear 
some  resemblance  to  xanthoma.  In  some  instances  the  lesions  are  yel- 
lowish, bluish,  or  purplish  almost  from  the  start.  Occasionally,  after 
they  disappear,  their  site  will  show  a  scarcely  perceptible  wrinkled  ap- 
pearance, as  in  one  of  my  own  cases,  which  persists;  or  exceptionally 
slight  atrophy  or  scarring  (Hallopeau,  Brongersma)  or  tissue-formation 
(Morrow's  case).  Exceptionally  some  distinct  atrophy  has  been  noticed. 
In  several  or  more  lesions  of  some  cases  there  may  be  a  tendency  to 
vesicular  capping.  New  efflorescences  continue  to  appear  from  time  to 
time,  some  of  which  are  more  or  less  evanescent,  like  ordinary  urticaria. 
There  may  be  a  feeling  of  solidity  in  the  lesions,  or  they  may  be  some- 
what soft  to  the  touch.  They  are  small  to  large  pea-sized,  and  some- 
times even  nodular.  In  fact,  cases  may  vary  considerably,  the  lesion  in 
some  being  largely  macular  (macular  form),  and  in  others  being  distinctly 
nodular  (nodular  or  tuberose  form).  The  eruption  may  be  somewhat 
scanty  or  profuse. 

The  covered  regions  of  the  body  usually  show  the  eruption  most 
abundantly,  although  other  parts,  especially  the  face  and  the  neck, 
are  often  likewise  involved.  The  disease  continues  for  years,  with 
periods  of  comparative  quiescence,  during  which  but  few  new  lesions  will 
make  their  appearance.  Itching  may  be  present  to  a  marked  degree,  or 
it  may  be  slight,  or  exceptionally  entirely  wanting.  The  general  health 
remains  unaffected,  although  occasionally  loss  of  sleep,  as  a  result  of  in- 
tense itching,  may  give  rise  to  some  nervousness  and  debility. 

Etiology  and  Pathology — It  is  seen  in  children,  in  most  in- 
stances beginning  before  the  third  or  fourth  months;  in  a  case  reported 
by  Crocker  it  was  practically  congenital.  Exceptionally  it  appears 
at  a  much  later  period — even  approaching  middle  life.1  Boys  seem  to 
furnish  the  majority  of  cases.  The  essential  cause,  and  even  contribut- 
ing or  predisposing  causes,  are  as  yet  unrecognized.  There  is  sometimes 
a  history  of  urticarial  tendency  in  the  family.  The  subjects  are,  as  a 
rule,  otherwise  seemingly  in  good  health.  In  one  instance  (Woldert) 
the  disease  followed  varicella.  It  is,  judging  from  case  reports,  much 
more  common  in  England  than  elsewhere. 

A  review  of  the  various  cases  reported  would  lead  to  the  opinion 
that  in  some  the  true  urticarial  element  is  preponderating,  while  in 
others,  especially  those  presenting  the  soft,  persistent,  xanthoma-like 
lesions,  there  is  a  new  growth  element.  The  impression  conveyed  by  the 
cases  under  my  observation  is  that  the  disease  is  essentially  an  urticaria, 

1  Graham  Little  (loc.  cit.)  had  collected  notes  of  22  adult  cases  up  to  1905;  several 
other  cases  have  been  reported  since  that  date:  Bohac  (Archiv,  Oct.,  1906,  p.  49), 
began  when  patient  aged  twenty-seven;  Graham  Little  (Brit.  Jour.  Derm.,  1908,  p.  232), 
began  when  patient  aged  thirty- two;  and  another  patient  aged  twenty- two,  ibid.,  1911, 
p.  185;  and  several  others  (Malcolm  Morris,  Eddowes,  and  others). 


(EDEMA   ANGIONEUROTICUM  191 

primarily  at  least,  and  that  the  subsequent  peculiarities  are  due  to 
secondary- changes  in  the  lesions.  The  anatomic  studies  (Thin,  Colcott 
Fox,  Unna,  Gilchrist,  Brongersma,  and  others)  show  that  it  has  in  some 
respects  the  structure  of  a  wheal,  with  edema  and  pigment  deposit  in  the 
epidermal  portion,  and  cellular  infiltration  made  up  principally  of  mast- 
cells.  This  last  feature  may,  indeed,  be  considered  characteristic;  the 
origin  of  the  cells  is  still  in  doubt,  Unna  believing  that  they  develop  from 
connective-tissue  cells.  The  investigations  of  Gilchrist  and  Brongersma 
seem  to  indicate,  as  summarized  by  the  latter,  that  the  mast-cells  existed 
before  the  formation  of  the  wheal,  and  as  a  result  of  the  rapid  edema  and 
other  changes  coincident  with  the  formation  of  the  wheal  have  been 
swept  together  from  the  tissues  in  the  neighborhood,  where  they  had 
already  existed  in  large  numbers.  Little  is  inclined  to  believe  that  there 
is  a  general  tendency,  probably  congenital,  to  overproduction  of  mast- 
cells  in  the  skin  of  these  patients,  the  local  excessive  accumulation 
(clinically  represented  by  macules  or  nodules)  determined  by  various 
accidental  phenomena. 

Diagnosis. — The  diagnostic  features  are  the  early  appearance  of 
the  eruption,  the  persistent,  urticaria-like  lesions  leaving  stains,  the 
usually  associated  ordinary  wheals  of  urticaria,  and  chronicity.  In 
those  instances  in  which  the  activity  of  the  malady  has  subsided,  and 
in  which  the  yellowish,  xanthoma-like  lesions  are  present,  there  might 
be  some  suggestion  of  multiple  xanthoma,  especially  if  there  is  no  itching; 
but  the  history  of  the  case,  the  characters  of  the  early  lesions,  and  the 
usually  occasional  presentation  of  wheals  will  prevent  error.  Moreover, 
rubbing  the  hand  firmly  over  the  lesions  will  usually  cause  them  to 
become  more  pronounced. 

Prognosis  and  Treatment. — The  disease  is  chronic  and  per- 
sistent, but  almost  invariably  begins  to  subside  as  puberty  is  approached, 
and  rarely  extends  into  adult  life.  Nor  is  it,  unfortunately,  much  in- 
fluenced by  therapeutic  measures.  The  usual  remedies  for  urticaria 
should  be  experimentally  prescribed.  The  most  promising  are  sodium 
salicylate,  pilocarpin,  belladonna,  and  arsenic,  in  moderate  dosage,  con- 
tinued for  some  length  of  time.  The  diet  should  be  looked  after,  and 
indigestible  foods  interdicted.  Any  contributory  condition  of  ill  health 
should  be  corrected.  External  treatment  is  sometimes  necessary  for  the 
relief  of  the  itching,  and  for  this  purpose  the  various  applications  pre- 
scribed for  urticaria  may  be  employed. 

OEDEMA  ANGIONEUROTICUM 

Synonyms.— Acute  non-inflammatory  edema;  Acute  circumscribed  edema;  Angio- 
neurotic  edema;  (Edema  circumscriptum;  CEdema  cutis  circumscriptum  acutum; 
Quincke's  disease;  Giant  urticaria  and  Urticaria  cedematosa  (many  cases);  Fr.,  CEdeme 
aigu. 

Definition — An  affection  characterized  by  one,  several,  or  more 
acute  circumscribed  edematous  swellings,  usually  in  regions  where  the 
tissues  are  readily  distensible,  as  the  eyelid,  ear  lobe,  lip,  etc.  Quincke 
was  the  first  to  calUspecial  attention  to  this  somewhat  rare  and  peculiar 


1 92  I  NFL  A  MM  A  TIONS 

malady,  since  which  time  Jamieson,  Strutting,  Riehl,  Collins,  Osier,  and 
many  others  have  reported  cases.1 

Symptoms. — The  swelling  may  present  itself  without  consti- 
tutional or  other  symptoms.  In  some  instances,  however,  there  are  a 
variable  degree  of  premonitory  malaise,  gastro-intestinal  disturbance, 
and  a  feeling  of  being  generally  out  of  sorts,  which  usher  in  the  cutaneous 
phenomena  and  sometimes  persist  throughout  the  attack.  Doubtless 
in  some  instances  these  may  be  due  to  edematous  swellings  in  the  gastric 
wall,  in  others  to  the  development  of  toxins  which  provoke  the  malady. 
The  swelling  itself,  however,  is  acute,  coming  on  suddenly,  and  reaching 
full  and  usually  enormous  development  in  a  few  seconds  or  minutes. 
Occasionally /however,  it  comes  on  somewhat  gradually,  one  or  twro  hours 
elapsing  before  its  acme  is  attained.  The  swelling  is,  as  a  rule,  rather 
sharply  circumscribed;  rarely  with  a  diffusing  tendency  into  the  neigh- 
boring tissues.  If  the  eyelid  is  the  region  involved,  the  eye  is  usually 
completely  closed;  if  the  lip,  the  part  is  stiff  and  large,  and  for  the  time 
scarcely  admits  of  opening;  and  if  both  lips  are  attacked,  temporarily 
incapacitating  for  talking  or  eating.  The  nose  is  also  occasionally  the 
site  of  this  swelling,  and  attains  considerable  dimensions,  but  not  so  large 
as  the  lip,  ear  lobe,  or  eyelid,  where  the  tissues  permit  of  greater  disten- 
tion.  The  extremities  are  likewise  frequently  subject  to  these  swellings. 
Less  commonly  other  parts  may  be  attacked,  even  the  tongue  and 
glottis.  According  to  the  analysis  of  71  cases  collected  and  tabulated  by 
Collins,  the  first  attack  was  noted  on  the  face  in  29  instances,  on  the 
extremities  in  22,  trunk  6,  larynx  5,  genitalia  3,  stomach  3,  gums  and 
palate  i,  neck  i,  and  mastoid  region  i.  While  the  swelling  is  usually 
enormous,  in  some  cases  it  is  relatively  slight,  or  may  vary 'somewhat 
in  different  attacks.  As  a  rule,  but  one  part  is  swollen  at  one  time, 
although  in  some  instances  several  lesions  may  appear  simultaneously 
or  one  after  the  other;  it  is  more  commonly  shifting,  disappearing  in  one 
place  and  reappearing  in  another.  The  swelling  may  be  of  the  normal 
color  of  the  skin  or  somewhat  paler,  or  it  may  be  of  a  pinkish  or  reddish 
hue.  It  is  somewhat  hard,  does  not  pit  like  ordinary  edema,  although  a 
slight  depression  of  transitory  character  may  usually  be  made  by  pressure. 

The  duration  of  the  swelling  varies;  it  may  disappear  as  rapidly 

1  Some  important  literature  references:  Quincke,  Monatshefte,  1882,  p.  129;  Jamie- 
son,  Edinburgh  Med.  Jour.,  June,  1883,  p.  1000;  J.  E.  Graham,  Canadian  Practitioner, 
Feb.,  1885,  p.  33;  Strubing,  Zeitschr.f.  klin.  Med.,  1885,  p.  381  (with  numerous  refer- 
ences); Matas,  New  Orleans  Med.  and  Surg.  Jour.,  1887-88,  vol.  xv,  p.  257;  Riehl, 
Wien.  med.  Presse,  1888,  pp.  354,  398,  and  431  (with  references);  Osier,  Internal. 
Jour.  Med.  Sci.,  1888,  p.  362;  Elliot,  Jour.  Cutan.  Dis.,  1888,  p.  19;  Unna,  Monats- 
hefte,  1889,  vol.  viii,  pp.  446  and  490;  Hartzell,  University  Med.  Magazine,  May, 
1890;  Collins,  Amer:  Jour.  Med.  Sci.,  1892,  vol.  civ,  p.  654  (an  admirable  analytic 
paper  with  full  bibliography);  E.  W.  Jacob,  Brit.  Jour.  Derm.,  1892,  p.  155  (with  bib- 
liography); Schlesinger,  Wien.  klin.  Wochenschr.,  1898,  p.  235;  Wende,  Jour.  Cutan. 
Dis.,  1899,  p.  178;  Onuf  (Onufrowicz),  Med.  Record,  Aug.  5,  1899,  p.  183  (and  allied 
conditions);  Baruch,  ibid.,  Aug.  19,  1899,  p.  257;  Kohn,  American  Medicine,  Dec.  21, 
1901,  p.  997  (with  review  of  the  literature  and  full  bibliography) ;  Morichaut-Beauchant, 
Annales,  1906,  p.  22  (review  with  many  references);  Burr,  The  Journal  of  Nervous  and 
Mental  Diseases,  July  12,  1912  (tongue  chiefly,  but  at  times  other  parts  also);  mercury 
(patient  had  tertiary  syphilitic  symptoms)  was  thought  at  first  to  provoke  or  aggra- 
vate; attacks  ceased  after  administration  of  salvarsan;  Wiel,  Jour.  Amer.  Med. 
Assoc.,  April  27,  1912,  p.  1246  (5  cases,  with  brief  review  and  references). 


(EDEMA   ANGIONEUROTICUM  193 

as  it  came,  or  more  commonly  last  several  hours,  or  in  some  instances 
a  few  days,  and  then  rapidly  or  gradually  melt  away.  The  attack 
may  thus  end,  or  it  may  continue  by  the  appearance  of  one  or  more 
swellings  elsewhere,  and  persist  for  several  days  or  one  or  two  weeks; 
exceptionally  for  months  or  a  year  or  more,  as  in  Graham's  case,1  the 
patient  scarcely  being  free  from  these  evanescent  swellings. 

It  is  not  uncommon  for  the  malady  to  recur  from  time  to  time,  and 
it  is  believed  that  there  is  a  tendency  to  recur  at  a  point  previously 
involved,  but  this  is  probably  merely  due  to  the  fact  that  there  are 
comparatively  few  regions  at  which  it  is  prone  to  occur,  rather  than 
to  any  engendered  weakness  of  the  part.  In  some  cases  there  is  itching 
or  burning,  and  almost  always  more  or  less  tension  or  a  feeling  of  stiff- 
ness in  the  part  occurs.  The  surface  temperature  in  some  cases  has 
been  noted  to  be  slightly  elevated,  in  others  reduced,  and  in  others  again 
undisturbed.  While  some  of  the  edematous  swellings — one  or  several — 
may  be  free  from  subjective  symptoms,  in  others  there  is  intense  itching, 
and  there  may  also  be  here  and  there,  scattered  over  the  surface,  ordinary 
urticarial  efflorescences.  In  some  instances  partial  local  anesthesia  or 
numbness  has  been  noted  for  a  short  time  after  the  disappearance  of  the 
swelling. 

Etiology  and  Pathology — The  affection  is  met  with  in  both 
sexes  and  almost  at  any  age,  being  probably  most  frequent  between 
early  youth  and  middle  life.  The  manifestation  is  closely  allied  to 
urticaria,  as  shown  by  the  not  infrequent  association  of  ordinary  wheals, 
or  history  of  urticarial  attacks.  Some  cases,  however,  seem  to  be  free 
from  suggestive  subjective  symptoms  and  other  evidences  of  an  urticarial 
character.  Striibing,  Quincke,  Osier,  and  others  have  called  attention 
to  the  frequently  shown  family  predisposition.  Osier  in  one  instance 
elicited  a  history  of  its  occurrence  in  five  generations.  Various  causes 
are  apparently  exciting,  the  most  frequent,  as  also  observed  in  urticaria, 
being  articles  of  food  which  disturb  digestion  or  give  rise  to  the  develop- 
ment of  gastric  or  intestinal  toxins.  Its  most  common  subjects  are  found 
in  those  of  weak  digestion  and  easily  disturbed  nervous  system.  In 
Matas'  case  of  daily  attack,  the  swellings  seemed  to  take  the  place  of  a 
malarial  attack.  In  many  instances  there  appears  to  be  a  systemic 
sympathy  or  auto-intoxication;  Lodor2  states  that  all  his  cases  except 
one  showed  a  marked  malaise  and  depression  preceding  the  attack,  and 
his  patients  could  thus  foretell  the  approaching  outbreak.  Horwitz3 
observed  3  cases  follow  traumatism,  and  in  Ashton's4  patients  the  attacks 
followed  exposure  to  draft  or  sudden  cooling  of  the  surface.  The 
outbreaks  in  Oppenheimer's  patients  were  excited  by  alcoholic  beverages. 
Wende  noted  in  the  attacks  in  his  case  an  association  of  albuminuria  and 
hemoglobinuria.  Exceptionally  aspirin  has  been  noted  to  provoke  a 
condition,  especially  about  the  head  and  face,  simulative  of  this  malady. 

Acute  circumscribed  edema  is  of  angioneurotic  origin — a  vaso- 
motor  neurosis,  in  short,  and  similar  to  urticaria.  It  is  probably  true, 

1  E.  E.  Graham,  Annals  ofGynecology  and  Pediatry,  April,  1894. 

2  Lodor,  Medicine,  Nov.,  1898.  3  Horwitz,  Medical  News,  April  16,  1892. 
4  T.  G.  Ashton,  Medical  News,  April  8,  1893. 

13 


1 94  INFLAMMA  TIONS 

as  Riehl  concluded,  that  the  exciting  cause  of  these  peripheral  vasomotor 
disturbances  is  to  be  found  in  the  central  nervous  system.  Lodor's 
studies  lead  him  to  believe  that  the  presence  in  the  blood  of  a  lympha- 
gogue  in  pathologic  quantity,  and  the  rapid  rise  of  lymph  pressure, 
produce,  in  areas  of  lessened  resistance,  a  sudden  and  rapid  vasomotor 
paralysis  in  such  regions.  He  quotes  Heidenhain's  observation  as  to  the 
various  substances  which,  when  injected  into  the  circulation,  have  the 
power  of  largely  increasing  the  flow  of  lymph, — such  food-products  as 
mussels,  etc.,  sometimes  egg-albumen,  sugars,  and  the  like, — and  to 
which  often  an  attack  is  to  be  ascribed. 

Diagnosis. — The  features  of  angioneurotic  edema — its  usually 
sudden  appearance  and  disappearance,  the  absence  of  positive  pitting 
upon  pressure,  and  the  regions  likely  to  be  involved,  with  frequently 
a  history  of  former  attacks  or  family  tendency,  and  often  of  urticarial 
outbreaks — are  sufficiently  characteristic  to  prevent  error.  Persistent 
edema  observed  as  a  symptom  in  association  with  other  diseases,  with 
lymphatic  or  glandular  obstruction,  is  readily  distinguished  by  its  very 
persistence. 

Prognosis  and  Treatment.— The  malady  is  usually  a  benign, 
although  often  a  troublesome,  one.  Rare  exceptions,  however,  of 
fatal  termination  due  to  involvement  of  larynx  and  glottis  have  been 
observed.  An  immediate  attack  is  generally  amenable  to  treatment, 
but  freedom  from  future  attacks  cannot  be  assured.  Much  will  depend 
upon  the  patient's  mode  of  living,  freedom  from  nervous  disturbance, 
and  strict  attention  to  dietary.  The  management,  in  fact,  is  essentially 
that  of  urticaria.  Saline  laxatives  and  antacids,  more  especially  sodium 
salicylate,  have  proved  most  useful  in  my  hands,  and  Hartzell  also  has 
had  most  satisfaction  with  this  plan.  Sodium  benzoate  in  5-  to  20-grain 
(0.35-1.35)  doses,  three  times  daily,  can  be  used  in  place  of  sodium 
salicylate,  and  for  purgative  or  laxative  purpose  I  can  cordially  commend 
the  ordinary  antacid  magnesia  (see  Urticaria) .  Salol  as  a  gastro-intestinal 
antiseptic  is  valuable.  Arsenic,  quinin,  pilocarpin  by  subcutaneous 
injection,  atropin,  ergot,  bromids,  etc.,  may  also  be  mentioned,  of  which 
the  most  valuable  are  pilocarpin  and  atropin.  In  Burr's  case  (a  syphil- 
itic) a  dose  of  salvarsan  had  so  far  (some  months  later)  resulted  in 
abolishing  the  attacks. 

PITYRIASIS  ROSEA1 

Synonyms. — Pityriasis  maculata  et  circinata  (Bazin);  Herpes  tonsurans  macu- 
losus  (Hebra);  Fr.,  Pityriasis  rose\ 

Definition. — A  mildly  inflammatory  affection,  characterized  by 
discrete  and  frequently  confluent,  plain  or  circinate,  salmon-tinted, 
pinkish  or  pale  red,  variously  sized,  slightly  raised,  scaly  efflorescences, 
seen  most  abundantly  upon  the  trunk. 

1  Early  literature:  Gibert,  Traite  pratique  des  maladies  de  la  peau,  Paris,  1860,  p. 
402;  Duhring,  "Pityriasis  Maculata  et  Circinata,"  Amer.  Jour.  Med.  Sci.,  Oct.,  1880; 
Behrend,  "Ueber  Pityriasis  rosea  (Gibert),  maculata  et  circinata  (Bazin),"  Berlin, 
klin.  Wochenschr.,  1881,  p.  552;  Colcott  Fox,  "On  the  Disease  of  the  Skin  named 
Pityriasis  Maculata  et  Circinata,"  Lancet^  Sept.  20,  1884,  p.  485. 


PITYRIASIS  ROSE  A  195 

Symptoms. — The  trunk,  and  especially  laterally,  usually  first 
shows  the  eruption.  It  may  appear  rapidly  and  attain  full  development 
in  the  course  of  several  days ;  or  its  appearance  may  be  slow  and  gradual, 
coming  out  irregularly  or  in  several  distinct  crops,  one  to  two  weeks  elaps- 
ing before  its  acme  is  reached.  In  some  cases,  as  Brocq1  has  pointed  out, 
the  affection  is  heralded  by  a  primary,  somewhat  large,  efflorescence, 
which  is  seen  most  frequently  anteriorly  near  the  middle  of  the  waist, 
and  this  is  the  forerunner  of  the  more  or  less  generalized  eruption,  which 
appears  from  four  to  ten  or  twelve  days  later.  The  lesions  are,  as  a  rule, 
but  slightly  elevated,  well  or  irregularly  rounded  or  oval  macules,  and 
with  trifling  or  moderate  scaliness.  They  vary  in  size  from  a  small  pea 
to  a  silver  quarter,  are  usually  quite  numerous,  pinkish  or  pale  red  in  color, 
and  often,  especially  toward  the  period  of  defervescence,  present  a  distinct 
salmon  tinge.  The  eruption  may  be  scanty,  consisting  of  thirty  to  sixty 
or  seventy  patches,  or,  as  more  commonly  occurs,  is  quite  abundant. 
The  scaliness  is  somewhat  variable,  usually  slight,  but  in  occasional  in- 
stances in  some  of  the  lesions  may  be  quite  pronounced.  As  a  rule, 
however,  the  lesions  do  not  remain,  as  just  described,  but  some  or  many 
of  them  spread  peripherally  and  become  less  marked  centrally,  present- 
ing a  circinate  patch;  the  central  part  is  noted  to  be  but  slightly  involved, 
while  the  periphery,  by  its  more  pronounced  scaliness,  is  quite  distinct. 
In  many  cases  the  circinate  character  presents  only  after  the  disease  has 
lasted  for  several  days  or  longer;  in  others  it  is  a  part  of  the  eruption  from 
the  start.  The  scaliness  is  rarely  abundant  in  these  latter  cases,  but  usu- 
ally bran-like  or  flaky,  and  of  a  gray  or  dirty-gray  color,  and  in  a  major- 
ity of  cases  most  marked  peripherally.  As  the  circinate  patches  extend, 
the  central  portions  are  gradually  clearing  up,  and  several  or  more  some- 
times coalesce  and  form  large  irregular  areas.  The  skin  is  rarely  thick- 
ened, shows  practically  no  infiltration,  the  process  being  usually  super- 
ficial. The  color  of  the  patches  varies  somewhat  in  different  cases,  in 
this  respect  there  seeming  to  be  two  or  three  varieties:  in  one  grayish 
with  a  faint  reddish  or  pink  tinge,  in  another  somewhat  similar  to  that  of 
parakeratosis  psoriasiformis  of  Brocq,  and  in  the  other  a  rather  striking 
salmon,  sometimes  coppery,  color,  suggestive  of  a  syphilid.  In  short, 
pityriasis  rosea  not  only  in  this  particular,  but  also  in  extent,  character, 
duration,  varies  considerably  in  different  cases,  in  some  instances  even 
presenting  a  close  resemblance  to  an  extensive  dermatitis  seborrhoica.2 

The  eruption  may  be  limited  to  the  trunk,  or  trunk,  neck,  upper 
arms,  and  thighs;  exceptionally  it  is  of  wider  distribution.  The  face 
is  not  often  involved.  After  one  or  two  weeks,  in  average  cases,  the 
eruption  begins  to  decline,  and  in  the  course  of  several  weeks,  or  at  the 
most  a  few  months,  it  has  entirely  disappeared.  Exceptionally,  it  is 
somewhat  slower  in  its  course.  Slight  itching  may  be  present,  espe- 
cially when  the  patient  is  warm  or  perspires,  but  in  most  instances  there 
is  an  entire  absence  of  subjective  symptoms.  As  a  rule,  there  is  no 

1  Brocq,  "Note  sur  la  plaque  primitive  du  pityriasis  rose  de  Gibert,"  Annales,  1887, 
p.  615. 

2  In  a  paper  well  illustrated  G.  H.  Fox,  Jour.  Amer.  Med.  Assoc.,  Aug.  17,  1912, 
called  attention  to  the  fact  that  the  disease  is  not  always  of  a  single,  clean-cut  type. 


196 


constitutional  involvement,  although  in  extremely  extensive  cases  there 
may  be  at  the  outset  slight  general  disturbance  of  mild  character. 

Etiology. — The  disease  is  rather  infrequent.     It  is  met  with  in 
both  sexes,  and  almost  at  any  age,  but  is  more  common  in  grown  children 


Fig-  37- — Pityriasis  rosea  in  an  adult  aged  thirty,  of  two  weeks'  duration,  and  in- 
volving trunk,  upper  part  of  the  thighs,  and  arms;  showing  the  slightly  to  moderately 
scaly  macular  and  circinate  patches — in  some  places  confluent. 

and  young  adults,  less  frequently  in  those  of  dark  hair  and  complexion 
than  in  those  of  the  medium  and  blonde  types.1     The  essential  cause  is 

1  Towle,  Jour.  Cutan.  Dis.,  April,  1904,  from  an  analysis  of  202  cases — 158  from  the 
records  of  the  dermatologic  department  of  the  Massachusetts  General  Hospital,  and  44 
from  the  private  records  of  Dr.  John  T.  Bowen — states:  Pityriasis  rosea  occurs  in  the 
two  forms — the  macular  and  the  circinate — with  about  equal  frequency:  affects  most 
often  the  trunk  and  upper  part  of  the  extremities,  but  is  occasionally  limited  to  one 
part;  it  is  more  frequent  in  the  autumn  months,  and  by  far  more  common  in  women 
than  in  men;  recurrences,  though  rare,  do  occur;  race  and  occupation  have  no  influence. 
His  other  conclusions  are  about  the  same  as  outlined  in  the  text;  D.  W.  Montgomery, 
ibid.,  1906.  p.  167,  gives  a  clinical  analysis  of  38  cases. 


PITYRIASIS  ROSE  A  197 

unknown,  but  that  time  will  disclose  a  parasitic  factor  is  scarcely  to  be 
doubted.  According  to  Thibierge,  the  disease  does  not  recur,  but  this, 
I  believe,  does  occasionally  take  place.  There  is  a  growing  tendency, 
not  without  reason,  to  consider  the  disease  as  possessing  contagious 
properties  of,  however,  a  feeble  character;  2  cases  in  the  same  family 
have  been  observed  by  Crocker,1  Zeisler,2  Fordyce,3  and  G.  H.  Fox.4 

Pathology. — Many  of  the  European  dermatologists,  especially 
those  of  Austria,  have  looked  upon  this  disease  as  disseminated  ring- 
worm, called  by  them  herpes  tonsurans  maculosus;  but  English,  French, 
and  Americans  are  well  assured  of  the  individuality  of  the  disease,  in 
which  ringworm  fungus  is  never  found.  The  truth  of  the  matter  seems 
to  be  that  there  is  a  disseminated  ringworm,  infrequent,  it  is  true,  but 
seen  chiefly  in  Austria,  which  closely  resembles  it,  although  many  of  the 
cases  so  considered  are  doubtless  those  of  pityriasis  rosea. 

While  pityriasis  rosea  is  probably  of  parasitic  origin,  as  yet  no  one, 
excepting  Vidal,5  whose  findings  have  never  been  corroborated,  except 
possibly  recently  by  Du  Bois,6  has  ever  discovered  a  parasite.  Other 
views  held  as  to  the  nature  of  the  disease  are :  that  it  is  allied  to  derma- 
titis seborrhoica,  and  that  it  may  be  a  mildly  inflammatory  disease, 
somewhat  similar  to  psoriasis.  There  is,  it  is  true,  in  some  cases  a  close 
clinical  resemblance  to  the  seborrheic  disease,  which  was  pointed  out 
by  Besnier,7  and  in  my  experience  it  is  sometimes  so  close  as  to  lead  to  the 
belief  that  it  may  possibly  belong  under  that  head. 

The  pathologic  anatomy  of  this  disease  has  been  investigated  by 
Jacquet,  Unna,  Tandler,  and  Towle,  and,  upon  the  whole,  indicates  that 
the  process  in  the  earlier  stage  or  in  mild  cases  is  an  extremely  mild 
inflammation  seated  in  the  upper  cutis,  of  a  serous  and  hyperplastic 
character,  always  more  marked  toward  the  periphery;  in  the  later 
stages  or  in  more  pronounced  lesions  the  inflammatory  changes  are 
emphasized,  and  there  is  displayed  a  tendency  to  irregularly  formed 
minute  pressure  vesicles  beneath  the  corneous  layer,  but  which  are 
not  macroscopically  visible.  Almost  the  whole  papillary  body  is  con- 
verted into  a  net  of  spindle-cells  with  stellate  connecting  processes. 

Diagnosis. — The  disease  is  to  be  distinguished  from  dermatitis 
seborrhoica,  tinea  circinata,  psoriasis,  and  the  maculopapular  scaly 
syphiloderm. 

1  Crocker,  Diseases  of  the  Skin,  second  ed.,  p.  288  (2  instances  in  2  members  of  the 
same  family). 

2  Zeisler,  Jour.  Cutan.  Dis.,  1893,  p.  494  (husband  and  wife). 

3  Fordyce,  ibid.,  p.  497  (husband  and  wife),  and  ibid.,  1898  (Soc'y  Trans.) .  p.  340 
(in  2  sisters  occupying  same  room). 

1  G.  H.  Fox,  ibid,  (mother  and  child). 

5  Vidal,  Annales,  1882,  p.  22. 

6  Du  Eois,Annales,  Jan.,  1912,  p.  33,  claims  to  have  found  a  fungus  closely  resembling 
the  microsporon  described  by  Vidal,  appearing  as  masses  of  round  spores  of  variable 
size  and  no  mycelia,  and  proposes  the  name,  in  honor  of  Vidal,  of  "microsporon  dispar. 
The  spores  were  found  within  the  follicular  and  glandular  orifices.     Du  Bois  describes 
3  cases  exemplifying  what  he  calls  three  types  of  the  disease— the  pityriasis  rosea  o 
Gibert,  the  common  type,  and  two  other  rarer  varieties,  a  psoriaform  parakerato; 
and  the  type  described  by  Vidal  as  pityriasis  circine  et  margine.     The  fungus  was 
found  in  all. 

7  Besnier,  Annales,  1889,  p.  108;  D.  W.  Montgomery,  Jour.  Cutan.  Dts.,  1906,  p. 
167,  discusses  this  as  well  as  other  points  in  an  analytical  paper  (38  cases). 


1 98  I  NFL  A  MM  A  TIONS 

Seborrhea  differs  in  having  greasy  scales,  in  its  more  gradual  appear- 
ance, in  its  usually  taking  its  start  from  a  seborrhea  of  the  scalp  or 
eyebrows,  and  in  the  evolution  and  character  of  the  patches  and  its 
persistent  course.  Seborrheic  patches  sometimes  show  (over  the  ster- 
num) slight  projection  into  the  sebaceous  follicles;  in  some  cases  the  diag- 
nosis may  be  difficult  at  first,  but  a  short  observation  will  usually  suffice 
to  clear  up  any  doubt. 

Ringworm  is  rarely  seen  in  such  profusion  as  pityriasis  rosea,  the 
ring  shape  is  more  distinct,  there  is  a  more  decided  disposition  to  central 
clearing,  even  when  the  patches'  are  small;  the  peripheral  portion  is 
usually  more  sharply  marginate  and  occasionally  is  vesicopapular  or 
vesicular.  Typical  ringworm  patches  are  also  often  seen  about  the  face 
and  hands,  unusual  sites  for  pityriasis  rosea.  In  suspected  cases  scrap- 
ings from  the  peripheral  portion  should  be  examined  by  the  microscope 
(see  Ringworm). 

Psoriasis  is,  as  a  rule,  more  inflammatory,  the  periphery  more  sharply 
marginate,  the  scaling  more  profuse,  and  patches  are  also  frequently 
seen  in  the  scalp,  especially  toward  the  border  of  the  forehead  and  mas- 
toid  regions,  and  generally  to  be  found  likewise  on  the  extensor  surfaces 
of  the  knees  and  elbows.  It  usually  comes  on  slowly,  and  at  first  rarely 
displays  any  tendency  to  ring-formation. 

The  maculopapular  syphiloderm,  if  scaly,  bears  a  close  resemblance, 
but  there  is  usually  distinct  infiltration,  it  is  of  a  darker  color,  and  lesions 
are  not  unusual  on  the  palms  and  face;  as  it  is  an  eruption  of  the  active 
stage  of  syphilis,  one  or  more  corroborative  symptoms  are  always  to  be 
found. 

Prognosis  and  Treatment — The  disease  usually  runs  its  course 
in  three  or  four  weeks  to  a  few  months,  disappearing  spontaneously. 
As  a  rule,  there  is  no  special  tendency  to  recurrence.  It  has  seemed  to 
me  that  the  use  of  certain  external  applications  tends  to  shorten  its 
course,  such  as  a  mild  sulphur  ointment,  from  20  to  60  grains  (1.3  to  4.) 
to  the  ounce  (32.)  of  petrolatum  or  benzoated  lard,  or  one  containing 
from  10  to  30  grains  (0.65  to  2.)  of  salicylic  acid;  or  an  ointment  contain- 
ing both  of  these  ingredients  may  be  prescribed: 

1^.     Acid,  salicylic!,  gr.  xv  (i.); 

Sulphur,  praecip.,  gr.  xxx  (2.); 

Petrolati, 

Ungt.  aquae  rosae,  aa  gss  (16.). 

The  selected  ointment  is  to  be  gently  rubbed  in,  in  small  quantity, 
once  daily;  the  excess  wiped  off,  and  a  mild  dusting-powder  applied. 
The  application  is  to  be  preceded  every  day  or  every  other  day  by  an 
ordinary  soap-and- water  bath;  or,  in  cases  in  which  the  scaliness  is 
somewhat  more  abundant  than  usually  observed,  with  an  alkaline  bath. 
Lotions  applied  with  a  piece  of  lint  or  as  a  spray  can  be  employed  in 
place  of  the  ointments,  but  do  not  seem  to  exercise  as  much  influence, 
althought  they  are  more  agreeable,  and  have  more  effect  in  control- 
ling the  itching  if  present;  the  following  may  be  used:  Carbolic  acid, 
if  drams  (6.)  to  the  pint  (500.)  of  water,  to  which  a  dram  (4.)  of  gly- 


DERMATITIS  EXFOLIATIVA  199 

cerin  and  an  ounce  (32.)  of  alcohol  may  be  added;  and  a  lotion  of  boric 
acid,  15  grains  (i.)  to  the  ounce  (32.)  of  water,  with  also  from  5  to  10 
grains  (0.32  to  0.65)  of  resorcin  added.  In  addition  to  the  external 
applications  a  saline  laxative  may  be  occasionally  prescribed,  along  with, 
if  in  any  way  indicated,  such  tonics  as  quinin,  strychnin,  and  iron. 

DERMATITIS  EXFOLIATIVA1 

Synonyms. — Pityriasis  rubra;  General  exfoliative  dermatitis;  Acute  general 
dermatitis;  Fr.,  Dermatite  exfoliatrice;  Erythrodermie  exfoliante  (Besnier). 

Definition. — A  more  or  less  generalized,  exceptionally  limited, 
exfoliating  inflammatory  disease  of  acute  or  subacute  type  and  of  variable 
duration,  arising  primarily  as  such  or  supervening  upon  other  chronic 
scaly  affections. 

Symptoms. — As  a  primary  affection  the  disease  may  begin  in- 
sidiously in  several  scattered  regions,  probably  more  commonly  (Leloir 
and  Vidal)  about  the  axillae,  genitocrural  region,  and  other  flexures; 
it  rapidly  spreads,  and  together  with  the  appearance  of  new  areas  soon 
covers  the  greater  part  or  the  entire  surface;  or  there  may  be  at  once 
more  or  less  general  involvement.  Exceptionally,  the  disease  may 
remain,  for  a  time  at  least,  more  or  less  limited  in  its  distribution  (Crocker, 
Bulkley,  and  others).  I  have  met  with  several  cases  in  which  the  chief 
brunt  of  the  process  was  borne  by  the  extremities. 

In  many  cases  the  outbreak  is  preceded  by  a  distinct  chill  or  chilli- 
ness, malaise,  and  sometimes  vomiting  and  febrile  action;  these  symp- 
toms may  or  may  not  continue.  The  skin  is  noted  to  be  hyperemic 

1  Important  literature:  Erasmus  Wilson,  Med.  Times  and  Gazette,  1870,  i,  p.  118, 
and  Treatise  on  Diseases  of  the  Skin;  Hebra,  in  Hebra  and  Kaposi's  Hautkrankheiten, 
second  edition,  1874,  vol.  i,  p.  398;  Hebra,  Jr.,  Archiv,  1876,  p.  508;  Anderson,  Brit. 
Med.  Jour.,  Dec.  8,  1877,  p.  812;  Baxter,  ibid.,  1879,  ii,  pp.  79  and  119  (an  important 
paper);  Jamieson,  Edinburgh  Med.  Jour.,  April,  1880,  p.  879;  Duhring,  Philada.  Med. 
Times,  Jan.  17,  1880;  Pye-Smith,  Guy's  Hasp.  Repts.,  1881,  vol.  xxv,  p.  27;  Hyde, 
Chicago  Med.  Jour,  and  Examiner,  Feb.,  1881;  Brocq,  "Etude  critique  et  clinique  sur 
la  dermatite  exfoliatrice  g6neralise"e,"  These  de  Paris,  1882;  abstract  in  Annales,  1883, 
p.  90  (an  important  paper),  and  (pityriasis  rubra),  Archives  General  de  Med.,  1884,  p. 
550;  Vidal  (histology),  Bull,  de  la  Soc.  Med.  des  Hdpitaux  de  Paris,  1882,  p.  101; 
Mackenzie,  Brit.  Jour.  Derm.,  1889,  p.  285  (an  important  paper— an  analytic  study  of 
21  cases);  Besnier  (6rythrodermie)  in  French  translation  of  Kaposi's  treatise  by  Besnier 
and  Doyon,  Elsenberg,  Archiv,  1887,  p.  727;  Leviseur,  Jour.  Cutan.  Dis.,  1890,  p. 
482;  Handford  (with  pigmentation),  Brit.  Jour.  Derm.,  1894,  p.  241 ;  discussion  (Petrini, 
Crocker,  Jamieson,  Brocq,  Unna,  Vidal,  Schwimmer,  Kaposi,  Hebra,  Jr.,  Besnier), 
"Congres  Internal,  de  Derm,  et  de  Syph.,"  1889,  Comptes  Rendus,  Paris,  1890,  pp.  43 
to  80;  Jadassohn,  Ueber  die  Pityriasis  Rubra  (Hebra),  Vienna  and  Leipzig,  1882,  and 
in  Archiv,  1891,  p.  941,  1892,  pp.  85,  271,  462  (an  exhaustive  histologic  and  pathologic 
study);  Leloir  and  Vidal,  Traite  des  Mai  de  la  Peau,  1889;  W.  G.  Smith,  Brit.  Jour. 
Derm.,  1898,  p.  437  (a  succinct  presentation  of  the  subject,  with  a  report  of  2  cases), 
and  discussion  (Payne,  Galloway,  Colcott  Fox,  Crocker,  Mackenzie,  Pringle,  Leslie 
Roberts,  Whitfield,  Malcolm  Morris,  and  others),  ibid.,  pp.  447  to  464;  Morrow  (fatal 
in  six  weeks,  with  abscess  formations),  Jour.  Cutan.  Dis.,  1898,  p.  541;  ?M.,  1887,  p. 
439  (from  psoriasis,  and  with  pustular  lesions— with  discussion);  Diehl  (following 
typhoid  fever),  ibid.,  p.  222;  Coleman,  Dublin  Jour,  of  Med.  Sci.,  January,  1898; 
Pringle,  Brit.  Jour.  Derm.,  1899,  p.  27;  Burnside  Foster,  Jour.  Cutan. _  Dis.,  April, 
1907,  p.  164  (13  cases — various  types;  among  which,  4  cases  of  dermatitis  exfohativa 
neonatorum,  and  2,  and  possibly  3  of  pityriasis  rubra);  Bowen,  "Seven  Cases  of  Der- 
matitis Exfoliativa  with  a  Fatal  Ending  in  Five,"  ibid.,  January,  1910  (clinical,  bacte 
riologic,  and  blood  examinations;  autopsy  reports). 


2OO  INFLAMMATIONS 

and  red,  with  at  first  usually  slight  and  sometimes  scarcely  perceptible 
inflammatory  infiltration;  later  it  may  become  more  pronounced,  and 
occasionally  quite  marked.  After  a  short  period — several  days  to  a  week 
or  more — the  characteristic  exfoliative  feature  presents,  the  exfoliation 
taking  place  as  thin,  variously  sized  flakes  or  as  slightly  thickened  imbri- 
cated scales.  As  a  rule,  however,  the  scales  are  thin,  and  usually  of  a 
dirty  gray  or  brownish  tinge;  the  underlying  skin  is  smooth,  red,  and 
shiny,  and  later  has  a  yellowish  cast.  The  process  thus  instituted  con- 
tinues, the  formation  of  new  scales  going  almost  hand  in  hand  with 
exfoliation  of  the  older.  There  are  at  times  in  some  cases  hyperesthesia 
of  the  skin  and  a  feeling  of  coldness.  If  the  dermatic  condition  is  of  an 
acute  type,  there  may  be  accompanying  febrile  action,  with  evening 
exacerbation;  on  the  other  hand,  when  the  process  is,  or  becomes 
sluggish,  there  is  usually  slight  temperature  depression  noted.  After 
a  variable  time — several  weeks  to  a  few  months — the  process  begins 
to  abate,  the  skin  loses  its  inflammatory  aspect,  is  less  red,  and  the 
exfoliation  is  less  marked  and  less  rapid.  Finally,  the  symptoms  all 
decline,  and  the  malady  comes  to  an  end,  complete  recovery  taking 
place.  In  other  cases  there  may  be  a  remission  for  a  short  time, 
and  then  a  fresh  exacerbation,  after  which,  or  after  two  or  three  such 
remissions,  recovery  ensues.  In  other  instances  the  disease  continues, 
either  with  or  without  short  or  long  remissions,  or  short  intermissions 
almost  indefinitely.  In  many  of  the  cases  of  primary  dermatitis  exfolia- 
tiva  recovery  has  usually  ensued  after  several  months,  and  the  patient 
remains  free  for  a  variable  time — months,  a  few  years,  or  longer — and 
then  has  another  attack.  In  some  instances,  however,  but  probably 
somewhat  exceptional,  recovery  when  once  established  is  lasting. 

In  the  persistent  cases  the  patient's  health  usually  begins  to  suffer, 
and  arthritic  symptoms  and  internal  and  other  complications  may  arise. 
In  these  chronic  and  severe  cases,  too,  the  process  often  invades  the 
mucous  membrane  of  the  mouth,  of  the  nose  and  conjunctiva,  and  may 
also  include  that  of  the  stomach  and  bronchial  tubes;  a  cachectic  condi- 
tion may  develop.  Furuncles  and  abscesses  are  sometimes  superadded. 
The  hairs  and  nails  are,  more  especially  in  severe  continuous  cases,  in- 
volved and  may  be  lost,  and  the  skin  becomes  atrophic,  tight,  and  limits 
the  movements  of  the  joints — pityriasis  rubra  (Hebra).  This  type  is 
extremely  rare.1 

In  cases  evolving  from  psoriasis  or  eczema  these  diseases  gradually, 
usually  after  repeated  or  long-continued  attacks,  lose  their  special 
characters,  the  surface,  commonly  in  its  whole  extent,  becomes  invaded, 
and  there  then  presents  the  ordinary  picture  of  an  exfoliating  dermatitis, 

1  E.  J.  Stout,  Philada.  Polyclinic,  Nov.  2,  1895,  has  reported  a  case  of  this  type  in 
which  there  were  permanent  flexion  of  the  finger-joints,  nail  involvement,  with  also 
some  suppurating  lymphatic  glands;  Bowen,  St.  Paul  Med.  Jour.,  Feb.,  1900,  also 
recorded  a  severe  and  persistent  example  of  the  Hebra  type;  this  case  since  died  of 
gradual  exhaustion  (see  Bowen's  paper  on  the  "Four  Forms  of  Generalized  Exfoliative 
Dermatitis  (Erythrodermies  exfoliantes  generalises,  Besnier),"  Jour.  Cntan.  Dis., 
1902,  p.  548;  F.  H.  Montgomery  and  Bassoe  have  also  recently  (Jour.  Cutan.  Dis., 
1906,  p.  298)  reported  a  case  with  histological  and  autopsy  findings;  Gilchrist,  Brit. 
Med.  Jour.,  Oct.  6, 1906,  has  reported  a  case  followed  by  peripheral  gangrene  of  the  right 
hand  and  left  foot. 


DERMATITIS  EXFOLIATIVA  2OI 

in  some  instances  with  slightly  more  infiltration  than  usually  observed 
in  cases  of  primary  dermatitis  exfoliativa. 

While  the  typical  disease  is  almost  always  erythematous  in  origin, 
exceptionally  cases  have  been  noted  in  which  there  was  some  vesicula- 
tion  in  the  early  stage.  Occasionally,  too,  considerable  fluid  exudation 
(Devergie)  or  a  slight  serous  undermining,  for  a  time  at  least,  occurs,  but 
probably  some  of  these  latter  cases  belong  more  properly  to  the  province 
of  pemphigus  foliaceus. 

The  primary  cases,  as  can  be  inferred,  are  of  various  grades  of  severity; 
in  rare  instances  of  the  markedly  acute  and  hasty  type  grave  symp- 


Fig.  38. — Dermatitis  exfoliativa,  showing  the  close  relationship  in  its  mildest  phase, 
as  in  this  case,  to  erythema  scarlatinoides.  Patient  a  working-man  aged  twenty-five. 
Four  attacks  in  two  years;  practically  limited  to  the  hands,  feet,  and  immediately 
adjacent  parts  of  the  forearms  and  legs.  Begins  with  burning  sensation,  moderate 
redness,  and  slight  swelling  (this  last  not  seen  in  erythema  scarlatinoides),  coming 
on  suddenly;  these  symptoms  soon  subside,  and  desquamation,  in  somewhat  thick,' 
lamellar  form,  and  sometimes  in  mass,  as  in  the  illustration,  gradually  presents.  No 
constitutional  symptoms.  An  attack  runs  its  course  in  about  three  weeks.  There 
was  a  suspicion  in  this  case  of  drug  ingestion  (quinin)  being  the  etiologic  factor,  sug- 
gested by  its  limited  localization  to  the  parts  named,  but  an  investigation  as  to  the 
facts  of  the  several  attacks  did  not  confirm  this. 

toms  of  a  septic  character  are  present,  and  death  ensues  in  the  course 
of  a  few  weeks.  On  the  other  hand,  and  probably  in  a  majority  of  the 
cases,  the  disease  may  persist  for  a  long  time  or  often  recur  without 
presenting  any  symptoms  of  an  alarming  character,  and  in  some  excep- 
tional cases,  instead  of  being  extensive,  it  may  be,  as  already  remarked, 
somewhat  limited  in  extent,  occasionally  to  the  hands  and  feet.  Swell- 
ings of  the  superficial  lymphatic  glands  have  been  noted  (Jadassohn) 
in  some  instances.  In  fact,  as  late  analytic  papers  (Brocq,  W.  G. 
Smith,  Bowen)  show,  the  disease  presents  itself  in  various  types  as  to 


2O2  INFLAMMA  TIONS 

extent  and  severity;  the  cases  varying  (Smith)  from  local  forms  to  the 
completely  generalized,  and  from  the  ill-defined  to  the  most  typical. 
Bowen's  observations  also  show,  as  do  my  own,  that  in  the  division  of 
cases  sharp  lines  cannot  be  drawn.  More  or  less  pigmentation  is  noted 
in  the  recurrent  and  chronic  cases. 

The  subjective  symptom  of  itching  is  present  to  a  variable  degree 
in  almost  all  cases  of  dermatitis  exfoliativa,  sometimes  slight,  sometimes 
intense;  a  feeling  of  tension  and  soreness  or  tenderness  are  also  fre- 
quently complained  of. 

Etiology. — The  disease  is,  as  it  is  ordinarily  met  with,  not  con- 
tagious, but  the  infantile  and  epidemic  varieties,  which  are  probably 
totally  distinct  morbid  entities,  and  elsewhere  separately  considered, 
are  doubtless  of  infectious  nature.  The  apparent  etiologic  or  predis- 
posing factors  are  varied,  and  it  must  be  conceded  that  the  essential 
cause  remains  practically  unknown.1  Although  clinically  similar  in 
their  chief  external  symptoms,  there  are  doubtless  several  processes 
etiologically  considered,  some  of  which  may  be  accepted  as  of  septic 
and  parasitic  origin.  The  malady  has  been  often  noted  to  occur  in 
gouty  and  rheumatic  subjects  (Duckworth,  Mackenzie,  Crocker,  and 
others),  and  has  also  been  seen  frequently  in  association  with  tuberculosis 
( Jadassohn) ,  and  in  a  few  instances  has  been  observed  to  follow  excessive 
alcoholism.  Central  or  peripheral  nerve  changes,  sometimes  noted, 
are  suggested  as  having  a  causative  relationship.  On  the  other  hand, 
in  some  cases  the  patients,  both  preceding  and  at  the  time  of  the  attack, 
have  been  in  fair  health.  As  has  been  already  stated,  it  sometimes 
develops  from  a  preexisting  psoriasis  or  squamous  eczema.  Local  irri- 
tation from  a  drug,  especially  chrysarobin,  arnica,  mercury,  and  iodo- 
form,  has  been  known  to  provoke  an  outbreak  in  some  instances;  and 
it  is  probable,  too,  that  the  ingestion  of  certain  drugs,  notably  quinin,  is 
responsible  for  some  of  the  obscure  and  acute  attacks. 

It  is,  fortunately,  a  rare  disease,  and  observed  most  frequently  in  those 
between  the  ages  of  twenty-five  and  sixty,  and  preponderantly  in  males. 

Pathology. — In  the  ordinary  types  of  dermatitis  exfoliativa 
various  findings  are  recorded  (Baxter,  Crocker,  Vidal,  Jadassohn,  and 
others),  dependent  upon  the  character,  severity,  and  persistence  of  the 
disease — from  a  purely  hyperemic  condition,  almost  or  wholly  similar 
to  that  of  erythema  scarlatinoides,  to  that  in  which  considerable  inflam- 
matory and  atrophic  changes  occur.  There  would,  indeed,  seem  to  be  a 
very  close  relationship  between  the  mild  acute  dermatitis  exfoliativa  and 
erythema  scarlatinoides. 

In  the  extreme  varieties  there  is  a  complete  obliteration  of  the 
papillae,  with  variable  atrophy  of  the  interpapillary  rete  prolongations. 
The  glandular  structures  disappear  in  part  or  wholly,  and  pigment- 
_  *  Tidy,  in  his  careful  analytical  study  ("The  Metabolism  in  Exfoliative  Derma- 
titis," Brit.  Jour.  Derm.  1911,  p.  133),  among  other  facts  brought  out  the  following: 
The  excretion  of  nitrogen  and  fluid  in  the  urine  is  deficient,  and  the  excretion  of  uric 
acid  excessive;  the  excess  of  nitrogen  and  fluid  is  excreted  by  the  skin;  the  amount  of 
uric  acid  excreted  diminishes  as  the  condition  of  the  skin  improves;  the  conclusion  is 
unavoidable  that  there  is  a  direct  connection  between  dermatitis  and  the  amount  of 
uric  acid  excreted;  the  changes  observed  in  the  urine  are  secondary  to,  and  a  necessary 
consequence  of,  the  activity  of  the  skin. 


PLATE  IV. 


Dermatitis  exfoliativa  in  a  male  adult  of  forty  years,  of  eight  months'  duration,  fol- 
lowing upon  a  moderately  extensive  psoriasis  of  ten  years'  standing.  With  the  excep- 
tion of  some  small  areas  on  the  legs  and  a  part  of  the  neck,  the  entire  surface,  including 
the  face,  was  involved,  with  slight  infiltration  of  the  skin,  and  in  a  continuous  state 
of  exfoliation. 


DERMATITIS  EXFOLIATIVA  203 

granule  deposit  is  noted  in  the  lower  epiderm,  partly  replacing  the 
rete  layer.  There  is  also  sometimes  noted  thickening  of  the  blood- 
vessel walls  in  the  subpapillary  plexus,  and  both  the  rete  and  corneous 
layer  may  be  thickened,  the  latter  irregularly,  and  exhibiting  imperfect 
keratinization.  Tuberculosis  of  internal  organs  has  been  found  in  a 
number  of  cases  of  the  severe — pityriasis  rubra  (Hebra) — type.1  Myelitis 
(Jamieson)  and  peripheral  and  central  inflammatory  nerve  changes 
(Quinquaud  and  Lancereaux)  have  been  recorded  in  a  few  instances. 

Diagnosis. — In  the  beginning  of  the  process  in  average  cases 
there  may  be  some  difficulty,  but  a  few  days'  observation  will  usually 
leave  no  doubt  as  to  its  nature.  The  exfoliative  symptom,  ordinarily 
without  systemic  symptoms  or  throat  involvement,  will  serve  to  dif- 
ferentiate it  from  scarlet  fever  and  from  erythema  scarlatinoides.  In 
its  early  stage,  however,  in  mild  cases  confusion  with  this  latter  malady 
is  possible,  and  in  such  cases,  for  a  time  at  least,  the  disease  seems  to 
be  almost  analogous.  Erythema  scarlatinoides  is  markedly  acute  in 
character,  the  skin  does  not  show  the  slightest  or  perceptible  infiltration; 
there  may  be  constitutional  symptoms ;  and,  finally,  its  course  is  relatively 
short,  and  the  exfoliation  frequently  occurs  in  large,  thin  lamellae  and 
sheets.  The  absence  of  blebs  as  a  feature  will  also  be  an  important  point 
of  difference  from  pemphigus  foliaceus.  Psoriasis  and  lichen  ruber, 
which  are  also  dry  scaly  diseases,  are  rarely,  if  ever,  universal,  the  skin 
is  more  thickened,  and  in  the  former  the  scaliness  is  more  abundant;  the 
beginning  papular  character  of  the  latter  and  the  presence  of  typical 
papules  here  and  there  at  the  borders  of  areas,  even  when  the  disease  is 
extensive,  are  sufficient  to  prevent  error.  Psoriasis  may,  however,  as 
already  stated,  develop  into  a  true  dermatitis  exfoliativa,  although  such 
termination  is  rare.  In  a  generalized  squamous  eczema  there  will  always 
be  found  some  areas  in  which  the  characteristic  gummy  oozing  of  that 
disease  is  present;  or  a  history  of  such  is  obtainable.  Moreover,  in 
eczema  there  is  usually  considerable  thickening  and  never  a  tendency  to 
thinning  and  atrophy. 

Prognosis  and  Treatment. — The  prognosis  can  be  inferred  from 
the  remarks  made  in  describing  the  disease.  Ordinarily  idiopathic 
cases  with  no  constitutional  involvement  usually  recover,'  although 
some  of  these  may  succumb  in  future  attacks.  Cases  with  septic  indi- 
cations are  grave,  and  end,  as  a  rule,  fatally.  The  cases  following  on 
psoriasis  and  eczema  are  persistent. 

Often  the  disease  seems  to  have  a  set  course,  and  to  be  uninfluenced 
by  treatment.  The  constitutional  treatment  aims  at  removing  any 
possible  etiologic  factor,  improving  the  tone  of  the  general  health,  look- 
ing after  the  digestion,  and  a  regulation  of  the  bowel  movements.  Pilo- 

1  Bruunsgaard  ("Beitrag  zu  den  tuberkulosen  Hauteruptionen.  Erythrodermie  ex- 
foliativa universalis  tuberculosa,"  Archiv,  vol.  Ixvii,  1903,  p.  226)  reports  a  fatal  case 
with  cutaneous  symptoms  somewhat  similar  to  the  Hebra  type,  but  more  inflamma- 
tory, in  which  tubercles  were  found  in  the  papillary  and  subpapillary  layers  of  the  skin 
and  around  the  hair-follicles;  bacilli  were  found  in  the  lymph-glands,  and,  apparently, 
it  was  primarily  a  tuberculosis  of  these  glands,  from  which  emboli  of  bacilli  were  earned 
to  the  skin,  producing  the  cutaneous  inflammatory  symptoms.  Miiller  has  recently 
(ibid.,  vol.  Ixxxvii,  1907,  p.  255)  reported  a  case  associated  with  tuberculous  lymphatic 
glands,  with  review  of  the  subject  and  references. 


2O4  INFLAMMA  TIONS 

carpin,  carbolic  acid,  quinin,  and  arsenic  are  remedies  which  have  been 
variously  advocated,  but  the  effect  is  usually  doubtful,  and  their  use 
requires  proper  caution.  Mook,1  however,  lauds  the  action  of  quinin, 
but  in  large  doses,  from  30  to  80  gr.  (2.0-4.65)  daily,  and  the  same  favor- 
able action  has  been  occasionally  observed  by  Jackson,2  Hyde,  and 
others.  Sodium  salicylate  and  arsenic  are  probably  most  frequently  of 
benefit.  In  severe  cases  special  efforts  should  be  made  to  sustain  the 
strength. 

The  external  treatment  is  necessary  in  all  cases  to  relieve  the  irri- 
tation; beyond  this  its  effect  is  questionable.  Strong  applications  are 
not  only  valueless,  but  are  almost  invariably  damaging.  Plain  petro- 
latum, with  or  without  i^  to  4  grains  (o.i  to  0.25)  of  carbolic  acid  to  the 
ounce  (32.),  is  usually  the  most  comforting  application.  In  some  cases 
a  cooling  salve,  as  cold  cream,  is  more  grateful.  Linimentum  calcis  is 
also  of  service.  The  following  mild  ointment  often  gives  considerable 

relief. 

1$.     Acid,  borici,  gr.  xv  (i.); 

Acid,  carbolici,  gr.  ij-iv  (0.135-0.25); 

Pulv.  amyli,  3ss  (2.); 

Petrolati,  3j  (32.). 

Bran,  gelatin,  and  starch  baths  are  often  of  benefit,  but  should  usually 
be  followed  by  an  oily  or  ointment  application.  Burnside  Foster  found 
the  most  satisfactory  external  treatment  to  consist  in  prolonged,  and 
when  possible,  continuous  baths;  after  the  former  the  patient  being  en- 
veloped in  flannel  soaked  with  either  cod-liver  oil  or  olive  oil.  Other 
mild  ointments  and  lotions,  and  sometimes  dusting-powders,  such  as 
prescribed  in  acute  eczema,  are  also  variously  employed  and  prove  sooth- 
ing. Engman  and  C.  J.  White3  have  found  in  the  moist  cases  that 
continuously  enveloping  the  patient  in  an  abundance  of  dusting-powder 
palliates  and  sometimes  cures ;  Engman  commending  cornstarch  powder, 
and  White,  borated  talcum,  for  this  purpose. 

DERMATITIS  EXFOLIATIVA  EPIDEMICA 

Synonyms. — Epidemic  skin  disease;  Epidemic  eczema;  Dermatitis  epidemica; 
Savill's  disease. 

Under  the  name  of  epidemic  skin  disease  Savill  first  described  (1891) 
a  disease  observed  in  London  institutions  presenting  essentially  the 
symptoms  of  dermatitis  exfoliativa,  with,  in  some  cases,  an  eczematous 
aspect.4  Since  then  others  have  observed  and  reported  similar  cases 

1  Mook,  "Large  Doses  of  Quinin  in  the  Treatment  of  Dermatitis  Exfoliativa,  with 
Report  of  Six  Cases,"  Jour.  Cutan.  Dis.,  1908,  p.  408  (with  3  good  case  illustrations); 
and  ibid.,  1910,  p.  458.  2  Jackson,  Hyde,  ibid.,  1910,  p.  21. 

3  C.  J.  White,  Boston  Med.  and  Surg.  Jour.,  May  4,  1911,  and  more  extensively  in 
Jour.  Cutan.  Dis.,  Dec.,  1912,  p.  705. 

4  Literature:   Savill,  Brit.  Jour.  Derm.,  1892,  pp.  35  and  69  (with  colored  plate  and 
several  phototypes);  Brit.  Med.  Jour.,  Dec.  5,  1891,  and  Jan.  9,  1892;  with  discussion 
in  Medical  Society  of  London,  Brit.  Med.  Jour.,  Dec.  5,  1891,  p.  1207;  Jour.  Cutan. 
Dis.,  1894,  pp.  281  and  329;  Russell  (bacteriology),  Brit.  Jour.  Derm.,  1892,  p.  106; 
Fordyce,  Soc'y  Trans.,  Jour.  Cutan.  Dis.,  1897,  p.  141;  Colby  and  Winfield,  ibid., 
1898,  p.  73;  Hutchinson,  Arch,  of  Surgery,  1891-92,  pp.  146  and  221;  Echeverria 
(histology),  Brit.  Jour.  Derm.,  1895,  p.  9.     A  monograph  on  the  disease  by  Savill, 
London,  1892,  is  complete,  with  a  number  of  illustrations. 


DERMATITIS  EXFOLIATIVA   EPIDEMICA  205 

(Hutchinson,  Lees,  Richards,  Milner,  and  others).  Unlike  dermatitis 
exfoliativa,  however,  it  was  observed  to  attack  a  number  of  individuals 
simultaneously,  or  one  rapidly  after  the  other,  and  with  fatal  issue  in 
10  to  20  per  cent,  of  the  cases.  Those  of  advancing  age  are  its  chief 
subjects,  and  more  commonly  males.  In  this  country  but  a  few  cases 
are  recorded  (Fordyce,  Colby  and  Winfield).  The  malady  begins  gener- 
ally in  summer  weather,  and  in  most  cases  without  premonitory  symptoms. 
In  others  anorexia,  vomiting,  diarrhea,  and  sore  throat  were  observed. 
It  first  appears  usually  as  patchy  erythematous  or  papular,  bright  or 
crimson  red  efflorescences,  and,  as  a  rule,  on  several  regions  and  with  slight 
itching.  Sometimes  vesiculation  is  noted.  The  legs  show  less  tendency 
to  primary  invasion  than  other  parts,  the  principal  first  sites  being  the 
face,  scalp,  and  arms.  Very  soon,  from  the  confluence  of  the  beginning 
and  constantly  arising  new  patches,  more  or  less  extensive  involvement 
results.  In  those  cases  with  vesicular  lesions,  owing  to  their  rupture, 
a  moist  surface  is  seen  at  first ;  it  rarely  persists,  but  gives  place  to  scali— 
ness.  There  is  noted  some  infiltration,  and  in  all  cases  exfoliation  rapidy 
results,  and  this  stage — exfoliating — lasts  a  variable  time — on  the 
average,  about  five  or  six  weeks.  The  scales,  differing  as  to  size,  are 
rapidly  formed  and  are  produced  in  great  quantities.  The  cervical  and 
postoccipital  lymphatic  glands  are  frequently  enlarged,  and  independently 
of  face  or  scalp  eruption.  The  redness  begins  to  subside,  the  infiltration 
still  persisting;  the  skin  assumes  a  shining  brownish  appearance.  Im- 
provement takes  place  slowly,  and  in  many  cases  there  are  several  re- 
lapses before  recovery  is  complete  and  permanent.  In  almost  all  cases 
conjunctivitis  is  observed.  The  hairs  and  nails  fall  out,  and,  although  a 
regrowth  takes  place,  it  is  slow.  Itching,  somestimes  slight,  sometimes 
intense,  is  present. 

When  the  disease  is  completely  established,  general  symptoms  of 
malaise,  anorexia,  and  prostration,  and  in  many  albuminuria,  are  noted; 
in  some  instances  which  are  complicated  by  furuncular  development 
there  is  some  temperature  elevation.  Diarrhea  is  often  associated. 
In  unfavorable  cases  tremor,  muscular  twitching,  labored  respiration, 
intestinal  disturbance,  pulmonary  complication,  cardiac  weakness,  and, 
in  some  cases,  marasmus,  lead  to  a  fatal  issue. 

Russell  and  Savill  found  a  diplococcus,  in  rod-like  segments,  resem- 
bling the  staphylococcus,  but  differing  from  the  latter  in  the  above  par- 
ticular and  by  the  fact  that  it  does  not  liquefy  gelatin.  Experimental 
animal  inoculations  seem  to  bear  out  its  pathogenic  importance.  The 
food  and  the  milk  supply  were  suspected  as  being  the  possible  source, 
but  nothing  definite  could  be  demonstrated.  Anatomically,  according 
to  Savill,  engorgement  of  the  vessels  and  extravasation  of  leukocytes  in 
the  corium,  serous  effusion,  etc.,  were  to  be  noted.  Echeverria  found 
"a  remarkable  and  new  sort  of  degeneration  of  the  nuclei  of  the  prickle 
layer  of  the  epidermis — viz.,  the  peridiaphania  of  the  nuclei." 

Treatment  consists  of  mild  applications,  such  as  prescribed  in  acute 
eczema,  but  seems  to  have  but  little  influence  in  shortening  the  course 
of  the  disease.  In  a  few  instances  in  which  the  disease  began  as  a  small 
area,  painting  it  over  with  iodin  tincture  or  collodion  aborted  it  (Crocker). 


206  INFLAMMA  TIONS 

DERMATITIS  EXFOLIATIVA  NEONATORUM1 

Synonyms. — Kilter's  disease;  Dermatitis  exfoliativa  infantum;  Keratolysis  neo- 
natorum. 

Under  this  name  Ritter  first  (1878)  thoroughly  described  a  disease 
occurring  in  the  newborn  in  which  the  cutaneous  symptoms  were 
closely  similar  to  those  of  dermatitis  exfoliativa  in  older  patients,  with 
now  and  then  a  case  presenting  some  analogy  to  pemphigus  foliaceus. 
Since  then  cases  have  been  recorded  by  other  observers  (Caspary,  Boeck, 
Elliot,  and  others),  although  the  disease  is  a  rare  one.  According  to 
Ritter  and  others,  the  disease  usually  begins  between  the  second  and  the 
fifth  week;  the  symptoms  vary  somewhat,  although  there  is  always  the 
essential  character,  sometimes  at  the  beginning  or  at  other  times  later, 
of  thin  epidermic  exfoliation,  leaving  here  and  there,  or  in  the  grave  cases 
more  or  less  generally,  the  red  exposed  rete  or  corium,  and  occasionally  in 
parts  presenting  a  distinctly  moist  surface.  In  other  instances  there  is  dis- 
played a  tendency  to  scattered  vesicobullous  formation  or  serous  under- 
mining, with  exfoliation,  the  former  being  more  properly  cases  of  this 
disease,,  some  of  the  latter  probably  related  to  or  examples  of  pemphigus 
neonatorum.2  It  frequently  begins  in  one  region,  often  about  the  chin, 
and  is  then  followed  by  general  involvement.  Buccal,  nasal,  and  con- 
junctival  mucous  membranes  show  invasion,  and  at  the  juncture  with 
the  integument  at  the  commissures  show  slight  crusting  or  fissuring. 
The  eruption  usually  appears  without  systemic  symptoms.  In  some 
patients  the  body-temperature  tends  below  the  normal,  and  maras- 
mic  symptoms  supervene  and  death  frequently  results.  On  the  other 

1  Literature:    Ritter,  Central-Zeiiung  fur  Kinder heilkunde,  Oct.  i,  1878;  Archiv, 
1879,  p.  129;  Archiv  fur   Kinderheilkunde,  1880,  p.  53;  Boeck  (described  as  pem- 
phigus foliaceus),  Archiv,  1878,  p.  17;  Bohn,  in  Gerhardt's   Handbuch  der  Kinder- 
heilkunde; Caspary,  Archiv,  1884,  p.  122;  Elliot,  Amer.  Jour.  Med.  Sci.,  Jan.,  1888, 
p.  i  (a  good  review  of  the  subject,  with  references);  Borland,  Philada.  Polyclinic, 
1896,  p.  385;  Escherich,    Verhandlungen  der   Deutschen  dermatolog.  Gesellschaft,  V. 
Congress,  1896,  p.  65;  Pagliari,  La  Pediatra,  Nov.,  1897,  p.  317 — abstract  in  Annales, 
1898,  p.  820;  Winternitz,  Archiv,  1898,  vol.  xliv,  p.  397;  Luithlen,  ibid.,  vol.  xlvii,  1899, 
p.  323;  Patek,  Jour.  Cutan.  Dis.,  1904,  p.  269;  Burnside  Foster  (loc.  cit.),  4  cases; 
Skinner  (review,  case  report,  histology,  with  case  and  histolcgic  illustrations,  and 
references),  Brit.  Jour.  Derm.,  1910,  p.  75;  Hazen  ("Pemphigus  Foliaceus  and  Derma- 
titis Exfoliativa  Neonatorum"),  Jour.  Cutan.  Dis.,  1912,  p.  325,  with  case  and  histo- 
logic  illustrations  and  bibliography. 

2  Hedinger  (Archiv,  1906,  vol.  Ixxx,  p.  349)  discusses  the  relationship  of  dermatitis 
exfoliativa  neonatorum  and  pemphigus  acutus  neonatorum,  and  concludes  that  the  two 
conditions  differ  in  degree  rather  than  in  kind;  he  reports  2  cases,  i  presenting  predomi- 
nantly symptoms  of  the  former  and  the  other  predominantly  of  the  latter.     The  further 
interesting  fact  is  that  both  the  cases  came  from  the  practice  of  the  same  midwife,  and  go 
to  indicate  that  both  these  conditions  are  probably  variants  of  impetigo  contagiosa. 
Hazen  is  of  the  opinion  that  the  exfoliation  is  secondary  to  a  generalized  cutaneous 
infection,  probably  with  the  staphylococcus  albus. 

Leiner  (ibid.,  1908,  vol.  Ixxxix,  p.  65,  with  colored  case  illustration),  and  Brit. 
Jour.  Children's  Diseases,  June,  1908,  p.  244,  describes  under  the  name  erythrodermia 
desquamativa  an  affection  occurring  in  breastfed  children,  usually  in  the  first  months 
of  life,  with  cutaneous  symptoms  very  similar  to  those  of  a  more  or  less  generalized 
eczema  seborrhoicum.  Most  of  the  cases  run  a  benign  course,  recovering  in  a  few 
weeks;  in  a  third  of  the  cases,  however,  intestinal  symptoms  supervene,  with  severe 
diarrhea,  fever,  marasmus,  and  finally  death.  .  Leiner  has  observed  43  cases  in  the 
past  five  years  in  the  Carolinen  Children's  Hospital  in  Vienna;  he  considers  it  distinct 
from  Ritter's  disease  and  of  the  nature  of  an  autotoxic  erythema. 


DERMATITIS  EXFOLIATIVA   NEONATORUM  2O/ 

hand,  after  persisting  one  to  three  weeks  or  longer,  recovery  ensues. 
Suppurative  processes — furunculous  and  phlegmonous  in  character 
—have  been  noted  as  sequelae  (Ritter).  A  single  case  has  come  under 
my  observation,  in  which  the  malady  presented,  a  week  or  so  after 
birth,  with  a  reddening  of  the  skin  and  more  or  less  general  exfoliation, 
with  here  and  there  a  tendency  to  slight  serous  exudation;  the  tempera- 
ture was  a  trifle  below  the  normal;  the  infant  presented  a  marasmic 
appearance,  but  finally,  after  two  or  three  weeks,  recovered.  The 
eruption  began  in  the  flexures,  especially  about  the  genitocrural  region. 

The  nature  of  the  disease  remains  still  obscure.  The  process  has 
been  variously  regarded  as  a  dermatitis  of  pyemic  origin  (Ritter);  as 
an  epidermolysis  (Caspary,  Skinner),  with  consecutive  hyperemia  of  the 
cutis;  as  a  peculiar  pemphigoid  eruption  (Behrend,  Brocq),  as  a  dermati- 
tis due  to  a  fungus  found  (Riehl1)  in  one  or  two  instances;  and  as  merely 
an  exaggeration  of  the  physiologic  epidermic  desquamation  noted  in 
the  newborn  (Kaposi).  In  one  instance  Winternitz  found  the  staphy- 
lococcus  pyogenes  aureus  and  albus  in  the  blood.  Hazen  found  the  latter 
in  the  fresh  vesicles.  Its  occurrence  in  institutions,  notably  in  Ritter's 
cases,  suggests  that  the  disease  is  contagious  or  infectious.  The  view 
sometimes  expressed  that  it  is  a  sequence  of  some  form  of  intra-uterine 
exanthem  is  negatived  by  those  cases  in  which  the  eruption  has  not  pre- 
sented until  four  or  five  weeks  after  birth.  The  pathologic  anatomy  has 
been  investigated  by  Winternitz,  Luithlen,  Skinner,  and  others,  but  the 
conditions  found  are  not  especially  different  from  the  average  cases  of 
dermatitis  exfoliativa,  except  that  there  is  usually  more  serous  exudate. 
The  principal  conditions  noted  are:  Hyperemia  of  the  skin  and  other 
signs  of  inflammation;  dilatation  of  the  vessels;  edema,  etc. 

Prognosis  and  Treatment. — The  prognosis  is  always  grave,  a 
fatality  of  about  50  per  cent,  being  recorded.  In  Ritter's  297  cases 
150  recovered,  145  died,  the  remaining  2  were  still  under  observation 
at  the  time  of  his  report.  The  loss  of  body-heat,  the  gravity  of  the 
attack,  marasmus,  and  secondary  septicemia  are  factors  in  various 
cases  directly  responsible  for  the  fatal  issue.  Treatment  consists  in 
sustaining  the  strength  of  the  patient  by  appropriate  means,  the  char- 
acter of  the  nourishment  receiving  special  attention;  the  child  should 
have  its  natural  nourishment — recovery  is  scarcely  to  be  expected 
unless  this  is  possible.  The  maintenance  of  the  body-heat  is  likewise 
of  essential  importance.  For  this  and  other  purposes  fats  or  oils  should 
be  freely  used  externally,  medicated  with  0.5  to  i  per  cent,  of  boric 
acid  or  ichthyol,  and  the  patient  wrapped  in  cotton  wadding.  The 
crusts  at  the  corners  of  the  mouth,  when  present,  should  be  frequently 
anointed  with  olive  or  almond  oil,  and  softened  and  gently  removed, 
as  their  presence,  together  with  the  resulting  fissuring,  restrains  the 
child  from  taking  sufficient  nourishment. 

1  Riehl,  cited  by  Elliot,  Morrow's  System,  vol.  iii  (Dermatology),  p.  321. 


2O8  INFLAMMA  TIONS 

PRURIGO 

Synonyms. — Fr.,  Strophulus  prurigineux;  Ger.,  Juckblattern. 

Definition.— Prurigo  is  a  rare  chronic,  inflammatory  disease, 
beginning  in  early  life,  characterized  by  discrete,  pin-head  to  small 
pea-sized,  solid,  firmly  seated,  slightly  raised,  pale-red  papules,  usually 
appearing  primarily  on  the  tibial  surfaces,  and  accompanied  by  intense 
itching  and  more  or  less  general  thickening  of  the  affected  skin. 

Symptoms. — There  are  two  varieties  usually  described,  prurigo 
mitis  and  prurigo  ferox  (also  called  prurigo  agria),  which,  however, 
really  represent  respectively  the  mild  and  severe  types  of  the  disease. 
In  many  cases  there  is  a  preliminary  stage  of  some  months  in  which 
itchiness  and  the  typical  wheals  and  papules  (urticaria  papulosa)  of 
urticaria  appear  from  time  to  time  or  more  or  less  continuously;  and 
for  some  time  after  the  typical  lesions  of  prurigo  have  appeared  wheals 
may  now  and  then  be  seen.  The  disease  proper  begins  with  the  appear- 
ance of  pin-head-sized  papules,  which  may  be  pale  red  in  color,  or  even 
the  same  color  as  the  skin.  They  appear  almost  invariably  over  the 
anterior  aspects  of  the  legs  below  the  knees,  and  at  first  they  can  scarcely 
be  seen,  but  can  be  felt  by  passing  the  hand  over  the  surface.  Itchiness 
of  the  parts  usually  first  attracts  attention.  Later,  from  natural  growth 
and  from  scratching,  the  lesions  are  noted  to  be  somewhat  larger  and 
pale  red  or  red  in  color,  and  some  or  many  covered  with  minute  blood- 
crusts.  They  may  be  in  moderate  quantity  or  exceedingly  numerous 
and  rather  thickly  set,  but  there  is  no  tendency  to  grouping.  At  the  same 
time  or  later  lesions  present  themselves  on  the  extensor  surfaces  of  the 
forearms,  and  gradually  or  rapidly  upon  other  parts.  In  mild  cases  the 
flexor  surfaces  are  scarcely  affected,  and  even  in  severe  type  the  flexures 
of  the  joints,  such  as  the  poplitea,  axilla,  etc.,  and  the  palms  remain  free 
from  papules.  In  severe  cases  the  eruption  may  be  more  or  less  general, 
and  the  face  also  shows  some  involvement;  the  scalp  is  usually  free,  but 
the  skin  is  dry  and  the  hair  lusterless.  The  disease  is  most  marked  on 
the  extremities,  and  more  especially  on  the  lower  half;  and  the  upper 
extremities  less  severely  than  the  lower.  The  buttocks  and  trunk  also 
show  decided  involvement  in  severe  cases.  The  skin  becomes  dry,  on 
the  worse  parts  thickened  and  hard  and  rough,  and  exhibits  branny  scali- 
ness;  the  hairs  are  rubbed  off  or  broken;  and  the  perspiration  is  prac- 
tically suspended.  The  color  is  a  pale  red  to  a  red.  The  superficial 
lymphatic  glands,  especially  the  inguinal,  show  enlargement,  some- 
times of  a  pronounced  character.  From  the  intense  itching,  excoria- 
tions and  long  and  deep  scratch-marks,  with  resulting  slight  scars,  are 
produced,  and  from  the  long-continued  irritation  pigmentation  results. 
In  extreme,  neglected  cases  it  is  not  uncommon  to  see  impetiginous 
and  ecthymatous  lesions  interspersed;  distinct  eczematous  conditions 
are  at  times  superadded.  New  crops  of  papules  may  appear  from 
time  to  time,  and  the  subjective  symptoms  at  such  periods  become  still 
more  intense.  In  some  instances  (prurigo  mitis)  the  disease  is  much 
less  pronounced,  and  consists  of  scattered,  deep-seated  papules,  chiefly 
over  the  extensor  surfaces  of  the  limbs,  especially  the  lower;  and  in 


PRURIGO 


209 


these  cases  the  mild  aspect  continues  throughout.  In  fact,  usually 
the  type,  as  regards  severity,  is  established  from  the  start,  although 
neglect,  poor  food,  and  bad  hygiene  lead  to  aggravation.  As  a  rule, 
the  disease  is  worse  during  the  cold  season. 

Etiology. — The  disease  usually  has  its  beginning  in  the  first  few 
years  of  life.  It  is  by  far  most  common  in  Austria  and  Hungary,  among 
the  poorer  classes,  and  it  is  relatively  more  frequent  in  the  Hebrew 
race  and  in  males.  Mild  types  are  sometimes  seen  elsewhere.  It  is 
extremely  rare  in  this  country,  and  when  observed  is  usually  in  immigrant 
subjects,  as  in  the  cases  reported  by  Wiggles  worth,1  Campbell,2  Zeisler,3 
and  Taylor.4  It  is,  in  its  milder  types,  less  rare  in  England.  Occasion- 
ally chronic  papular  eczema  cases  closely  resembling  the  mild  varieties 
are  observed;  and  doubtless  many  of  the  milder  cases  of  prurigo  are  con- 
sidered, and  perhaps  are,  examples  of  what  is  generally  recognized  as 
urticaria  papulosa.  It  is  not  contagious,  and  heredity  does  not  seem 
to  be  a  factor.  It  develops,  as  a  rule,  in  those  in  poor  general  health. 
Neglect,  lack  of  proper  food,  and  bad  hygiene  are  apparently  influential. 
Climatic  conditions  may  also  be  in  a  measure  etiologic.  The  essential 
cause,  whether  neurotic,  toxemic,  or  parasitic,  is  not  known;  the  neurotic 
view  predominates. 

Pathology. — The  true  nature  of  prurigo  remains  obscure.  There 
is  still  much  divergent  opinion,  on  reviewing  which  J.  C.  White5  expressed 
the  following  conclusion :  One  cannot  go  further  than  accept  the  existence 
of  a  condition  of  early  childhood,  allied  to  pruritus  and  urticaria  in  its 
visible  manifestations,  and  not  to  be  positively  distinguished  from 
them  in  its  first  stages,  often  becoming  in  certain  parts  of  the  world  a 
chronic  affection  due  to  some  inexplicable  national  cutaneous  traits  or 
inherent  customs  of  living,  a  condition  which  certainly  lacks  many  of 
the  essential  elements  of  individuality. 

The  pathologic  changes6  are  such  as  are  met  with  in  chronic  hyper- 
plasias,  such  as  eczema,  and  anatomically  the  process  scarcely  admits 
of  differentiation.  The  essential  lesion— the  papule— which,  according 
to  investigation  by  several  pathologists,  has  its  origin  in  the  rete,  is  of 
a  minute  cystic  character,  and  contains  a  clear  fluid  and  some  epithelia; 
its  upper  covering  is  the  entire  corneous  layer,  which  is  undisturbed, 
except  secondarily.  It  is  thought  to  have  some  connection  with  the 
sweat-gland  duct.  Apparently  there  are  no  changes  in  the  peripheral 
nerves.  By  some  observers7  the  papule  is  thought  to  be  largely  a 

1  Wigglesworth,  Amer.  Jour.  Syph.  and  Derm.,  1873,  p.  i  (patient  of  American 
parentage). 

2  Campbell,  Arch.  Derm.,  1878,  p.  119  (patient  native  born,  but  of  German  parer 
age). 

3  Zeisler,  Jour.  Cutan.  Dis.,  1889,  p.  408  (12  cases— only  i  of  American  parentage, 
although  several  born  in  this  country). 

4  Taylor  and  Van  Gieson,  New  York  Med.  Jour.,  1891,  vol.  lin,  p.  i;  Bade,  Jour. 
Cutan.  Dis.,  1902,  p.  569  (also  a  case  in  a  child  of  foreign  parentage).  _  _ 

5  J.  C.  White,  "Prurigo,"  Jour.  Cutan.  Dis.,  1897,  p.  2  (with  many  cited  opmi 
and  literature  references).  ,    ,  , 

6  Van  Gieson,  in  Taylor  and  van  Gieson's  paper,  loc.  dt.,  gives  a  good  resume  ol  t 
histology,  with  numerous  illustrations  and  references;  also  Holder,  Trans.  Amer.  Derm. 
Assoc.  for  IQOI.  n. 

7  Holder,  "Prurigo,  and  the  Papule  with  the  Urticarial  Basis,    Jour.  Cutan.  Uis., 
1911,  p.  228,  with  brief  review  of  the  subject. 

14 


2IO  INFLAMMATIONS 

result  of  traumatism — from  the  scratching  and  rubbing  of  a  pruritic 
skin. 

Diagnosis. — A  typical  example  of  prurigo  scarcely  admits  of 
error:  the  poor  general  health,  its  early  beginning,  long  duration,  the 
dry,  harsh,  hard,  and  thickened  skin,  especially  over  the  extensor  sur- 
faces, the  freedom  of  the  flexures  of  the  joints,  the  peculiar,  scarcely  ele- 
vated papules,  the  intense  itching,  with  the  consequent  excoriation,  and 
the  enlarged  inguinal  glands,  are  characteristic.  The  milder  cases  possess 
the  same  features,  but  much  less  marked,  and  closely  resemble  papular 
eczema.  It  is  to  be  noted  that  in  neglected  cases  eczematous  symptoms 
are  added;  but  treatment  will  soon  remove  these,  and  the  character  of 
the  true  disease  be  disclosed.  A  careless  examination  might  lead  to  a 
confusion  with  a  long-continued  pediculosis  or  scabies. 

Prognosis  and  Treatment.— The  severe  cases  are  practically 
hopeless  as  to  permanent  relief,  although  much  can  be  done  in  every 
case  toward  palliation.  Under  favorable  circumstances  and  the  insti- 
tution of  early  treatment  the  milder  cases  admit  of  cure,  but  even  in 
these  latter  recurrences  are  often  observed.  The  imported  cases  in 
this  country  usually  show,  after  a  time,  marked  amelioration  and  even 
complete  disappearance — resulting  from  the  better  food  and  more  com- 
fortable and  hygienic  mode  of  living. 

Both  constitutional  and  local  measures  are  required  in  the  manage- 
ment of  the  disease.  The  systemic  treatment  aims  to  put  the  patient  in 
a  thoroughly  healthy  state,  with  attention  to  hygiene,  and  with  usually 
such  remedies  as  cod-liver  oil  and  iron,  manganese,  and  a  generous 
dietary.  Carbolic  acid,  pilocarpin  (hypodermically  administered),  and 
thyroid  extract  have  their  advocates ;  arsenic  seems  without  influence. 

The  external  treatment,  which  is  of  essential  importance,  consists 
of  frequent  warm  to  hot  plain  or  alkaline  baths,  tar-baths,  baths  of 
potassium  sulphid,  followed  by  an  oily  application.  A  ,?-naphthol 
ointment — in  children,  of  2  per  cent,  strength,  and  in  adults,  of  5  per 
cent. — rubbing  it  in  every  night,  is  highly  extolled  by  Kaposi,  and  is 
the  favorite  method  in  Vienna;  every  second  day  a  prolonged  bath 
in  warm  water  with  naphthol-sulphur  soap  is  taken.  The  frequent 
use  of  sapo  viridis,  or  its  tincture,  with  baths,  is  also  valuable  in  older 
subjects,  followed  by  emollient  ointments.  Strong  salicylic  acid  oint- 
ments, from  20  to  60  grains  (1.3  to  3.)  to  the  ounce,  are  also  useful 
in  some  cases.  In-  cases  in  which  marked  eczematous  eruption  has 
been  added,  mild  applications  are  at  first  demanded. 

PRURIGO  NODULARIS1 

Prurigo  nodularis  (Hyde,  Zeisler)— lichen  obtusus  corneous  (Brocq, 
C.  J.  White),  tuberosis  cutis  pruriginosa  (Hiibner,  Herxheimer) — is 

l  Literature:  Hardaway,  Arch.  Derm.,  1880,  p.  129;  Corlett,  "A  Peculiar  Disease 
of  the  Skin,  Accompanied  by  Extensive  Warty  Growths  and  Severe  Itching,"  Jour. 
Cutan.  Dis.,  1896,  p.  301  (with  case  illustration;  male);  Johnston,  "A  Papular,  Persist- 
ent Dermatosis,"  Jour.  Cutan.  Dis.,  1899,  p.  49  (with  case  and  histologic  illustra- 
tions); Brocq,  La  Pratique  Dermatologique,  1902,  vol.  iii,  pp.  201,  213,  216;  Kreibich, 
'Urticaria  Persians  Verrucosa,"  Archiv,  1899,  vol.  xlviii;  Hartmann,  "Ueber  eine 
urticariaartige  Hauterkrankung,"  Archiv,  1903,  vol.  Ixiv  (severe  cases,  suggestively 


PRURIGO  NODULAR  IS  211 

doubtless  distinct  from  hypertrophic  lichen  planus,  which  in  some  of  its 
features  it  resembles.  It  is  a  rare  malady,  and  was  first  described  by 
Hardaway  (1880)  under  the  descriptive  title  "multiple  tumors  of  the  skin 
accompanied  by  intense  itching,"  and  later  by  Brocq,  Johnston,  Kreibich, 
Schamberg  and  Hirschler,  Hiibner  and  Herxheimer,  Fasal,  C.  J.  White, 
Zeisler,  and  others.  It  is  not  improbable  that  some  of  the  cases  described 
under  the  names  "acne  urticata,"  "urticaria  perstans,"  "urticaria  per- 
stans  verrucosa,"  etc.,  represent  the  same  malady.  It  is  characterized 
by  more  or  less  rounded,  firm,  often  hard,  elevated  pinkish- white  or 
gray  to  brownish-red  pea-  to  cherry-sized  papules  or  nodules;  scattered 
over  the  legs,  sometimes  the  arms,  and  occasionally  elsewhere;  they  are 
exceedingly  itchy  and  persistent,  and  usually  become  covered  with  an 
adherent  scaly  layer  or  stratified  layers,  which  in  some,  owing  to  the 


Fig.  39. — Prurigo  nodularis  (courtesy  of  Dr.  Joseph  Zeisler). 

violent  scratching  often  engendered,  give  place  to  an  excoriated  sur- 
face and  blood  crust.  Sometimes  the  lesions  or  some  of  them  may  be 
quite  warty  in  aspect  and  to  the  touch;  and  rarely  there  may  be,  as 
in  a  case  observed  by  me,  in  a  few  nodules,  especially  those  on  the 
lowest  part  of  the  leg,  a  disposition  to  summit  vesiculation.  The  lesions 
are,  as  a  rule,  not  numerous  (thirty  to  fifty  or  more)  and  almost  always 

similar  to  this  disease);  Hubner  (Herxheimer's  Clinic),  "Tuberosis  Cutis  Pruriginosa," 
Archiv,  1906,  vol.  Ixxxi  (one  of  the  Hartmann  cases);  Schamberg  and  Hirschler,  "Two 
Cases  of  Multiple  Tumors  of  the  Skin  in  Negroes,  Associated  with  Itching,"  Jour. 
Cutan.  Dis.,  1906,  p.  151  (with  case  and  histologic  illustrations;  patients  both  women); 
C.  J.  White,  "Lichen  Obtusus  Corneous— An  Unusual  Type  of  Lichenification,"  Jour. 
Cutan.  Dis.,  1907^.385  (with  review  of  allied  cases,  case  and  histologic  illustrations); 
Hyde,  "Treatise  in  Skin  Diseases,"  8th  edition,  1909,  p.  174;  Jackson,  "Case  of  Mul- 
tiple Tumors  Associated  with  Itching,"  Jour.  Cutan.  Dis.,  1909,  p.  39  (case  demonstra- 
tion; on  right  thigh  only) ;  Zeisler,  "A  Case  of  So-called  Prurigo  Nodularis,"  Jour.  Cutan. 
Dis.,  Nov.,  1912  (with  case  illustration;  review  of  reported  cases — similar  and  allied. 
Zeisler,  to  whose  papers  I  am  indebted  for  some  references,  calls  attention  to  suggestive 
cases  shown  on  Plate  II,  Ikonographia  Dermatologica  of  1906. 


2  I  2  INFLAMMA  TIONS 

remain  discrete;  exceptionally  two  or  three  or  more  crowding  closely 
together  almost  to  the  degree  of  actual  coalescence,  and  forming  a 
small  nodular  patch.  They  are  dull  and  sluggish  looking,  entirely 
lacking  the  shiny  and  glazed  appearance  of  lichen  planus.  When  well 
established  they  show  little  if  any  disposition  to  change,  either  toward 
further  development  or  to  involution;  and  they  may  then  remain  for 
years.  Its  course  is  persistently  chronic;  even  when  a  lesion  is  cut 
out,  another  is  apt  to  come  in  its  place.  A  few  of  the  patients  have  alleged 
that  the  first  appearance  of  the  eruption  was  as  "blisters,"  or  as  wheals, 
although  medical  observation  of  the  cases  later  fails,  excepting  in  White's 
case,  to  corroborate  this;  however,  constant  rubbing  or  scratching  may 
produce  on  one  or  two  lesions  an  attempt  at  vesicle  or  small  thin  bleb 
formation,  and,  less  frequently,  by  accidental  infection,  a  pustular  tend- 
ency. While  the  eruption  is  generally  somewhat  disseminated,  excep- 
tionally it  may  be  limited  to  a  region,  such  as  the  thigh  (Jackson's  case) ;  and 
when  close  together  the  intervening  and  surrounding  skin,  doubtless  from 
the  rubbing  and  scratching,  may  become  rough  and  somewhat  thickened. 

The  cause  is  not  known.  The  cases,  in  this  country  at  least,  have, 
excepting  Corlett's  case  (?)  all  been  women,  mostly  between  the  ages  of 
thirty  and  fifty;  the  malady  may  begin,  however,  as  early  as  the  age  of 
twelve,  possibly  earlier.  The  histopathology  has  been  studied  by  the 
various  observers  named,  and  have  disclosed  features  of  a  papuloverru- 
cous  nature,  with  usually  the  horny  layer  markedly  increased,  and  in- 
flammatory changes  of  a  peri  vascular  character  in  the  corium,  less  in  the 
papillary  layer;  and  occasionally  round,  concentrically  arranged  nest-like 
and  column-like  bodies  in  the  corium,  spreading  about  the  blood-vessels. 
Johnston  found  a  tiny  vesicle  inclosed  somewhat  deeply  in  the  central 
apical  portion.  Johnston  is  of  the  opinion  that  the  malady  is  to  be 
grouped  with  prurigo.  C.  J.  White  thought  the  histopathology  of  his 
case  approached  rather  closely  that  of  lichen  planus  hypertrophicus, 
though  his  patient  exhibited  some  wheals. 

Prognosis  and  Treatment — All  forms  of  treatment  have  been 
tried  in  this  rare  disease,  and  the  literature  does  not  record  a  recovery. 
For  a  while  the  medicated  varnishes  employed  in  psoriasis  and  the  x-ray 
seemed  to  be  of  some  slight  benefit.  In  Johnston's  case  there  was  some 
improvement  from  full  doses  of  arsenic,  and  in  C.  J.  White's  case  from 
the  use  of  chrysarobin  and  lactic  acid.  In  my  case,  under  observation 
for  five  or  six  months,  all  plans  proved  futile,  the  #-ray  and  chrysarobin 
applications  bringing  some  temporary  betterment.1 

1  Zeisler,  who  also  used  chrysarobin  and  #-rays,  states  "that  the  latter  had  a  curious 
effect — under  their  influence  the  hard  keratomatous  growths  seemed  to  soften  and 
become  transformed  into  vesicular  lesions,  which  would  gradually  dry  up.  .  .  ." 
I  noted  this  change  in  some  of  the  lesions  in  my  case.  The  patient,  in  my  case,  was 
a  young  woman  of  twenty-four,  in  whom  the  eruption  had  first  appeared  when  a  child 
of  about  ten  to  twelve  years  of  age;  first  in  the  lowest  parts  of  the  legs.  At  present 
the  eruption  was  quite  abundant  on  both  legs  below  the  knees  with  a  few  lesions  on 
one  thigh  just  above  the  knee,  and  some  lesions  had  lately  appeared  on  both  arms; 
some  were  closely  grouped  in  threes  and  fours,  but,  as  a  rule,  they  were  discrete;  the 
itching  was  intense,  worse  at  night;  while  under  observation  a  few  of  the  lesions 
under  chrysarobin  applications  and  *-ray  seemed  to  soften,  become  vesicular — almost 
bullous — dry  up,  and  disappear.  The  patient  stated  that  she  had  noted  this  change 
occasionally  before.  I  had  first  viewed  this  case  as  an  unusual  one  of  warty  hyper- 
trophic  lichen  planus. 


LICHEN  PLANUS 


213 


LICHEN  PLANUS 

Synonyms.— 'Lichen  ruber  planus;  Lichen  psoriasis. 

Definition. — An  inflammatory  disease  characterized  by  pin-head 
to  small  pea-sized  flattened,  glistening,  crimson  or  violaceous  papules, 
with  often  a  slight  central  depression,  and  often  an  irregular  or  angular 
base;  tending  to  coalescence  and  the  formation  of  areas  with  a  rough- 
ened or  scaly  surface. 

Symptoms. — The  disease,  first  clearly  described  by  Wilson,1  is 
in  the  larger  number  of  cases  somewhat  limited,  but  it  may  be  more 
or  less  widely  distributed  over  the  entire  surface.  The  favorite  sites 
in  the  former  are  about  the  flexor  aspects  of  the  wrists  and  forearms 
and  the  lower  part  of  the  leg.  The  limited  form  of  the  disease  usually 
begins  insidiously.  The  lesions  at  first  are  discrete,  scattered,  bright 
or  dark  red  in  appearance,  slightly  elevated,  with  a  flattened,  shining, 


Fig.  40. — Lichen  planus  of  moderate  development,  in  a  woman  aged  twenty-five, 
and  of  several  months'  duration.  Practically  limited  to  the  arms  and  mainly  on  flexor 
aspects. 

or  glistening  top,  in  the  central  part  of  which  there  is  usually  a  minute 
depression.  The  base  may  be  rounded;  but  more  frequently  it  is  irregu- 
larly quadrangular  or  angular,  usually  with  perpendicular  sides;  excep- 
tionally minute  stellate  projections  are  noted  at  the  base.  In  size  they  are 
generally  a  trifle  larger  than  a  pin-head.  In  larger  lesions,  if  present,  there 
may  be,  more  especially  after  they  have  existed  for  some  time,  a  wider 
depression  centrally,  resulting  in  a  slightly  ringed  formation;  or  occasion- 
ally new  lesions  spring  up  contiguous  to  the  border  while  the  central  part 
flattens  down  and  partially  or  completely  disappears.  In  occasional  in- 
stances this  ring-like  tendency  (annular  lichen  planus)  in  several  or  more 
of  the  lesions  or  patches  may  be  quite  pronounced.  Sometimes  several 
lesions  will  arrange  themselves  as  a  straight  or  irregular  line.  Excoria- 
tions and  scratch-marks  are  apt  to  show  a  development  of  the  efflores- 
cences. Lesions  continue  to  arise,  in  the  average  case,  close  to  others,  and 

1  E.  Wilson  reported  a  large  number  of  cases  in  Jour.  Cutan.  Med.,  London,  1869, 
vol.  iii,  No.  10. 


214 


2NFLAMMA  TIONS 


several  or  more  coalesce,  and  solid  patches  of  various  sizes  result;  the 
surface  of  these  is  noted  to  be  rough  or  slightly  scaly.  The  scaliness 
is  generally  insignificant  or  branny,  usually  quite  adherent,  but  rarely 
marked.  The  lesions  and  areas  are  now,  as  a  rule,  noted  to  be  of  a  pur- 
plish color  which  is  quite  charac- 
teristic. Some  may  disappear, 
leaving  considerable  pigmenta- 
tion, which  is  slow  in  fading. 
In  exceptional  instances  slight 
atrophy  may  occur  in  places.1 
Although  some  of  the  lesions  and 
areas  may  tend  to  disappear, 
the  eruption  is,  as  a  rule,  persist- 
ent, new  efflorescences  appear- 
ing from  time  to  time.  The  dis- 
ease may  thus  remain  upon  the 
affected  region,  more  particularly 
the  lower  legs,  and  continue  in- 
definitely, with  but  slight  varia- 
tion. 

While  the  plane  or  flat  lesion 
is  the  characteristic  one  of  lichen 
planus,  in  some  cases  there  is  an 
admixture  of  a  distinctly  follicu- 
lar  and  acuminate  papule  with  or 
without  a  slightly  protruding 
horny  plug;  exceptionally  this 
latter  type  may  be  predominant, 
and  in  still  rarer  instances  prac- 
tically all  lesions  may  be  of  this 
type. 

In  the  leg  region,  and  occa- 
sionally elsewhere — more  especi- 
ally the  forearms — the  lesions 
are  sometimes  much  larger. 

Fig.    4i--Lichen   planus-hypertrophic        They    are     from    a    Sma11    to    a 
papules.  large  pea  in  size,  with   rounded 

or  lenticular  base,  and  flattened 

or  slightly  conic  in  shape,  dark  red,  brownish,  or  purplish  in  color, 
with  flattening  of  the  summit  or  of  the  entire  lesion;  the  surface 
somewhat  rough  and  branny  or  smooth  (lichen  obtusus ;  lichen  planus 
hypertrophicus).  Occasionally  the  confluent  plaques,  especially  about 
or  near  the  ankle,  are  markedly  thickened,  sometimes  quite  dark  in 
color,  hard,  rough,  and  wart-like — lichen  planus  verrucosus.  Excep- 
tionally the  lesions  may  be  waxy  in  appearance.  They  may  coalesce 

1  See  interesting  paper  on  the  variant  forms,  etc.,  by  Crocker  ("Lichen  Planus:  Its 
Variations.  Relations,  and  Limitations"),  with  discussion,  Brit.  Jour.  Derm.,  1900.  p. 
421;  also  Engman's  report,  "Annular  Lichen  Planus,"  Jour.  Cutan.  Dis.,  May,  1901; 
Lieberthal,  "Lichen  Planus  Hypertrophicus."  Jour.  Amer.  Med.  Assoc.,  Jan.  n,  1902. 


LICHEN  PLANUS 


215 


and  form  large  areas,  as  with  the  smaller  papules;  the  central  part 
of  the  patches  may  persist,  or  it  may  disappear  and  show  staining  and, 
exceptionally,  atrophy.  In  rare  instances  this  tendency  to  atrophy 
in  lichen  planus  (lichen  planus  atrophicus1)  lesions  is  quite  striking: 
the  individual  papules  tend  to  enlarge  peripherally  to  the  size  of  a  pea 
or  dime,  thinning  centrally  as  they  enlarge,  and  thus  presenting  a  ring 
appearance;  eventually  the  whole  lesion  may  become  thinned  down, 
disappearing,  and  leaving  behind  an  atrophic  white  spot.  Doubtless  a 
few  of  the  cases  of  so-called  white  spot  disease  (q.  v.)2  may  thus  originate. 
In  occasional  instances  the  white  spot  is  somewhat  sclerotic  and  mor- 
phea-like  (lichen  planus  morphceicus  (Stowers),  lichen  planus  keloidi- 
formis  (Pasolow)). 

The  more  or  less  generalized  form  of  lichen  planus  may  begin  as 
such  or  develop  from  the  limited  form.3  The  lesions  usually  appear  more 
or  less  rapidly,  are  at  first  rather  pale  red  than  deep  red;  some  are  waxy 
and  semitranslucent,  and  conic  and  rounded  in  shape,  and  may  or  may 
not  have  the  central  depression.  Many,  and  sometimes  all,  the  lesions  are, 
however,  similar  to  those  described  in  the  limited  form — angular,  flat, 
dark  red,  and  umbilicated.  They  are  apt  to  appear,  first,  or  most  numer- 
ously, on  the  trunk,  but  the  extremities  are  also  invaded,  and  sometimes 
markedly.  Sooner  or  later  the  color  becomes  dark  red  or  violaceous. 
There  is  the  same  tendency  toward  close  aggregation  and  coalescence 
here  and  there,  with  the  resulting  solid  patch,  a  trifle  rough  and  scaly. 
Exceptionally  in  some  regions  the  lesions  appear  close  together,  forming 
narrow,  bead-like  bands  (so-called  lichen  ruber  moniliformis).  This 
formation  is  likewise  seen  in  the  limited  form,  and  may  constitute  the 
major  part  of  the  eruption,  as  in  cases  reported  by  Kaposi,  Dubreuilh, 
and  G.  H.  Fox. 

The  deep-red  or  violaceous  color  of  the  papules  of  lichen  planus 
as  ordinarily  met  with  is  usually  most  marked  on  the  lower  parts  of 
the  legs.  Single  isolated  papules  are  usually  free  from  any  attempt 
at  scaliness;  exceptionally,  however,  a  minute,  thin,  filmy  scale  sur- 
mounts it.  Minute  whitish  or  grayish  points  and  striae,  and  sometimes 

1  Dubreuilh  and  Petges,  "Lichen  plan  atrophique,"  Annales,  1907,  p.  715,  report  a 
case,  and  review  reported  cases  (with  references).     Ormsby,  Lichen  planus  sclerosus 
et  atrophicus  (Hallopeau) ;  a  report  of  six  cases  (five  new)  with  a  review  of  the  litera- 
ture, Jour.  Amer.  Med.  Assoc.,  Sept.  10,  1910,  p.  901,  with  references  and  illustrations; 
the  writer  found  sites  of  predilection:   upper  portions  of  the  trunk,  about  the  breasts, 
over  the  clavicles,  extending  over  the  shoulders  and  downward  over  the  upper  part  of 
the  back,  also  the  neck,  axillae,  and  forearms.     The  characteristic  lesion  is  an  irregular, 
often  polygonal,  flat  topped,  white  papule,  with  occasionally  a  yellowish  tinge;  on  a 
skin  level  or  slightly  elevated,  with  one  to  several  or  more  black  or  dark  horny,  comedo- 
like  plugs,  or  minute  pit-like  depressions  showing  the  sites  of  former  plugs;    isolated 
and  in  plaques,  they  leave  white  delicate  smooth  scars.     Radiotherapy  is  beneficial. 

2  F.  H.  Montgomery  and  Ormsby,  "White  Spot  Disease,"  Jour.  Cutan.  Dis.,  1907, 
p.  12  (third  case — lichen  planus  atrophicus). 

8  Exceptionally  such  a  case  develops  in  such  a  way  as  to  suggest  a  systemic  malady. 
D.  W.  Montgomery  and  Alderson  report  (Jour.  Amer.  Med.  Assoc.,  1909,  vol.  liii,  p. 
1457,  with  brief  review  and  references)  a  case  of  lichen  planus  appearing  acutely,  the 
eruption  being  profuse  and  more  or  less  general,  with  brighter  colored  lesions,  quite 
fiery  in  appearance,  with  febrile  and  other  constitutional  disturbances — indicative  of  a 
constitutional  disorder— suggestively  similar  to  the  acute  exanthemata.  Engman  and 
Mook,  Interstate  Med.  Jour.,  June,  1909,  cite  cases  and  circumstances  favoring  the 
idea  that  this  disease  is  a  systemic  one  (review  and  references). 


2 1 6  I  NFL  A  MM  A  TIONS 

minute  red  points,  are  not  infrequently  to  be  seen  on  the  surface  of  the 
lesions,  more  particularly  those  of  larger  size,  and  especially  where  co- 
alescence has  taken  place,  the  presence  of  which  Wickham1  considers 
pathognomonic  of  this  disease.  On  the  other  hand,  the  shining  or  glazed 
appearance  which  may  be  readily  seen  when  the  lesions  are  looked  at 
askant,  is  usually  observable  on  all  discrete  lesions. 

While  the  eruption  may  be  quite  extensive  and  be  distributed  in 
smaller  and  larger  plaques  over  the  entire  surface,  it  is  never  univer- 
sal. Even  in  extreme  cases  there  are  always  some,  and  usually  many, 
free  areas.  It  is,  as  a  rule,  more  or  less  symmetric,  although  cases  are 
met  with  in  which  the  areas  of  disease  may  be  on  one  side,  and  a  few  in- 
stances are  on  record  in  which  it  had  a  zoster-like  distribution.  The 
face  is  an  uncommon  site,  even  when  the  eruption  is  abundant.  The 
palms  and  soles  are  only  occasionally  involved. 

Occasionally  summit  vesiculation  is  noticed  in  some  of  the  lesions; 
and  exceptionally  distinct  vesicles  and  blebs,  as  in  cases  recorded  by  Unna,2 
Kaposi,3  Leredde, 4  Mackenzie,5  Hallopeau  and  Le  Sourd,6  Colcott  Fox,7 
Allen,8  Whitfield,9  Engman,10  and  others;  in  rare  instances  it  may  be  quite 
a  pronounced  feature.  It  has  been  suggested  that,  in  some  of  the  cases 
at  least,  the  vesicular  and  bullous  lesions  might  be  due  to  the  arsenic  so 
commonly  administered  in  this  disease,  but  in  Whitfield's  review  of  17 
collected  cases,  in  g  of  the  patients  this  drug  had  not  been  taken. 

The  mucous  membrane  of  the  mouth  is  quite  frequently  the  seat  of 
lesions  (E.  Wilson,  Hutchinson,  Crocker,  and  others),  and  sometimes 
it  begins  there  primarily,  as  Thibierge,11  Crocker,12  Petersen,13  and  others 
have  shown;  it  sometimes  precedes  the  skin  eruption  by  some  weeks,  and, 
in  rare  instances,  continues  practically  limited  to  this  region.14  In  this 

1  Wickham,  Annales,  1895,  p.  517. 

2  Unna,  Medical  Bulletin,  Phila.,  1885,  p.  145. 

3  Kaposi,  Archiv,  1892,  pp.  340,  342,  and  344. 

4  Leredde,  Annales,  1895,  P-  637. 

6  Mackenzie,  Brit.  Jour.  Derm.,  1899,  p.  26. 

6  Hallopeau  and  Le  Sourd,  Jour.  mal.  cutan.,  Nov.,  1899  (vesicles — in  palms). 

7  Colcott  Fox,  Brit.  Jour.  Derm.,  1895,  P-  22- 

8  Allen,  Trans.  Amer,  Derm.  Assoc.for  1901;  Jour.  Cutan.  Dis.,  1902,  p.  260. 

9  Whitfield,  Brit.  Jour.  Derm.,  1902,  p.  161  (with  case  and  histologic  illustrations). 
10  Engman,  Jour.  Cutan.  Dis.,  1904,  p.  207  (with  case  and  histologic  illustrations  and 

bibliography);  Miller,  "A  Case  of  Lichen  Planus  Bullosus,"  Jour.  Cutan.  Dis.,  1911,  p. 
332  (with  pertinent  bibliography). 

"Thibierge,  "Des  lesions  de  la  muquese  linguale  dans  le  lichen  planus,"  Annales. 
1885,  p.  65  (this  contains  a  review  of  published  cases). 

12  Crocker,  "On  Affections  of  the  Mucous  Membranes  in  Lichen  Ruber  vel  Planus," 
Monatshefte,  1882,  vol.  i,  p.  161. 

13  Petersen,  St.  Petersburg  med.  Wochenschr.,  1899,  p.  33  (brief  case  report).     See 
also  Teuton's  paper,  "Casuistisches  zum  Lichen  ruber  planus  der  Haut  und  Schleim- 
haut,"  Berlin,  klin.  Wochenschr.,  1886,  p.  374  (with  references). 

14  Some  recent  contributions  on  lichen  planus  of  the  mucous  membranes  are:  Mew- 
born,  Jour.  Cutan.  Dis.,  1905,  p.  176  (case  presentation).     Among  10  unusual  cases 
reported  by  Beltmann  (Archiv,  vol.  Ixxv,  p.  379)  is  one  in  which  the  only  regions  in- 
volved were  the  mouth  and  urethra;  Vorner,  Dermatolog.  Zeitschr.,  1906,  vol.  xiii,  p.  107. 
notes  that  umbilication  may  also  be  observed  in  these  mucous  membrane  lesions; 
Dubrenilk  ("Histologie  du  lichen  plan  des  muquenses,"  Annales,  1906,  p.  123)  states 
that  the  lesions  of  the  mucous  membranes  are  histologically  essentially  the  same  as  those 
of  the  skin);  Lieberthal,  "Lichen  planus  of  the  oral  mucosa,"  Jour.  Amer.  Med.  Assoc., 
Feb.  16,  1907  (2  cases,  with  illustrations);  Favera,  Monatshefte,  1909,  vol.  xlviii,  p.  293 
(with  2  histologic  cuts  and  partial  bibliography). 


LICHEN  PLANUS 

region  the  disease  consists  of  white  or  whitish  dots  or  papules,  plaques, 
or  streaks,  as  a  rule  but  slightly  raised.  It  bears  a  strong  resemblance 
to  the  appearances  produced  by  cauterization  with  silver  nitrate.  As 
a  rule,  these  lesions  give  rise  to  no  discomfort;  occasionally  there  is  a 
feeling  of  slight  soreness. 

The  glans  penis  has  likewise  been  noted  to  be  the  seat  of  lesions,  and 
sometimes  before  their  appearance  elsewhere,  as  recorded  by  Bulkley1 
and  others.2  The  eruption  has  also  been  observed  on  the  inside  and 
outside  of  the  vulva,  as  well  as  on  the  anal  mucosa.  On  the  glans  penis 
as  well  as  on  the  vulva  the  lesions,  which  sometimes  tend  to  the  annular 
development,  are  either  white,  when  the  part  is  habitually  covered,  or 
of  the  usual  'color  observed  elsewhere  when  uncovered.  It  is  thought 
not  improbable  that  in  the  more  or  less  generalized  cases  of  lichen  planus, 
especially  the  acute  rapidly  spreading  variety,  the  mucous  membranes  of 
the  gastro-intestinal  tract  may  be  also  involved. 

The  disease  in  children  usually  presents  the  same  symptoms  as 
when  occurring  in  adults,  but  there  is  a  type  occurring  in  infants,  de- 
scribed by  Crocker3  and  Colcott  Fox,4  in  which  the  eruption  (quoting 
Crocker)  comes  out  acutely  in  groups,  each  papule  of  which  is  some- 
times acuminate  at  first,  but  the  top  seems  to  die  down  and  a  scale 
comes  off,  leaving  a  smooth,  shining,  angular  papule,  of  a  brighter  red 
than  usual,  though  it  may  get  a  purplish  tint  subsequently.  Limbs, 
trunk,  or  both  may  be  the  seat  of  the  eruption.  There  is  considerable 
itching. 

The  course  of  lichen  planus  is  in  most  cases  slow,  insidious,  and 
chronic.  In  some  instances,  it  is  true,  as  already  remarked,  the  out- 
break may  be  extensive  and  somewhat  rapid,  but,  as  a  rule,  the  erup- 
tion is  slow  in  development,  and  in  the  majority  of  patients  somewhat 
limited  in  extent.  In  many  of  the  limited  cases,  after  reaching  a  cer- 
tain point,  it  may  remain  practically  stationary  for  a  long  time,  or 
there  is  retrogression  of  some  lesions  along  with  the  appearance  of 
new  papules.  Exceptionally,  it  tends  after  a  time  to  disappear  spon- 
taneously, but,  as  a  rule,  it  is  persistent.  There  are  rarely  any  gen- 
eral symptoms  except  in  cases  of  acute  outbreaks  or  exacerbations, 
and  even  then  but  slight  and  transitory.  In  more  or  less  generalized 
cases  a  marasmic  tendency  has  occasionally  been  recorded. 

The  subjective  symptoms,  consisting  of  burning  and  itching,  but 
usually  the  latter,  vary  somewhat  in  different  cases  and  often  in  the 
same  case.  Occasionally  the  itching  is  not  troublesome  or  so  slight 
as  to  give  rise  to  no  complaint;  generally,  however,  it  is  an  annoying 
symptom,  and  sometimes  so  intense  as  to  deprive  the  patient  of  restful 
sleep. 

Etiology — The  disease  is  not  frequent.  It  is  seen  in  both  sexes, 
and  most  commonly  during  active  adult  life,  being  rare  in  children. 

Bulkley,  Arch.  Derm.,  1881,  p.  135. 

2Fordyce,  Jour.  Cutan.  Dis.,  1912,  p.  351,  demonstrated  a  case  with  lesions  on 
the  penis  and  mucous  membrane  of  inner  side  of  cheek — nowhere  else. 

3  Crocker,  Diseases  of  the  Skin,  firs?  ed.,  1888,  p.  215;  second  ed.,  1893,  p.  302. 

4  Colcott  Fox,  "Notes  on  Lichen  Planus  in  Infants,"  Brit.  Jour.  Derm.,  1891,  p. 
201  (7  cases). 


21 8  INFLAMMATIONS 

Exceptionally  the  malady  has  been  observed  in  two  or  three  members 
of  the  same  family  (Brocq,  Lustgarten,  Ormerod,  Ledermann,  Jadassohn, 
Hallopeau,  F.  Veiel,  and  others).1  It  is  most  frequently  observed  in 
those  of  the  neurotic  class,  after  prolonged  worry,  overwork,  anxiety, 
nervous  shock,  or  exhaustion;  and  is  met  with  relatively  oftener  in  private 
than  dispensary  practice.  In  fact  it  would  seem,  in  most  cases  at  least, 
that  the  disease  is  the  result  of  disturbance  of  the  nervous  system.  This 
appears  to  have  further  support  in  the  fact  that  it  has  occasionally  been 
noted  to  follow  nerve  distribution  and  also  nerve  injuries.  It,  however, 
occurs  in  those  apparently  well  nourished  as  well  as  in  those  showing 
malnutrition. 

Almost  all  authors  of  note  recognize  its  frequency  among  the  ner- 
vously depressed  and  exhausted.  Duhring2  holds  strongly  to  this  view, 
stating  that,  according  to  his  experience,  patients  are  generally  found  to 
be  suffering  from  debility  arising  from  improper  nourishment,  overwork, 
nervous  depression,  and  similar  conditions,  and  that  nervous  symp- 
toms are  often  prominent.  I  have  myself  long  had  under  observation  2 
cases  (women)  who  have  had  recurrences  when  worn  out  with  prolonged 
winter  social  exactions.  A  few  others  hold  the  view  of  a  possible  systemic 
infection.3 

According  to  Crocker  and  Colcott  Fox,  the  infantile  cases  seem,  for 
the  most  part,  to  occur  in  those  whose  vitality  has  been  weakened  by 
constitutional  taint,  such  as  scrofula,  syphilis,  and  the  like. 

Pathology. — Lichen  planus  is  apparently  an  inflammatory  proc- 
ess, but  what  the  initial  exciting  pathologic  factor  is  remains  as  yet 
unknown.  That  it  is  a  neuropathic  affection  seems  probable,  Col- 
cott Fox  suggesting  that  the  first  step  may  be  a  neuroparalytic  hyper- 
emia.  The  question  4  of  its  relationship  to  pityriasis  rubra  pilaris  (lichen 
ruber)  is  still  an  unclosed  one,  although  the  large  preponderance  of 
opinion  considers  them  two  distinct  affections.  It  seems  certain,  how- 
ever, that  in  some  cases  of  extensive  lichen  planus  occasionally  papules 
similar  or  closely  similar  to  those  characterizing  pityriasis  rubra  pilaris 
(lichen  ruber)  are  observed.5 

The  pathologic  anatomy  has  been  studied  by  Robinson,  Crocker, 
Torok,  Unna,  Polano,  Fordyce,  Sabouraud,  and  others.  The  disease 

1  F.  Veiel,  "Lichen  ruber  planus  als  Familienerkrankung,"  Archiv,  vol.  xciii,  H.  3, 
1908. 

2  Duhring,  Diseases  of  the  Skin,  third  ed.,  1882,  p.  259;  Spiethoff  reports  (Archiv, 
Jan.,  1911,  Bd.  cv,  H.  i  and  2,  p.  69)  a  case  in  which  there  was  an  associated  pernicious 
anemia. 

3  Norman  Walker  (Introduction  to  Dermatology)  thinks  it  possible  that  it  may 
later  be  found  among  the  infective  granulomata. 

4  See  Discussion,  Compt.  Rend.,  "Congress  Internal,  de  Derm,  et  de  Syph.,"  Paris, 
1889. 

5  Kaposi  believes  that  lichen  planus,  sometimes  called  the  lichen  planus  of  Wilson, 
is  related  to  the  malady  described  by  Hebra  as  lichen  ruber,  and  to  the  former  he  gave 
the  name  lichen  ruber  planus,  and  to  the  latter,  lichen  ruber  acuminatus.     This  view 
obtained  for  some  years,  but  was  followed  by  a  more  or  less  general  reversion,  and 
the  acceptance  of  the  opinion  that  these  two  so-called  types  or  forms  really  represented 
two  distinct  and  separate  cutaneous  maladies,  although  a  few  eminent  diagnosticians,  as 
Neumann  and  Hebra,  Jr.,  as  well  as  several  others,  have  noted  cases  in  which  the  two 
coexist.     Lichen  ruber  acuminatus,  Kaposi  further  considers,  as  is  now  generally  ad- 
mitted, as  identical  with  pityriasis  rubra  pilaris. 


LICHEN  PLANUS 


:2I9 


has  its  seat  in  the  upper  part  of  the  corium,  and  usually  around  a  sweat- 
duct.  The  hair-follicles  have  no  determining  influence  in  the  sittJ^,- 
tion  of  the  papules.  The  changes  are  somewhat  different,  depending 
upon  the  duration  and  character  of  the  lesion.  The  rete  and  corneous: 
layer  are  noted  to  be  thickened,  and  the  papillae  enlarged,  the  vessels 
of  the  latter  showing  dilatation.  Fordyce1  noted  the  earliest  changes 
to  consist  in  dilatation  of  the  vessels  and  lymph  spaces  of  the  papillae.  , 
The  papule  results  (Sabouraud)2  from  a  proliferation  of  the  mononuclear  \ 
cells  in  the  papillae  crowding  out  the  interpapillary  processes  of  the 
epidermis,  becoming  edematous  to  a  variable  degree,  even  in  some  in- 
stances, to  the  degree  of  vesiculation.  The  central  point  of  the  depression 
usually  corresponds  to  the  sweat-duct  orifice,  the  depression  resulting 
from  reabsorption  and  degeneration  of  the  infiltration;  the  sweat-glands 
are  not  affected. 

The  first  characteristic  change  noted  in  the  epidermis  is  thought  to 
be  an  acanthosis,  followed  by  epithelial  atrophy,  and  a  hyperkeratosis, 


Fig.  42. — Lichen  planus — section  of  two  contiguous  papules  of  not  very  long  stand- 
ing (low  magnification):  A,  Corneous  layer,  thickened  slightly;  B,  rete  and  granular 
layers,  considerably  thickened;  C,  C,  round-cell  collection  in  upper  part  of  the  corium 
and  papilla;,  some  of  the  latter  thus  crowded  out,  others  enlarged  by  the  increase  in 
length  of  the  interpapillary  rete;  D,  muscle  bundle  (courtesy  of  Dr.  A.  R.  Robinson). 

intercellular  edema,  and  colloid  degeneration  of  the  prickle-cells.  Histo- 
logically,  the  mucous  membrane  lesions  present  the  same  features  as  those 
of  the  skin. 

Diagnosis.— The  irregular  and  angular  outline,  the  flattened  top, 
the  slight  central  depression,  the  glistening  or  glazed  appearance,  the 
dull  red  or  purplish  color,  the  tendency  to  patch-formation  of  a  slightly 
rough  and  scaly  surface,  with  outlying  typical  papules,  together  with  the 
history  and  course  and  usually  itchy  character— are  features  which  are 
peculiar  to  this  disease,  and  will  generally  prevent  an  errror  in  diagnosis. 
The  larger  patches  look  somewhat  like  psoriasis,  but  the  distribution  is 
different  and  they  are  less  scaly,  of  different  color,  and  about  the  edges 
are  to  be  found  the  characteristic  papules.  A  patch  of  psoriasis  is  due  to 
peripheral  extension,  that  of  lichen  planus  usually  to  accretion  of  new 
papules. 

1  Fordyce,  "The  Lichen  Group  of  Skin  Diseases;  A  Histologic  Study,"  Jour.  Cutan. 
Dis.,  1910,  p.  57  (with  excellent  histologic  illustrations). 

2  Sabouraud,  Annales,  1910,  p.  491  (pathologic  anatomy;  excellent  illustratio 


220 

' 


INFLAMMA  TIONS 


While  the  patches  of  the  disease  may  resemble  squamous  eczema, 
the  characters  of  the  papules,  always  to  be  found,  are  essentially  dif- 
ferent; and  in  an  extensive  papular  or  scaly  eczema  there  is  often  the 
presence  of  a  few  intermingled  vesicles  or  a  history  of  such  or  of  oozing ; 
lichen  planus  is  in  almost  all  cases  a  dry  disease  throughout,  and  the 
lesions  are  papular  and  not  vesicular,  moreover,  the  papules  of  eczema 
are  rounded  or  acuminate.  It  is  only  in  exceptional  instances  that  some 
of  the  lesions  of  lichen  planus  may  show  vesicular  and  bullous  develop- 


m  i  \ 


Fig.  43. — Lichen  planus — section  from  a  chronic  patch  (moderately  high  magnifica- 
tion) :  a,  b,  c,  Show  respectively  the  corneous  layer,  granular,  and  rete — all  consider- 
ably thickened;  e,  e,  microscopic  cavities,  with  serous  exudate;  d,  corium,  infiltrated 
with  exuded  round  cells,  and  with  marked  increase  in  the  size  of  the  connective-tissue 
corpuscles  (courtesy  of  Dr.  A.  R.  Robinson). 

ment — all  of  the  other  papules  preserving  their  usual  characteristics 
throughout. 

I  have  known  it  to  be  mistaken  for  the  miliary  papular  syphiloderm, 
but  in  this  latter  the  lesions  are  usually  rounded  or  conic,  and,  while 
tending  to  aggregate,  do  not  form  solid  areas,  are  of  a  somewhat  different 
color,  and  almost  invariable  show  some  scattered  miliary  pustules,  and 
often  a  few  larger  pustules;  moreover,  it  being  an  eruption  of  the  active 
stage  of  syphilis,  there  are  corroborative  signs  of  that  disease  to  be 
found. 


LICHEN  PLANUS  221 

From  pityriasis  rubra  pilaris  the  following  differences  are  usually 
given:  the  lesions  of  pityriasis  rubra  pilaris  are  round  or  conic,  not  shining 
or  glistening,  not  irregular  in  outline;  are  rarely  umbilicated ;  show 
a  scaly  film  on  the  summit;  are  red,  and  never  violaceous,  in  color; 
and  while  the  eruption  is  limited  at  first,  it  tends  to  general  involve- 
ment. According  to  Hebra's  own  description,  however,  there  would 
seem  at  times  a  clinical  resemblance  in  some  of  the  papules  of  the  two 
affections.  Those  of  pityriasis  rubra  pilaris  are,  however,  seated  about 
the  hair-follicles. 

Prognosis. — Its  natural  course  is  persistent  and  often  progressive, 
and  shows  little  tendency  to  spontaneous  recovery.  With  treatment 
it  can  be  cured,  sometimes  in  a  few  months,  but  oftener  a  much  longer 
time  is  required.  There  is  in  some  cases  a  disposition  to  one  or  more 
recurrences.  The  pigmentation  finally  disappears,  but  sometimes 
months  elapse  before  it  is  entirely  gone;  occasionally  on  the  legs  the 
discoloration  is  permanent. 

Treatment. — The  patient  is  to  have  the  benefit  of  good  plain 
food,  hygienic  living,  and,  when  possible,  outdoor  life  and  freedom 
from  mental  worry  or  care.  The  various  tonics  and  cod-liver  oil  may 
be  prescribed  when  indicated.  The  main  remedies  in  this  disease, 
however,  are  arsenic,  mercury,  quinin,  and  strychnin.  Arsenic  in  many 
cases  has  a  direct  specific  influence,  given  in  increasing  doses  to  the 
point  of  tolerance,  and  continued  for  some  time;  mercury  is  also  valuable 
and  seems  to  have  a  direct  action  in  some  instances.  These  two  drugs, 
and  especially  the  former,  are,  if  no  centra-indications  exist,  to  be,  as  a 
rule,  always  prescribed,  and,  along  with  other  indicated  remedies,  usually 
lead  to  recovery.  The  former  is  given  in  the  beginning  dosage,  three 
times  daily,  of  2\  or  3  minims  (0.165  or  °-2)  °f  Fowler's  solution  or  sodium 
arsenate  solution,  or  the  equivalent  of  arsenious  acid,  and  gradually  in- 
creased to  5,  6  (0.33,  0.4),  or  more;  larger  doses  than  10  minims  (0.65) 
are  rarely  required,  and  if  no  benefit  is  obtained  with  this  amount,  it  is  not 
likely  to  ensue  from  a  greater  quantity.  Mercury  can  be  given  in  the 
form  of  the  corrosive  chlorid  (Norman  Walker),  or  the  biniodid  in  the 
dose  of  -g1^  to  YY  grain  (0.002  to  0.0055),  or  as  the  protiodid  in  dosage  of  £ 
to  \  grain  (0.008  to  0.033).  Quinin  is  also  valuable,  and  should  be  given 
in  fairly  full  doses — 9  to  15  grains  (0.6  to  i.)  daily.  Hartzell  has  had 
favorable  action  in  some  instances  from  sodium  salicylate.1  Strych- 
nin is  an  excellent  tonic  in  these  cases.  Constitutional  treatment2 
should,  as  a  rule,  be  continued,  in  somewhat  lessened  dosage,  one  or  two 
months  after  the  eruption  has  disappeared. 

External  treatment  is  of  great  importance,  both  for  influencing 
the  eruption  and  for  allaying  the  itching  usually  present,  and  in  the 
limited  form  of  the  disease  often  alone  suffices  to  bring  about  a  cure. 

1  Hartzell,  "The  Salicylates  in  the  Treatment  of  Lichen  Planus,"  Jour.  Amer.  Med. 
Assoc.,  1907,  vol.  xlix,  p.  225  (with  a  report  of  some  unusual  forms). 

2Hutchins,  Jour.  Cutan.  Dis.,  1912,  p.  615,  describes  an  interesting  case  of  dif- 
fused lichen  planus  (in  a  male,  six  years  of  age),  followed  by  vesicobullous  infected 
lesions,  some  of  the  vesicles  and  bullae  where  lichen  planus  lesions  had  not  been;  cured 
by  an  autogenous  vaccine  made  from  culture  of  the  staphylococcus  obtained  from  a 
vesicle. 


222  INFLAMMATIONS 

In  cases  of  any  considerable  extent  alkaline  baths  every  other  day,  or 
in  irritable  cases,  bran,  gelatin,  or  starch  baths  daily,  are  of  service,  to 
be  followed  on  the  patches  with  ointment  applications  or  with  lotions. 
The  most  efficient  application  in  the  general  run  of  cases  is  liquor  car- 
bonis  detergens;  this  is  to  be  applied  at  first  diluted  with  10  to  15  parts 
water,  but  if  no  irritation  is  produced,  it  may  gradually  be  strengthened, 
and  in  some  cases  can  be  used  pure.  It  is  to  be  dabbed  on  thoroughly 
twice  daily,  and  oftener  if  the  itching  demands  it.  It  the  skin  becomes 
unpleasantly  dry  or  harsh,  its  application  can  occasionally  be  followed 
with  cold  cream;  or  it  may  be  prescribed  in  ointment  form,  i  or  2  drams 
(4.  to  8.)  to  an  ounce  (32.)  of  simple  cerate  or  a  mixture  of  simple  cerate 
and  cold  cream.  The  vegetable  tars,  expecially  the  oil  of  cade  and  oil  of 
birch  (oleum  rusci),  are  also  excellent  in  chronic  cases,  but  are  stronger 
than  liquor  carbonis  detergens,  and  have  a  more  marked  and  persistent 
odor;  they  are  best  applied  in  ointment  form,  i  to  2  drams  (4.  to  8.)  to  the 
ounce  (32.).  In  acute  inflammatory  and  irritable  cases  the  calamin-zinc- 
oxid  lotion  and  the  plain  or  carbolized  boric  acid  lotion  act  satisfactorily, 
stronger  applications — liquor  carbonis  detergens — being  resorted  to 
later.  This  calamin-and-zinc-oxid  lotion  and  the  other  mild  lotions  used 
in  eczema  can  also  be  advised  for  the  disease  occurring  in  infants  and 
children.  For  thick,  hardened,  or  verrucous  areas,  a  10  to  20  per  cent, 
salicylic  acid  rubber  plaster  or  plaster-mull  can  be  used  until  the  thick- 
ness is  reduced ;  or  paintings  with  varying  strength  of  caustic  potash  solu- 
tions, beginning  with  the  liquor  potassae,  can  be  used  cautiously,  washing 
off  immediately  afterward,  and  supplementing  with  a  mild  ointment,  such 
as  zinc-oxid  or  diachylon  ointment.  In  obstinate  patches  of  this  charac- 
ter stimulation  or  slight  superficial  cauterizing  action  with  carbon-dioxid 
snow  (q.  D.)  can  be  cautiously  tried. 

When  the  lesions  are  close  together  and  patchy,  as  on  the  fore- 
arms, the  galvanic  current,  of  4  to  10  milliamperes  in  strength,  applied 
three  or  four  times  weekly,  has  had  in  some  of  my  cases  a  material 
influence;  the  application  should  be  rapidly  labile,  except  over  thick- 
ened areas,  where  the  electrodes  can  be  held  stationary  for  one  or  two 
minutes.  In  these  cases,  too,  the  static  current  applied  with  the  roller 
electrode  and  the  high-frequency  current  applied  with  the  flat  vacuum 
electrode  are  also  sometimes  of  service. 

A  Chronic  Itching  Lichenoid  Eruption  of  the  Axillary  and  Pubic 
Regions. — Brocq,  Fox,  Fordyce,  Haase,1  and  others  have  reported 
cases,  few  in  number,  characterized  by  a  more  or  less  limited  and 
localized  patch  formation  usually  in  the  axillary  and  pubic  regions, 
made  up  of  closely  set,  more  or  less  coalescent,  somewhat  firm  or  hard 
pin-head  to  pea-sized  papules,  seemingly  seated  on,  and  an  intimate 

1  G.  H.  Fox,  "Two  Cases  of  a  Rare  Papular  Disease  Affecting  the  Axillary  Regions," 
with  histopathologic  report  by  Fordyce,  Jour.  Cutan.  Dis.,  1002,  p.  i  (with  histologic 
cuts);  Fordyce,  "A  Chronic  Itching,  Papular  Eruption  of  the  Axillae  and  Pubes;  Its 
Relation  to  Neurodermatitis,"  Trans.  Amer.  Derm.  Assoc.,for  1908,  p.  118  (with  case 
and  histologic  cuts);  Haase,  "A  Chronic,  Itching  Papular  Eruption  of  the  Axillae, 
Pubes,  and  Breast,"  Jour.  Amer.  Med.  Assoc.,  Jan.  21,  1911  (with  case  and  histologic 
cuts). 


LICHEN  PLANUS 


223 


part  of,  a  locally  infiltrated  thickened  skin.  Some  of  the  lesions  show 
a  slight  central  depression,  some  are  .flattened,  some  rounded,  and 
most  of  them  showing  a  central  grayish  plug.  The  lines  of  the  skin 
of  the  involved  area  are  accentuated,  and  when. the  skin  is  put  on 
the  stretch  markedly  so.  The  lesions  and  patch  are  of  normal  skin 
color  or  dirty  gray,  sometimes  with  a  dull  violet  or  pinkish  tinge. 
The  process  is,  as  a  rule,  insidious  in  its  appearance  and  is  an  ex- 
tremely sluggish  one,  very  slow  in  progress  and  after  a  time  usually 
remaining  stationary.  The  itching  is  often  a  prominent  symptom,  occa- 
sionally at  times  almost  intolerable,  and  some  of  the  papules  are  generally 
noted  to  be  excoriated.  The  itching  is  often  the  first  symptom  observed, 
leading  to  rubbing  and  scratching,  and  being  sooner  or  later  followed  by 
the  papulation  and  thickening.  The  hairy  parts  of  the  axillary  and  pubic 
regions  are  favorite  sites — less  frequently  about  the  nipples  also.  The 
hairs  of  the  affected  part,  after  the  appearance  of  the  lesions,  usually 
become  brittle  and  lusterless,  and  to  an  extent,  or  even  completely, 
break  offor  fall  out.  The  malady  is  persistent  and  rebellious  to  treatment. 
The  clinical  picture  is  suggestive  of  the  combined  symptomatology  of  a 
pityriasis  rubra  pilaris,  lichen  planus,  and  a  papular  sclerous  eczema.  It 
represents  a  condition  or  class  of  cases  called  "lichenification"  by  the 
French;  and  Fordyce  and  Haase  believe  it  should  be  placed  under  Brocq's 
group  of  "chronic  circumscribed  neurodermatitis  (nevrodermite  chronique 
circonscrite) ."  Most  observers  have  doubtless  placed  these  rather  rare 
cases  as  variant  examples  of  lichen  planus  or  eczema.  Histologically 
there  were  found  acanthosis  and  some  parakeratosis,  with  hypertrophied 
papillae,  edematous  at  their  tips;  lymphocytic  infiltration  about  the  ves- 
sels and  pilosebaceous  apparatus,  with,  in  some  instances,  involvement  of 
the  sweat-gland  apparatus  also. 

I4chen  nitidus  is  a  rare  eruption,  first  described  by  Pinkus 
(1901),  and  since  by  this  same  writer  (9  cases  in  all),  Lewandowsky 
(2  cases),  Arndt  (12  cases),1  Kyrle  and  McDonagh  (i  case),2  and  Sutton.3 
The  lesions  are  small,  usually  flat,  sharply  margined  papules,  roughly 
circular  or  polygonal  in  shape,  scarcely  raised  above  the  level  of  the 
skin,  of  skin  color,  pale  red,  or  yellowish  brown.  They  are  almost 
uniformly  of  the  same  size,  and  often  a  minute  aperture  can  be  detected 
in  the  center  of  the  papule.  The  lesions  are  usually  disseminated, 
never  coalesce  or  show  any  disposition  to  form  groups,  although  some- 
times they  may  tend  to  pack  together  closely.  They  are  persistent 
and  without  change;  after  years  they  may  spontaneously  disappear, 
leaving  no  trace.  The  favorite  regions  are:  the  genital  organs  (its  most 
typical  site),  abdomen,  especially  about  the  umbilicus,  the  flexures  of 

1  Arndt,  Dermatolog.  Zeitschr.,  1909,  vol.  xvi,  H.  9  and  10  (clinical,  histologic,  with 
review);  good  abstract  in  Brit.  Jour.  Derm.,  Jan.,  1910. 

2  Kyrle  and  McDonagh,  Brit.  Jour.  Derm.,  1909,  p.  339  (case,  a  girl  aged  eighteen; 
eruption  more  or  less  generalized;  histologic  plate;  and  resum6  of  Pinkus'  cases). 

3  Sutton,  Jour.  Cutan.  Dis.,  1910,  p.  597,  case,  male,  aged  thirty-five;  eruption  on 
anterior  fold  of  both  axilla,  in  groin,  around  the  umbilicus,  upper  anterior  surface  o 
each  forearm,  flexor  surfaces  of   the  wrists,  and  dorsal  aspect  of   both  thumbs;  e) 
perimental  inoculations  (two  guinea-pigs)  negative;  histologic  and  case  illustratic 
with  review  and  references. 


224  INFLAMMATIONS 

the  elbows,  and  the  palms.  There  are  no  subjective  symptoms,  and  this 
and  the  fact  that  the  eruption  is  insignificant,  usually  on  covered  parts, 
and  often  scarcely  noticeable  except  upon  close  examination,  probably 
explain  why  so  far  all  the  cases  have  only  come  accidentally  under  obser- 
vation; with  one  exception  they  were  all  male  subjects.  Nothing  is 
known  as  to  its  etiology  and  pathogenesis,  although  Kyrle  and  McDonagh 
believe  it  is  probably  brought  about  by  a  tuberculous  toxin.  Histolog- 
ically,  a  lesion  has  a  structure  resembling  tubercle. 

The  papules  have  some  resemblance  to  those  of  lichen  planus,  and 
also  a  variable  suggestiveness  of  small  multiple  flat  warts,  the  flat  form 
of  lichen  scrofulosum,  and  lichenoid  syphiloderm.  The  malady  does 
not  seem  to  be  materially  influenced  by  treatment. 

THE  CHRONIC  RESISTANT  MACULAR,  AND  MACULO- 
PAPULAR  SCALY  ERYTHRODERMIAS 

The  various  cases  considered  under  this  head  seem  sufficiently  dis- 
tinctive to  separate  them  from  the  various  dermatoses  to  which  they 
bear  resemblance.  They  have  all  much  in  common  and,  according 
as  the  one  or  other  feature  is  the  more  pronounced,  are,  in  some  of  their 
clinical  aspects,  suggestive  of  seborrheic  eczema,  sometimes  of  seborrheic 
eczema  of  a  moderately  to  markedly  psoriatic  type,  of  pityriasis  rosea,  of 
the  early  prodromal  erythematosquamous  eruption  of  granuloma  fun- 
goides,  and  the  disappearing  and  almost  disappeared  plaques  of  lichen 
planus.  They  have  been  grouped  by  Brocq  under  the  head  of  para- 
psoriasis;  by  Crocker,  under  lichen  variegatus;  by  Jadassohn,  under 
psoriasiform  and  lichenoid  exanthem,  and  dermatoses  psoriasiformes ; 
and  by  Colcott  Fox  and  Macleod,  under  resistant  maculopapular  scaly 
erythrodermias.  Of  the  4  or  5  cases  that  I  have  met  with  in  the 
past  several  years,  a  few  were  closely  simulative,  clinically,  of  a  mild 
seborrheic  eczema,  with  some  features  of  a  pityriasis  rosea,  and  a  few, 
in  their  general  aspects,  represented,  clinically,  a  medley  of  a  mild  sebor- 
rheic eczema  and  a  disappearing  lichen  planus,  the  whole  having  a  varie- 
gated or  marbled  appearance. 

The  first  cases  of  importance  were  reported  under  the  name  para- 
keratosis  variegata,  by  Unna,1  in  collaboration  with  Santi  and  Pollitzer. 
They  were  characterized  by  a  more  or  less  generalized  red  exanthem,  but 
sparing  the  head,  palms,  and  soles,  leaving  in  some  regions — trunk  and 
thighs — small  irregular  sunken  patches  of  normal  skin  free,  giving  the 
eruption  a  reticulated  or  mottled  appearance.  Over  the  reddened  por- 
tion there  was  a  fine  lamellar  desquamation.  The  color  was  deeper 
on  the  lower  portion  of  the  body,  but  not  uniform,  even  for  the  same 
region,  varying  from  a  yellowish  red  to  a  bluish  red.  The  affected  patches 
were  slightly  raised  from  the  surface,  their  borders  sharp,  their  cuticular 
areas  slightly  marked,  and  their  surface  beneath  the  desquamating  scales 
bright  and  waxy.  The  larger  patches  appeared  to  the  touch  decidedly 
infiltrated,  like  an  erythema  papulatum,  the  smaller  patches  resembling 

1  Unna,  Santi,  and  Pollitzer,  Monatshefte,  1890,  vol.  x,  p.  404;  abstract  in  Brit. 
Jour.  Derm.,  1890,  p.  217. 


SCAL  Y  ER  YTHRODERMIAS 


22$ 


recent  lichen  planus  papules.  There  were  no  subjective  symptoms.  The 
affection  had  lasted  in  both  cases  for  several  years  or  longer.  One  of 
the  cases  had  been  sent  to  Hamburg  by  Besnier,  who  had  at  first  regarded 
the  disease  as  an  unusual  form  of  lichen  planus  universalis,  but  con- 
cluded, after  a  time,  that  the  affection  was  one  sui  generis.  The  histo- 
logic  examination  showed  in  both  cases  the  changes  to  be  limited  to  the 
papillary  layer  and  the  epidermis. 

In  both  cases  the  malady  proved  resistant  to  the  most  energetic 
chrysarobin  treatment,  and  yielded  only  to  a  vigorous  course  of  applica- 
tions of  pyrogallol,  during  which  treatment  the  poisonous  effects  of  this 
drug  from  absorption  were  prevented  by  the  exhibition  internally  of  large 
doses  of  dilute  hydrochloric  acid. 

Under  the  name  erythrodermie  pityriasique  en  plaques  disseminees 
Brocq1  recorded  a  case  of  a  superficial  patchy,  slightly  scaly  eruption, 


Fig.  44. — Parakeratosis  variegata. 

which  he  was  inclined  to  believe  had  some  features  in  common  with 
parakeratosis  variegata,  just  referred  to,  a  conclusion  with  which  J.  C. 
White2  does  not  agree,  a  material  and  essential  difference  being  the 

1  Brocq,  Journal  des  praticiens,  1897,  p.  577;  and  "Parapsoriasis,"  Jour.  Cutan.  Dis., 
1903,  p.  315  (with  review  and  references). 

2J.  C.  White,  Jour.  Cutan.  Dis.,  1900,  p.  536  (with  histologic  examination  by 
C.  J.  White);  Colcott  Fox  and  Macleod  in  a  recent  valuable  and  exhaustive  clinical 
and  histologic  contribution,  "On  a  Case  of  Parakeratosis  Variegata,"  Jour.  Cutan.  Dis., 
1901,  p.  424,  and  Brit.  Jour.  Derm.,  1901,  p.  319,  go  over  the  entire  literature  of  cases 
which  seem  to  present  similar  or  allied  conditions:  M6neau,  Jour.  mal.  cutan..  May, 
1902  (parakeratosis  variegata;  man  aged  twenty-one;  had  existed  since  aged  ten;; 
Graham  Little,  Brit.  Jour.  Derm.,  1902,  p.  218  (erythrodermie  pitynasique,  a 
demonstration;  girl  aged  ten);  C.  J.  White,  Jour.  Cutan.  Dis.,  1903,  p.  153  (r  case' 
with  histologic  illustration);  Anthony,  Jour.  Cutan.  Dis.,  1906,  p.  455  C1  ca;Le>  c'imcal 
and  histologic,  with  brief  review  and  bibliography);  Torok  in  Mracek  s  Handbuch; 
Riecke,  Archiv,  1907,  vol.  Ixxxiii,  pp.  51,  205,  and  411  (3  cases,  lichenoid,  with  analytic 
15 


226  INFLAMMATIONS 

entire  absence  of  any  papular  tendency.  The  eruption  is  characterized 
by  scattered,  variously  sized,  scarcely  elevated  plaques,  which  are 
fairly  well  or  quite  sharply  defined;  are  of  a  brownish,  pale-rosy,  or 
pale-red  color,  and  with  a  surface  very  slightly  scaly,  the  scaliness 
varying  considerably,  being  extremely  slight  in  White's  first  case, 
somewhat  more  pronounced  in  his  second  and  third  cases,  as  well  as 
in  Brocq's  patient,  but  never  excessive  or  conspicuous.  The  brownish 
tint  is  sometimes  the  predominant  shade,  although  in  Brocq's  patient 
a  tawny  hue  was  more  noticeable ;  for  the  most  part,  however,  the  color 
is  pale  red  or  rosy.  There  is  often  an  ill-defined,  marbled,  and  reticu- 
lated appearance  of  the  eruption.  The  eruption  is  more  or  less  general, 
the  trunk  especially  being  favored,  and  sometimes  the  patches  coalesce 
in  places.  It  is  at  its  worst  in  winter,  and  partly  or  wholly  disappears  in 
mild  weather.  The  eruption,  as  a  rule,  gives  rise  to  no  troublesome  sub- 
jective symptoms;  occasionally  there  is  slight  itchiness.  The  integu- 
ment is  rather  dry,  the  perspiratory  function  seeming  to  be  lessened.1 
Of  the  cases  reported,  one  was  in  a  child  aged  nine,  the  others  were  adults, 
Brocq's  case  being  advanced  in  years.  In  another  instance  in  a  case 
recently  reported  by  Ravogli,2  which,  he  considers,  possesses  features 
which  place  it  with  the  cases  just  referred  to,  the  patient  was  aged  three, 
and  the  eruption  almost  universal,  but  still  showing  the  coalescence 
from  rounded  patches  of  considerable  size.  This  patient  had  had  two 
previous  attacks. 

Brocq,  in  a  later  paper,  divides  the  cases — under  the  name  of  para- 
psoriasis — into  three  groups:  (i)  Parapsoriasis  guttata  (bearing  close 
relationship  or  resemblance  to  psoriasis);  (2)  parapsoriasis  lichenoides 
(intermediate  in  relationship  or  resemblance  between  lichen  and  psoriasis) ; 
(3)  parapsoriasis  in  patches  (closely  allied  and  showing  resemblance  to 
seborrhoea  psoriasiformis  (dermatitis  seborrhoica) ,  the  erythrodermies 
pityriasiques  en  plaques  disseminees).  These  cases  are  characterized 
by  (i)  an  almost  complete  absence  of  pruritus;  (2)  a  very  slow  evolution; 
(3)  a  distribution  in  circumscribed,  sharply  defined  patches,  whose  dimen- 
sions are  from  2  to  6  cm.  in  diameter,  which  are  scattered  here  and  there 
over  the  integument;  (4)  an  almost  complete  absence  of  infiltration  of  the 
derma;  (5)  a  pale  redness  (pinkish  colored);  (6)  a  fine  pityriasic  desqua- 
mation;  (7)  an  extraordinary  resistance  to  the  local  applications  usually 

review  of  reported  cases);  Trimble,  "The  Chronic  Scaly  Erythrodermias"  (3  cases, 
with  cuts  and  brief  review  and  references),  Jour.  Amer.  Med.  Assoc.,  1909,  vol.  liii,  p. 
264;  Corlett  and  Schultz,  Jour.  Culan.  Dis.,  1909,  p.  49  (3  cases  with  review,  references, 
and  histologic  plates);  Morris  and  Dore,  Brit.  Jour.  Derm.,  1910,  p.  249,  i  case, 
lichenoid  type  (parakeratosis  variegata),  in  man  aged  fifty,  of  six  to  eight  years'  dura- 
tion; good  illustration;  Arndt  (Lesser's  Clinic),  Archiv,  Bd.  c,  Heft  1-3  (8  cases, 
with  review,  histologic  cuts,  and  bibliography);  Hodara,  Dermatolog.  Wochenschr., 
July  6  and  13,  1912,  vol.  Iv,  pp.  848  and  877,  a  case  of  parakeratosis  variegata  (Unna's 
type);  review,  bibliography,  and  histologic  cut;  Wilfred  Fox,  Brit.  Jour.  Derm.,  1912, 
p.  21 — case  demonstration;  patient,  woman  aged  forty-nine;  pityriasis  lichenoides 
chronica  or  lichen  variegatus  type;  began  on  face,  and  now  (five  years  later)  has  ex- 
tended downward  to  middle  of  trunk,  with  patches  on  buttocks  and  thighs;  past  year 
few  isolated  bullae  have  been  appearing,  particularly  on  the  neck  and  shoulders. 

1  In  Trimble's  3  cases  there  was  a  very  noticeable  and  rather  excessive  sweating  on 
the  face,  which,  as  is  usually  the  fact,  was  not  involved  in  the  disease. 

2  Ravogli,  Jour.  Amer.  Med.  Assoc.,  July  13,  1901  (with  histologic  examination  by 
Heidingsfeld). 


LICHEN  SCROFULOSUS 


227 


employed  in  the  treatment  of  psoriasiform  or  pityriasic  seborrhea;  in 
fact,  only  yielding  slowly  and  imperfectly  to  the  most  energetic  appli- 
cations of  pyrogallol. 

The  -pathologic  histology  has  been  studied  by  Brocq,  Colcott  Fox 
and  Macleod,  C.  J.  White,  and  others.  C.  J.  White  found,  both  in 
J.  C.  White's  case  and  his  own,  the  following:  (i)  Open  network  forma- 
tion of  the  stratum  corneum,  composed  of  non-nucleated  horny  cells; 
(2)  absence  of  the  stratum  lucidum;  (3)  great  atrophy,  or  even  total 
absence,  of  the  stratum  granulosum;  (4)  in  places,  compression  of  the 
rete  cells  and  reduction  of  the  layers  composing  the  stratum  spinosum; 
absence  of  the  palisade  layer;  and,  finally,  greatest  divergence  from  the 
normal  directly  over  the  parts  of  the  corium  mostly  affected;  (5)  edema- 
tous  condition  of  the  corium;  and  (6)  reduction  in  the  amount  of  elastin. 
Macleod's  study1  of  the  Colcott  Fox-Macleod  case  and  of  Perry's  case 
(about  the  same  type  as  the  White  cases)  showed:  Dilatation  of  the 
subepidermal  capillaries;  a  flattening  and  edema  of  the  papillary  body;  an 
attenuation  of  the  fibrous  element;  an  infiltration  of  small  cells,  consisting 
of  small  connective-tissue  cells,  mast-cells,  and  leukocytes;  a  thinning  of 
the  epidermis ;  an  edema  and  dilatation  of  the  nuclear  spaces ;  a  deficiency 
in  the  transitional  layers,  and  an  imperfect  stratum  corneum.  Corlett 
and  Schultz's  findings  are  in  a  measure  similar,  but  they  indicate  also, 
as  partly  foreshadowed  by  C.  J.  White,  that  there  is  primarily  a  basic 
vascular  involvement  to  which  the  other  cutaneous  changes  are  due, 
beginning  as  an  endothelial  hypertrophy  and  hyperplasia,  with  con- 
secutive perivascular  infiltration  and  proliferation,  leading  to  narrow- 
ing and  complete  obliteration  of  the  lumina  of  the  veins;  the  arterioles 
may  show  endothelial  swelling,  but  this  occurring  only  after  the  peri- 
phlebitis  is  well  marked. 

The  treatment  of  these  cases,  as  already  referred  to,  is  not  very  satis- 
factory. Engman2  and  Mook  report  improvement  with  the  administra- 
tion of  mercuric  chlorid,  believing  its  favorable  effect  due  to  its  action 
on  the  thickening  of  the  vessels.  The  local  remedies  most  efficacious 
seem  to  be  those  commonly  employed  in  psoriasis,  especially  pyrogallol. 

LICHEN  SCROFULOSUS3 

Synonym. — Lichen  scrofulosorum. 

Definition. — A  chronic,  mildly  inflammatory  disease,  usually 
occurring  in  scrofulous  subjects,  characterized  by  millet-seed-sized, 
rounded  or  flattened,  reddish  or  yellowish,  more  or  less  grouped,  slightly 
desquamating  papules. 

In  recent  years  many  contributions  having  in  view  the  grouping 

1  Macleod,  Brit.  Jour.  Derm.,  1902,  p.  220;    Civatte  (of  Brocq's  service)  ("note 
pour  servir  a  1'etude  des  tuberculides  papulo-squameuses;  trois  cas  de  tuberculides  a 
forme  de  parapsoriasis,"  Annales,  1906,  p.  209),  from  his  investigations  and  review,  be- 
lieves that  parapsoriasis  might  be  an  atypical  tuberculosis  of  the  skin. 

2  Engman,  "Discussion,"  Jour.  Cutan.  Dis.,  1911,  p.  559- 

3M6neau,  "Du  lichen  scrofulosorum,"  Jour.  mal.  cutan.,  1899,  p.  6,  gives  ai 
admirable  account  and  review  of  this  subject,  with  bibliography.     See  also  papers  and 
discussion  on  the  same,  Trans.  Internal.  Derm.  Congress,  London,  1896,  and  those 
referred  to  in  the  course  of  the  text. 


228  INFLAMMATIONS 

together  of  several  cutaneous  diseases  which  are  more  or  less  peculiar 
to  scrofulous  individuals  have  been  made  by  Hallopeau  (toxi-tuber- 
culides),  Darier,  Hyde,  Boeck  (erythemes  tuberculeux) ,  and  Johns- 
ton1 (cutaneous  paratuberculoses) ,  and  others,  diseases  of  which  the 
lesions,  while  not  due  directly  to  the  presence  of  tubercle  bacilli,  are 
attributed  to  their  toxins,  the  organisms  having  their  seat  in  some 
other  part  of  the  body,  either  close  to  the  skin  or  in  the  deeper  organs. 
The  various  maladies  thus  included  are  lichen  scrofulosus,  lupus  erythem- 
atosus,  erythema  induratum,  acne  varioliformis  (acne  necrotica),  hidra- 
denitis  suppurativa,  and  a  few  other  affections.  That  these  affections 
are  commonly  seen  in  the  tuberculous  or  those  of  tuberculous  history 
cannot  be  doubted,  and  that,  moreover,  some  present  suggestive  his- 
tologic  features.  That  the  explanation  advanced  (tubercle  toxins)  is 
the  correct  one,  requires,  I  believe,  greater  substantial  evidence,  however, 
before  it  can  be  accepted  unreservedly.  For  this  reason  I  have  preferred, 
for  the  present,  to  consider  these  affections  separately,  and  in  their  cus- 
tomary places,  and  not  under  a  general  class  heading.  It  is  true  that 
accumulating  facts  are  almost  conclusive  as  to  the  tuberculous  relation- 
ship of  lichen  scrofulosus,  but  with  the  other  affections  named,  the 
evidence  is  as  yet  too  scanty  to  warrant  a  definite  decision. 

Symptoms. — This  malady  is,  as  a  rule,  free  from  subjective  symp- 
toms and  insidious  in  its  development,  so  that  it  is  generally  not  noted 
until  well-defined  patches  have  formed.  The  lesions  are  small,  at  first 
scarcely  more  than  a  pin-point  in  size,  but  which  later  usually  attain 
that  of  a  pinhead.  They  almost  always  arise  close  together,  in  irregular 
bunches  or  groups,  rounded  or  segmentel  in  configuration ;  at  first  bright 
or  dull  red,  they  later  assume  a  livid  or  brownish  tone,  and  often  become 
fawn-colored  or  yellowish,  which  in  some  instances  closely  approaches 
the  tint  of  the  normal  skin.  Not  infrequently  new  lesions  arise  in  the 
interspaces  of  the  older  papules,  and  between  the  patches  or  groups,  so 
that  in  some  cases  considerable  surface  is  covered,  and  if  the  lesions  are 
yellowish  or  near  the  skin  hue,  the  eruption  presents  some  resemblance 
to  goose-flesh  (cutis  anserina).  As  a  rule,  however,  the  malady  is  usually 
represented  by  but  a  limited  number  of  patches  or  areas.  The  lesions 
become  capped  by  minute  scales,  and  although  they  may  be  close  together, 
never  actually  coalesce.  The  older,  usually  central,  papules  of  the 
patch  often  undergo  involution,  flatten  down,  and  thus  results  the 
crescentic  or  segmental  outline  often  observed ;  minute  yellow  stains  mark 
the  site  of  lesions  which  have  disappeared.  The  eruption  is  commonly 
limited  to  the  trunk,  especially  the  lower  two-thirds,  and  more  frequently 
toward  the  lateral  aspects.  Less  frequently  it  may  also  be  found  upon 
the  arms  and  legs,  and  in  the  latter  situation  occasionally  slight  hem- 
orrhagic  extravasation  may  be  noted  in  the  lesions,  giving  them  a  livid 
aspect — lichen  lividus.  Exceptionally  some  of  the  papules  are  of  a 
larger  size,  and  may  contain  centrally  a  yellowish  sebaceous  plug,  and 

1  J.  C.  Johnston,  "The  Cutaneous  Paratuberculoses,"  Phila.  Monthly  Med.  Jour., 
February,  1899,  p.  78  (an  extremely  valuable  exposition,  with  resume  and  bibliography); 
Riecke,  article  "Lichen  Scrophulosorum,"  in  Mr&cek's  Handbuch  der  Hautkrankheiten. 
vol.  iv,  p.  521  (also  gives  a  complete  exposition  with  bibliography). 


LICHEN  SCROFULOSUS 


229 


sometimes  several  or  more  are  distinctly  pustular  and  acne-like.  In 
rare  instances  this  latter  feature  is  quite  pronounced.  In  occasional 
cases,  more  especially  in  the  older  patients,  there  is  noted  an  associated 
small  nodular  eczematoid  eruption  about  the  scrotum,  sometimes  a  veri- 
table eczema. 

The  course  of  the  malady  is  exceedingly  chronic,  often  lasting  -for 
years,  new  lesions  and  patches  arising  from  time  to  time,  and  some 
gradually  disappearing;  in  other  instances  the  eruption,  after  a  variable 
time,  fading  away,  and  later  recurring.  While  the  minute  yellow  stains 
usually  left  by  the  papules  remain  for  a  shorter  or  longer  time,  eventually 
there  is  not  observable  a  trace  of  the  previous  eruption ;  very  exception- 
ally, however,  minute  atrophic  scars,  but  rarely  more  than  few  in  num- 
ber, are  observed.  Evidences  of  scrofula  are  usually  found  associated 
with  the  eruption. 

Etiology. — The  disease  is  extremely  rare  in  this  country,1  less  so 
in  France,  not  uncommon  in  England,2  and  most  frequent  throughout 
Germany,  especially  Austria.  The  malady  is  one  of  childhood  and 
adolescence,  rarely  observed  under  two  or  three  years,  and  seldom  above 
twenty  or  twenty-five.  Sex  does  not  seem  to  exert  much  influence, 
although  it  is  somewhat  more  common  in  males,  markedly  so  in  Germany. 
It  is  a  disease  of  the  scrofulous,  and  the  positive  evidence  at  hand, 
though  scant  compared  to  the  negative,  gives  it  a  place,  I  believe,  among 
the  tuberculoses  of  the  skin,  although  with  one  or  two,  but  not  abso- 
lutely conclusive,  exceptions  (Jacobi,  Wolff)3  bacilli  have  not  been 
found  in  the  lesions  (Riehl,  Darier,  Lukasiewicz,  Jadassohn,  and  others). 
Animal  inoculations  have  failed  (Leredde,  Jadassohn,  Hallopeau,  Lafitte, 
and  others)  in  almost  all  trials,  although  in  a  few  instances  they  have  been 
followed  by  tuberculosis  (Pellizari,  Jacobi).  In  14  cases  out  of  16  in 
which  Jadassohn  injected  tuberculin  there  was  the  characteristic  reac- 
tion. Schweninger  and  Buzzi  saw,  apparently  as  a  result  of  tuberculin 
injections  in  a  tuberculous  subject,  lichen  scrofulosus  develop;  and 
recently  Nobl4  records  5  cases,  clinically  typical,  which  were  in  reality 
examples  of  reaction  of  the  skin  after  inunction  of  a  tuberculin  ointment. 

1  Bronson,  Archives  of  Derm.,  1875,  p.  137  (case  demonstration);  Shepherd,  Canada 
Med.  and  Surg.  Jour.,  1880-81,  vol.  ix,  p.  283  (a  case);  Gottheil,  Jour.  Cutan.  Dis., 
1886,  p.  133  (with  cut  and  some  literature  references);  Currier,  Jour.  Cutan.  Dis.,  1892, 
p.  403  (case  demonstration — doubtful);  Hyde,  ibid.,  1897,  p.  453  (a  case);  Gilchrist, 
Johns  Hopkins  Hosp.  Bull.,  1899,  p.  84  (negro  child).     Professor  Duhring  (Diseases  of 
Skin,  third  edit.,  1882)  states  that  he  has  not  met  with  a  case  in  this  country.     My  ex- 
perience, including  services  at  two  institutions  at  which  children  form  a  large  propor- 
tion of  the  patients,  is  the  same — not  a  single  case  has  come  under  my  observation.^ 

2  In  England  cases  have  been  observed  by  Tilbury  Fox  (Trans.  London  Clin.  Soc'y, 
1879,  p.  190  (6  cases,  with  colored  plate);  Crocker,  ibid.,  p.  195,  and  Diseases  of  Skin, 
second  edit.  (15  cases);   and  Brit.  Jour.  Derm.,  1899,  p.  38  (case  demonstration); 
Pringle,  Brit.  Jour.  Derm.,  1894,  p.  218  (case  demonstration);  Perry,  ibid.,  1895,  p.  156 
(case  demonstration);  Colcott  Fox,  ibid.,  p.  153  (case  demonstration);  Little,  ibid., 
1900,  p.  167  (case  demonstration);  and  others. 

.  3  Jacobi,  Verhandl.  der  deutsch.  dermatolog.  Gesellschaft,  III.  Congress,  1891,  p.  69 
(with  histologic  plate);  Wolff,  ibid.,  VI.  Congress,  1899;  Haushalter,  Annales,  1898, 
p.  455,  found  bacilli  in  lesions  of  2  cases  described  by  him,  but  in  these  cases  the  lesions 
were  quite  large,  discrete,  disseminated,  and  also  upon  the  face,  and  represent  more 
closely  cases  of  disseminated  tuberculosis  of  the  skin. 

4  Nobl,  "Zur    Pathogenese  des  Lichen  Scrophulosorum,"   Dermatolog.  Zeitschr., 
1909,  vol.  xvi,  p.  205  (with  some  references). 


230  INFLAMMA  TIONS 

The  almost  invariable  association  of  the  malady  with  evidences  of  scrof- 
ula, such  as  glandular  enlargements,  ulcers,  caries  of  the  bones,  phthisis, 
and  tuberculous  family  history  (Hebra-Kaposi,  T.  Fox,  Duhring,  Crocker, 
Hyde,  and  almost  all  others),  considered  with  the  other  facts  just  pre- 
sented, indicate  that  it  is  to  be  considered  a  tuberculous  eruption,  the 
failure  to  find  bacilli  leading  some  observers  (Hallopeau,  Hyde,  Brocq, 
Johnston,  and  others)  to  attribute  it  to  the  toxins  of  the  organisms  seated 
at  near  or  remote  parts. 

Pathology. — The  disease  has  its  seat  about  the  pilosebaceous  folli- 
cles. Anatomic  investigations  (Kaposi,  Sack,  Jacobi,  Leredde,  Unna, 
and  others)  show  that  the  papule  is  made  up  of  an  infiltration  of  lym- 
phoid,  epithelioid,  and  giant-cells,  the  inflammatory  changes  beginning 
first  around  the  vessels,  in  and  about  the  hair-follicles,  sebaceous  glands, 
and  about  the  papillae  surrounding  the  follicular .  opening.  The  cutis 
beneath  the  degenerated  epidermis  undergoes  caseous  degeneration. 
Gilchrist1  states  that  in  his  case  (a  negro)  the  microscopic  sections  pre- 
sented two  striking  features:  (i)  Semiglobular-looking  masses,  situ- 
ated in  the  horny  layer,  and  especially  around  the  hair-follicles;  (2) 
marked  pathologic  changes  in  the  upper  portion  of  the  corium  beneath 
these  masses,  and  also  about  the  hair-follicles,  especially  the  deepest 
portion;  the  latter  was  characterized  by  its  tuberculous  structure. 
There  is,  therefore,  in  the  histologic  picture  a  similarity  to  the  struc- 
ture of  miliary  tubercle,  and  a  further  support  to  the  belief  in  the  tuber- 
culous character  of  the  disease;  Jacobi,2  Sack,3  Hallopeau  and  Darier,4 
and  Lesselier,5  from  their  findings,  speak  most  strongly  to  this  effect. 

Diagnosis — The  disease  is  to  be  differentiated  chiefly  from 
the  miliary  papular  syphilid,  keratosis  pilaris,  and  papular  eczema. 
The  first  is  an  eruption  of  the  active  stage  of  syphilis,  and,  in  addition 
to  the  eruption  being  widely  distributed,  other  symptoms  of  this  disease 
can  always  be  found.  The  usual  regions  for  keratosis  pilaris  are  the 
limbs,  most  commonly  the  thighs,  especially  the  outer  surface;  there 
is  practically  no  tendency  to  form  groups  or  patches.  Papular  eczema 
is  rarely  seen  on  the  trunk  alone, — a  favorite  region  for  lichen  scrofulosus, 
— and  it  is  decidedly  itchy,  and  frequently  some  of  the  lesions  are  vesicu- 
lar or  papulovesicular.  These  various  characters  suffice  ordinarily  to 
distinguish  these  several  eruptions  from  lichen  scrofulosus.  In  this 
latter  the  patchy  and  sluggish  features,  together  with  the  usual  presence 
of  scrofulous  symptoms,  will  also  serve  to  prevent  error. 

Prognosis  and  Treatment.— The  malady  readily  responds  to 
treatment;  if  let  alone,  it  persists  an  indefinite  time.  The  classic  treat- 
ment of  Hebra,  which  rapidly  cures,  consists  of  cod-liver  oil  internally 
and  externally;  small  or  moderate  doses  should  be  administered.  Ameri- 
can and  English  patients  would  seriously  object  to  oleum  morrhuae  as 
a  local  application,  and  experience  teaches  that  mildly  stimulating  oily 

1  Gilchrist,  Johns  Hopkins  Hasp.  Bull.,  1899,  p.  84. 

2  Jacobi,  loc.  tit. 

3  Sack,  Monalshefte,  1892,  vol.  xiv,  p.  437. 

4  Hallopeau-Darier,  Annales,  1892,  p.  45. 

5  Lesselier,  ibid.,  1906,  p.  897  (out  of  17  cases,  found  in  14  the  structure  of  the 
tubercle). 


PITYRIASIS  RUBRA    PILARIS 


23I 


applications  or  ointments  will  act  as  effectually.  Crocker  found  that 
inunctions  of  plain  vaselin,  or  with  15  drops  of  the  solution  of  subacetate 
of  lead,  or  5  grains  (0.35)  of  thymol  to  the  ounce  (32.),  were  quite  as 
efficient  as  cod-liver  oil  applications. 

PITYRIASIS  RUBRA  PILARIS 

Synonyms.— Lichen  psoriasis  (Hutchinson) ;  Lichen  ruber  (Hebra);  Pityriasis 
pilaris  (Devergie,  Richaud);  Lichen  ruber  acuminatus  (Kaposi);  Fr.,  Pityriasis  rubra 
pilaire. 

Definition — A  rare  disease,  characterized  by  grayish,  pale-red, 
or  reddish-brown  papules,  seated  at  the  mouths  of  the  hair-follicles, 
with  minute,  somewhat  hard  or  horny,  centers,  and  which  in  places 
become  confluent  and  result  in  thickening  and  scaliness. 

Since  the  writings  on  this  disease  by  Devergie,1  and  later  Richaud,2 
Besnier,3  and  other  French  observers,  there  has  been  much  discussion 
as  to  its  identity  with  those  cases  described  by  Hebra4  under  the  name 
of  "lichen  ruber."  Kaposi,  who  was  Hebra's  assistant  as  well  as  son- 
in-law,  and  who  had  seen  some  of  Hebra's  cases  (although  none  of  the 
fatal  ones),  later  described  the  disease  under  the  name  of  "lichen  ruber 
acuminatus,"  in  order  to  distinguish  it  from  the  lichen  planus  of  Wilson; 
inasmuch  as  the  French  observers  considered  Kaposi's  lichen  ruber 
acuminatus  as  their  pityriasis  rubra  pilaris,  the  conclusion  would  seem 
inevitable  that  the  latter  is  identical  with  Hebra's  lichen  ruber.  A 
study  of  the  colored  plates5  in  existence  of  these  alleged  different  diseases 
is,  however,  confirmatory  of  their  identity.  The  obscuring  facts  are: 
(i)  Hebra  stated  that,  "while  the  entire  number  of  our  earlier  cases 
(about  14)  died,  in  no  case  under  our  care  since — at  least  three  times  as 
many — has  such  results  ensued,  but,  on  the  contrary,  under  treatment 
(heroic  arsenical  treatment)  a  steady  progress  was  made  to  final  and  com- 
plete recovery";  and  (2)  Hebra's  account6  of  the  disease  is  in  some  par- 
ticulars different  from  the  description  of  pityriasis  rubra  pilaris  as  we 
see  it  to-day.  These  two  facts  led  me  formerly  to  consider  the  two  mala- 
dies as  distinct,  and  they  so  appeared  in  the  earlier  editions  of  this  book, 

1  Devergie,  Traite  pratique  des  maladies  de  la  peau,  1857,  second  edit.,  p.  454. 

2  Richaud,  "Etude  sur  le  pityriasis  pilaris,"  These  de  Paris,  i877._ 

3  Besnier,  "Observations  pour  servir  a  1'histoire  clinique  du  pityriasis  rubra  pilaris," 
Annales,  April,  May,  and  June,  1889  (based  upon  28  cases). 

4  Hebra  and  Kaposi's  Hautkrankheiten,  first  edit.,  1862,  vol.  ii,  p.  315. 

5  Barensprung  and   Hebra's  Atlas,  Erlangen,  1865,  plates  xiv  and  xvi;  Hebra's 
Atlas,  plate  ii,  part  iii;  Newman's  Atlas,  plate  xli,  and  Archiv,  1892,  vol.  xxiv,  p.  3; 
Besnier,  Annales,  1889,  vol.  x,  following  p.  388;  same  in  La  Pratique  Dermatologique, 
vol.  iii,  with  also  2  copies  of  moulages  (Nos.  728  and  972)  in  Baretta,  St.  Louis'Museum, 
Paris;  Tiltoiry  Fox's  Atlas,  plate  xxxix;  Crocker's  Atlas,  plate  xxxiii;  Morrow's  Atlas, 
plate  Iviii  (copy  of  Neumann's  case);  Taylor's  Atlas,  plate  liv,  and  New   York  Med. 
Jour.,  Jan.  5,  1889;  and  in  G.  H.  Fox's  Atlas. 

In  addition  to  the  literature  bearing  upon  the  disease  in  connection  with  the  colored 
plates  mentioned  (especially  the  articles  by  Besnier  and  Taylor)  and  that  specifically 
referred  to  in  the  course  of  the  text,  the  interested  reader,  desiring  to  pursue  the  subject, 
can  consult  the  following:  Kaposi,  Archiv,  1889,  vol.  xxi,  p.  743,  and  1895,  vol.  xxxi,  p. 
i;  Neumann,  Archiv,  1892,  vol.  xxiv,  p.  3;  Neisser,  Verhl.  d.  deutschen  Derm.  Gesell., 
IV.  Congress,  p.  495  (with  discussion);  Discussion,  Trans.  Internal.  Derm.  Congr., 
Paris,  1889;  G.  H.  Fox,  Morrow's  System,  vol.  iii  (Dermatology),  p.  324;  Discussion, 
N.  Y.  Derm.  Soc'y,  Jour.  Cutan.  Dis.,  1902,  p.  572. 

•  Hebra  and  Kaposi's  Hautkrankheiten,  second  edit.,  vol.  i,  p.  388. 


232  JNFLAMMA  TIONS 

but  a  further  study  and  consideration  of  the  subject,  as  outlined  above, 
have  changed  my  opinion.  Hebra's  differences  in  the  description  of  the 
clinical  features  can  be  explained  upon  the  justifiable  assumption  that  it 
included  cases  of  lichen  planus;  but  we  are  still  left  to  wonder  why, 
before  instituting  heroic  arsenical  treatment,  all  his  cases  died,  inasmuch 
as  pityriasis  rubra  pilaris  as  we  see  it  now  is  comparatively  benign,  with 
no  fatal  tendency,  and,  moreover,  seems  wholly  uninfluenced  by  arsenical 
treatment. 

Cases  have  been  described  in  America  by  Taylor,1  White,2  Zeisler,3 
Ravogli,4  Heidingsfeld,5  and  others.  The  disease  seems  rarer  in  Eng- 
land than  elsewhere,  although  an  Englishman,  Tarral,6  was  the  first 
one  who  clearly  described  a  case  of  the  disease,  and  in  late  years  other 
cases  have  been  encountered  by  Hillier,  Tilbury  Fox,  Fagge,  Jamie- 
son,  West,  and  Liddell.7 

Symptoms. — The  disease  often  involves  the  greater  part  of  the 
entire  surface,  or  it  may  remain  limited  to  one  or  two  regions.  It 
usually  begins  insidiously,  and,  as  a  rule,  the  first  manifestations  noticed 
are  a  scaly  condition  of  the  scalp  and  thickened  areas  upon  the  palms 
and  soles.  Soon  the  characteristic  follicular,  pale-red  or  brownish  pap- 
ules appear  either  on  the  dorsal  surface  of  the  fingers  and  hand,  about 
the  abdomen  or  the  extensor  surfaces  of  the  extremities,  especially  the 
forearms;  or  they  may  present  more  or  less  synchronously  upon  all  these 
several  regions.  In  one  of  the  cases  under  my  observation  it  began  on 
the  back  of  the  neck,  and  for  a  long  time  remained  limited  to  this  region. 
They  are  somewhat  hard  to  the  touch,  acuminated,  and  at  the  central 
point  is  seen  a  small  horny  formation,  usually  pierced  by  a  hair,  or  show- 
ing the  extremity  of  a  broken  hair.  The  papules  only  extremely  rarely8 
show  slight  peripheral  enlargement,  in  the  manner  of  a  psoriasis  papule. 
While  discrete  at  first,  new  papules  arise  and  become  aggregated,  forming 
confluent  areas  of  variable  size,  which  are  noted  to  be  yellowish-red  or 
grayish-red  in  color,  thickened,  rough,  dry,  and  slightly  scaly,  and  with 
an  accentuation  of  the  natural  lines  of  the  skin,  and  sometimes  a  tendency 
to  fissuring  about  the  joints.  These  confluent  areas  bear  some  resem- 
blance to  psoriasis,  but  the  scaliness  is  more  of  a  branny  character,  never 
so  flaky  or  laminated  or  so  pronounced  as  in  psoriasis.  Along  with  these 
areas  the  palms  and  soles  are  the  seat  of  diffused  thickening,  and  the  face, 
usually  beginning  at  the  brow  and  near  the  nose,  becomes  dry,  slightly 

1  R<  S'  Ta^ur'  "Lichen  Ruber  as  Observed  in  America,"  New  York  Med.  Jour., 
Jan.  5,  1889  (with  a  colored  plate,  several  case  and  histologic  cuts—a  most  admirable 
and  complete  paper). 

2  J.  C.  White,  Jour.  Cutan.  Dis.,  1894,  p.  468. 

3  Zeisler, ^Chicago  Med.  Record,  1899,  vol.  xvi,  p.  533. 

1  Ravogli,  Cincinnati  Lancet-Clinic,  1890,  vol.  xlii,  p.  333  (with  histologic  cuts). 
Heidingsfeld,  ibid.,  June  3,  1899  (with  histologic  cuts);  Shields,  Lancet-Clinic, 
July  30,  1910. 

Tarral,  communication  to  Rayer,  Traite  theorique  el  pratique  des  maladies  de  la 
peau,  Pans,  1835,  second  ed.,  vol.  ii,  p.  158;  also  quoted  by  Besnier,  loc.  cit. 

See  paper  by  West,  Brit.  Jour.  Derm.,  1895,  p.  273  (with  case  illustrations),  and 
Liddell,  ibid.,  p.  279  (with  histologic  examination). 

8Whitfield,  Soc'y  Trans.  Brit.  Jour.  Derm.,  1902,  p.  470,  and  1904,  p.  462,  showed 
such  a  case — presenting,  in  fact,  at  different  times  or  in  different  areas,  some  of  the 
features  of  typical  pityriasis  rubra  pilaris,  psoriasis,  and  dermatitis  exfoliativa;  Thibierge, 
La  Pratique  Dermatologie,  vol.  iii,  also  refers  to  this  possible  peripheral  enlargement. 


PLATE  V. 


Pityriasis  rubra  pilaris  in  a  mulatto  girl,  involving  the  entire  surface.  Began  when 
six  or  seven  years  old,  and  gradually  extended,  reaching  generalization  when  ten  years 
old  (at  the  time  photograph  was  taken).  Family  free  from  skin  disease,  and  brothers 
and  sisters,  six  in  all,  well  and  healthy.  Under  treatment  improvement  has  slowly  taken 
place,  so  that  a  year  ago,  when  last  seen,  then  aged  sixteen,  not  more  than  one-third  of 
the  surface  remained  affected,  the  eruption  then  consisting  of  some  large  confluent  scaly 
areas  and  patches  of  closely  crowded  discrete  follicular  papules.  The  patient's  general 
health  has  continued  good  throughout. 


PIT  YR I  A  SIS  RUBRA    PILARIS  233 

or  moderately  thickened  and  scaly,  but  with  no  tendency  to  papular 
formation.  Ectropion  of  the  lower  eyelids  sometimes  ensues.  The 
lesions  on  the  dorsal  surfaces  of  the  ringers  usually  remain  discrete,  and, 
as  likewise  even  in  cases  of  considerable  scaly  development,  are  quite 
distinctly  pronounced. 

The  disease  on  both  the  scalp  and  the  face  is  somewhat  variable 
as  to  degree,  from  a  reddish,  slightly  scaly  condition  to  that  of  some 
thickening  and  marked  scaliness,  almost  to  the  extent,  on  the  latter 
region,  of  producing  a  mask  to  the  parts.  The  hairs  of  the  scalp  show 
but  little,  if  any,  involvement.  The  nails,  on  the  contrary,  are  often 
brittle,  rough,  dull,  striated,  and  they  show  a  tendency  to  break  and 
crack.  The  disease  is  in  most  cases  progressive,  but  after  some  months, 
after  reaching  a  variable  extent,  it  may  remain  stationary  for  a  time 
and  then  advance  again;  or  there  may  be  periods  of  slight  retrogression 
and  progression.  It  may  be  so  extensive  as  to  cover  in  most  of  or  prac- 
tically the  entire  surface,  in  which  event  a  generalized  thickened  and 
inelastic  condition  of  the  skin  is  observed,  covered  with  grayish  scales, 
usually  moderate  in  quantity,  and  dry  and  harsh  to  the  touch;  the  natural 
lines  of  the  skin  are  considerably  exaggerated,  and  sometimes  cracks  about 
the  joints  occur.  In  such  instances  the  papular  element  is  scarcely  recog- 
nizable, although,  as  remarked,  discrete  papules  are  still,  as  a  rule,  to  be 
found  on  the  backs  of  the  phalanges.  In  less  extensive  cases  large  gray- 
ish plaques,  irregularly  shaped  but  commonly  oblong,  are  to  be  seen  on 
different  parts,  especially  the  extremities,  with  outlying  typical  papules 
and  with  some  irregularly  scattered  over  the  general  surface.  In  cases 
of  any  extent  the  face,  scalp,  and  hands  rarely,  if  ever,  escape.  As  a 
rule,  there  are  no  subjective  symptoms  complained  of;  occasionally, 
slight  itching.  The  general  health  remains  apparently  unaffected. 

Etiology  and  Pathology. — The  disease  is  rare  and  the  cause 
is  unknown.  Neither  heredity,  sex,  nor  color  seems  to  have  any  etio- 
logic  significance.  It  has  been  observed  (Besnier,  Hallopeau  and 
Brodier,  Rasch)  in  quite  young  children,  in  Rasch's1  case  at  the  age 
of  two  and  a  half  years;  indeed,  in  the  majority  of  cases  it  has  its  begin- 
ning in  childhood  or  early  youth.  Of  5  cases  under  my  observation, 
i  was  a  mulatto  girl  of  ten,  in  whom  it  developed  when  aged  six;  the 
others  were  a  woman  aged  twenty,  a  negress  aged  twenty-five,  and  two 
men,  aged  respectively  twenty-five  and  thirty.  They  were  all  apparently 
in  good  health,  and  did  not  seem  to  be  seriously  inconvenienced,  although 
in  3  the  disease  was  almost  universal.  There  is  an  instance  on  record  of 
several  cases  in  a  family.2  As  yet  there  is  scant  foundation  for  the  theory 
of  its  tuberculous  causation. 

The  pathologic  anatomy  (Jacquet,  Taylor,  Ravogli,  Hartzell, 
Heidingsfeld,  and  others)  discloses  that  the  disease  is  a  hyperkeratosis, 
secondary  inflammatory  changes  resulting.  The  essential  and  primary 
hornification  occurs  in  the  epithelial  lining  of  the  orifice  of  the  hair- 

1  Rasch,  Dermatolog.  Centralblatt,  No.  7,  1899,  p.  199. 

2  De  Beurmann,  Bith  and  Henyer,  "Pityriasis  rubra  pilaire  familial, 

1910,  p.  609  (4  cases,  two  brothers  and  two  sisters,  in  a  family  of  six  children   tne 
other  two  being  free);  the  father  was  thought  to  have  had  it  in  a  mild  way,  hut  t 
somewhat  uncertain;  two  cousins  were  reported  to  have  a  similar  condition. 


234  INFLAMMATIONS 

follicle,  producing  the  papule;  the  projecting  horny  spine  being  due 
to  the  collected  mass  of  cornified  epithelium  within  the  follicle.  All 
the  epidermic  layers  are  markedly  thickened,  more  especially  the  upper 
corneous  part. 

The  sweat-duct  outlets  may  sometimes  show  similar,  but  relatively 
insignificant,  changes.  Round-cell  infiltration  is  noted  about  the  hair- 
follicles  and  to  a  less  extent  in  the  papillae.  In  one  of  my  cases  sec- 
tions, from  one  of  which  the  herewith  illustration  was  taken,  were 
kindly  made  by  Dr.  Hartzell,  who  reported  as  follows: 

"The  epidermis  was  three  or  four  times  thicker  than  normal,  the 
increase  in  thickness  being  most  marked  in  the  corneous  and  prickle- 


Fig.  45. — Pityriasis  rubra  pilaris:  a,  Thickened  corneous  layer;  b,  hypertrophied 
rete;  c,  hair-follicle;  d,  cell  infiltration  about  follicle;  e,  corneous  plug  in  mouth  of 
follicle  (section  from  the  case  herein  pictured — section  and  photomicrograph  by  Dr.  M. 
B.  Hartzell). 

cell  layers.  The  corneous  layer,  while  everywhere  thicker  than  normal, 
was  most  markedly  increased  in  and  around  the  mouths  of  the  hair- 
follicles,  in  which  it  formed  plugs  of  considerable  size,  projecting  some 
distance  above  the  surface  and  extending  well  into  the  follicle.  Many 
of  the  cells  of  the  rete  mucosum  showed  greatly  enlarged  nuclei  which 
stained  badly  or,  in  many  instances,  not  at  all.  The  papillae  of  the 
corium  were  decidedly  increased  in  length,  were  only  slightly  wider  than 
normal,  and  contained  a  moderate  number  of  small  round-cells  with  a 
few  'mastzellen.'  Along  the  entire  length  of  the  hair-follicles  there  was 
a  fairly  abundant  round-cell  infiltration.  Neither  the  sebaceous  nor  the 
sweat-glands  showed  any  appreciable  alteration." 

Diagnosis. — In  well-developed  cases  there  is  rarely  difficulty  in 


PITYRIASIS  RUBRA    PILARIS  235 

the  diagnosis;  the  follicular  papules  containing  a  horny  projection  and 
broken  hair-shaft,  and  usually  to  be  found  even  in  extensive  cases,  espe- 
cially on  the  dorsal  aspects  of  the  fingers,  the  thickened,  harsh,  rough, 
and  slightly  or  moderately  scaly  skin,  the  thickened  palms  and  soles,  the 
marked  scaliness  of  the  face  and  scalp,  constitute  a  picture  usually  quite 
characteristic.  In  mild  and  moderate  cases  the  papular  lesions,  gener- 
ally crowded  together,  with  the  features  described,  will  be  sufficiently 
distinctive.  When  more  or  less  general,  it  may  show  some  similarity  to 
some  cases  of  dermatitis  exfoliativa,  but  in  this  latter  there  is  rarely 
material  thickening,  the  skin  is  redder,  and  the  scaliness  more  pro- 
nounced. It  can  scarcely  be  mistaken  for  psoriasis — in  the  latter 
the  beginning  lesions,  their  character,  and  their  growth  by  peripheral 
extension,  instead  of  by  accretion  of  new  papules  as  in  pityriasis  rubra 
pilaris,  and  the  absence  usually  of  palmar  and  marked  facial  involvement, 
are  entirely  different.  The  scaly  plaques  of  lichen  planus  present  some 
features  similar  to  the  plaques  of  this  malady,  but  the  dark-red  or  vio- 
laceous tinge  of  the  border  and  of  outlying  lesions  in  the  former,  and 
the  flattened,  frequently  umbilicated,  characters  of  the  discrete  papules, 
as  a  rule,  always  to  be  found,  and  the  itchiness  and  almost  invariable 
absence  of  involvement  of  face,  scalp,  and  palms,  are  distinguishing 
characters. 

Prognosis. — The  disease  is  always  persistent  and  rebellious  to 
treatment.  Retrogression,  however,  may  take  place,  and  even  com- 
plete recovery  has  been  recorded;  recurrence  often  ensues.  The  cases 
under  my  care  all  improved,  but  not  one  was  cured;  only  one  was 
under  my  care  a  sufficiently  long  time,  however,  to  expect  more  than 
betterment.  In  this  last — the  case  shown  in  the  ^lustration — the  dis- 
ease, when  the  patient  was  seen  several  months  ago,  was  still  gradually 
retrogressing. 

Treatment.— The  treatment  of  this  malady  consists  essentially 
in  the  administration  of  tonics,  when  necessary,  sudorifics,  and  exter- 
nally bran,  starch,  or  alkaline  baths,  and  oils  or  ointment  applications. 
Exercise,  proper  food  and  living  are,  of  course,  of  great  value.  Arsenic 
is  only  exceptionally  valuable  in  this  disease;  but,  in  view  of  Hebra's 
experience  as  to  its  remarkable  efficiency  in  continued  large  doses,  it 
might,  in  extensive  cases,  be  tentatively  tried  in  steadily  increasing 
dosage.1  Sodium  cacodylate,  in  i-  to  3-grain  (0.07-0.2)  doses,  adminis- 
tered hypodermically,  proves  sometimes  of  value.  Thyroid  extract 
seemed  of  slight  service  in  i  case,  but  as  the  external  treatment  was 
being  carried  out  at  the  same  time,  it  was  doubtful  to  which  the  benefit 
was  due.  Little2  had  some  effects  from  its  use  in  one  instance,  begin- 
ning with  \\  grains  (o.i)  and  increasing  to  3  grains  (0.2)  three  times 
daily.  Jaborandi  or  pilocarpin  will  sometimes  have  a  favorable  influence 
by  its  action  on  the  perspiratory  glands.  If  the  nutrition  is  poor,  cod- 
liver  oil  is  a  remedy  of  considerable  value. 

1  Heidingsfeld,  Jour.  Cutan.  Dis.,  1906,  p.  371,  found  his  3  cases  uninfluenced  by 
this  drug  in  respect  to  its  internal  administration  and  the  hypodermic  injectic 
sodium  arsenate;  but  favorably  influenced  by  hypodermic  injections  of  atoxyl,  and,  to 
lesser  extent,  by  cacodylic  acid. 

2  Little,  Brit.  Jour.  Derm.,  1900,  p.  412- 


236  INFLAMMA  TIONS 

The  external  remedies  are  about  the  same  as  used  in  psoriasis  and 
in  ichthyosis.  In  cases  of  decidedly  irritable  skin,  bran  or  starch  baths, 
daily  or  three  or  four  times  weekly,  prove  serviceable.  Alkaline  baths 
are  most  frequently  to  be  used,  and  can  be  made  up  with  the  various 
alkalis  usually  employed.  Oil  or  ointment  applications  should  be  made 
once  or  twice  daily,  as  well  as  immediately  after  a  bath.  An  oint- 
ment of  salicylic  acid,  from  10  to  60  grains  (0.654-4.)  to  the  ounce 
(32.),  is  one  of  the  most  efficient.  Weak  tar  ointments  are  also  at  times 
of  service.1  Markedly  thickened  and  hard  areas  can  be  treated  by  a 
10  to  20  per  cent,  salicylic  acid  plaster,  or  this  remedy  can  be  applied 
in  collodion,  2  to  10  per  cent,  strength.  Pyrogallol  and  resorcin  salves 
have  been  extolled,  but  the  use  of  the  former  must  be  restricted  to  small 
areas  for  fear  of  absorption.  The  scalp  is  to  be  shampooed  frequently 
with  tincture  of  green  soap,  and  an  ointment  or  oil  applied. 

PSORIASIS 

Synonyms. — Lepra  and  Lepra  alphos  (of  old  authors);  Fr.,  Psoriasis;  Ger.,  Psori- 
asis; Schuppenflechte. 

Definition. — Psoriasis  is  a  chronic  inflammatory  disease,  charac- 
terized by  more  or  less  numerous  dry,  reddish,  variously  sized,  rounded 
and  sharply  defined,  more  or  less  thickened  patches,  covered  with  white, 
grayish-white,  or  mother-of-pearl-colored  imbricated  scales,  usually 
abundant  in  quantity. 

Symptoms. — Psoriasis  is  always  a  dry  scaly-papular  eruption — 
oozing  or  liquid  exudation  never  occurs,  and  such  other  lesions  as  vesicles, 
pustules,  etc.,  are  never  observed.2  It  usually  begins  slowly  by  the 
appearance  of  a  variable  number,  few  or  many,  of  scattered  pin-point 
or  pin-head-sized,  slightly  elevated  maculopapules  or  papules,  covered 
with  whitish  or  grayish-white  scales,  at  first  thin  and  epidermic.  These 
lesions  increase  slowly  and,  as  a  rule,  very  gradually  in  size,  and,  as 

Graham  Little  (Discussion,  Brit.  Jour.  Derm.,  1911,  p.  182)  cleared  up  the 
eruption  in  a  case  with  an  ointment  consisting  of  i  ounce  of  salicylic  acid  and  3  drams 
of  oil  of  cade,  after  many  other  applications  had  failed. 

2  Some  of  the  more  recent  literature  upon  clinical  phases: 

Analytic  and  clinical: 

Greenough,  Boston  Med.  and  Surg.  Jour.,  Sept.  10,  1885;  Bulkley,  Maryland  Med. 
Jour.,  Sept.  26  and  Oct.  4,  1891;  Pye-Smith,  Guy's  Hospital  Reports,  1880-81,  vol.  xxv, 
p.  233,  and  1889,  vol.  xlvi,  p.  419;  Nielsen  (with  full  consideration  of  etiology  and 
pathogeny,  and  rare  atypical  clinical  types,  with  numerous  literature  references), 
Monatshefte,  1892,  vol.  xv,  pp.  317  and  365;  also  in  New  Sydenham  Society's  Selected 
Monographs  on  Dermatology,  1893,  p.  57i;Rille  (in  children,  with  complete  bibliog- 
raphy), Wien.  med.  Wochenschr.,  1895,  p.  2098;  P.  S.  Abraham,  Brit.  Med.  Jour., 
April  14,  1906. 

Atypical  cases: 

Rosenthal,  Archiv,  Erganzungsheft,  1893,  i,  p.  79;  Waelsch,  Prager  med.  Wochen- 
schr., 1898,  p.  73;  Deutsch.  Wien.  klin.  Wochenschr.,  1898,  p.  130;  Beyer,  Wien.  klin. 
Wochenschr.,  1901,  p.  824  (with  full  review  of  the  subject). 

Horny  formations,  with  epitheliomatous  development:  White  (J.  C.),  Amer.  Jour. 
Med.  Sci.,  Jan.,  1885;  Hebra,  Jr.,  Monatshefte,  1887,  vol.  vi,  p.  i;  Hartzell  (bibliog- 
raphy to  date,  and  especially  bearing  upon  arsenic  as  the  causative  factor),  Amer. 
Jour.  Med.  Sci.,  Sept.,  1899;  Schamberg,  Jour.  Cutan.  Dis.,  1907,  p.  26. 

Leukodermic  areas:  Hallopeau  et  Gasne,  Bull,  de  Soc.  franfaise,  July,  1898;  Rille, 
Dermatolog.  Zeitschrift,  Nov.,  1898. 

Kleoidal  formation:  Purdon,  Jour.  Cutan.  Dis.,  1883,  p.  203;  Anderson,  quoted  by 
Crocker,  Diseases  of  Skin,  third,  ed.,  p.  363. 


PSORIASIS 


237 


they  grow  peripherally,  the  scale  accumulation  becomes  more  marked 
and  imbricated.  During  this  time  new  spots  are  usually  appearing. 
The  earliest  lesions  growing  larger,  often  at  different  rates  of  rapidity, 
together  with  the  appearance  of  the  new  scaly  papules,  soon  result  in  a 
characteristic  clinical  picture: 

Twenty  to  a  hundred  or  more  patches,  varying  in  size  from  a  pin- 
head  to  a  silver  dollar,  are  usually  present;  they  are  sharply  defined 
against  the  sound  skin,  are  slightly  elevated  and  thickened  or  infiltrated, 
and,  if  undisturbed,  are  more  or  less  abundantly  covered  with  whitish, 


Fig.  46. — Psoriasis  in  a  lad  aged  twelve,  of  a  year's  duration,  showing  small  (guttate) 
lesions  and  larger  plaques  on  arms;  distribution  general. 

silvery,  grayish,  or  mother-of-pearl-colored  scales;  at  the  extreme  per- 
iphery the  red  edge  of  the  underlying  skin  beneath  the  scales  can  be 
seen;  from  a  few  or  many  of  the  patches  the  scales  have  probably  been 
rubbed  off  by  the  clothing  or  intentionally  removed,  and  the  bases  are 
then  seen  to  be  bright  or  dark  red  in  color,  disclosing  the  inflammatory 
nature  of  the  disease.  Gently  scraping  the  uncovered  surface  of  a 
patch,  which  seems  to  be  coated  over  with  a  thin  whitish  or  reddish- 
white  pellicle  (Bulkley),  with  the  finger-nail  will  result  in  minute  abra- 
sions of  the  vascular  papillary  layer  of  the  corium,  and  the  appearance 


238 

of  one  or  several  minute  drops  of  blood.  The  patches  are  usually  scat- 
tered irregularly  over  the  general  surface,  but  are  commonly  more 
numerous  on  the  extensor  surfaces  of  the  arms  and  legs,  especially 
about  the  knees  and  elbows.  Several  lesions  which  may  have  been 
close  together  will  often  have  coalesced  and  a  large  irregularly  shaped 
patch  be  formed — always,  however,  with  the  edges  sharply  denned  against 
the  sound  skin;  movement  of  joints  affected  may  give  rise  to  fissuring. 
It  is  possible,  too,  that  in  a  few  patches  the  central  portion  may  have 
begun  to  undergo  retrogressive  change,  and,  sunken  down,  become  less 
scaly  or  entirely  disappear;  such  patches  are  then  circinate  or  ring- 
like. 

Such  a  clinical  picture  is  the  one  usually  seen  after  the  disease  has 
lasted  several  months  or  longer.  It  will  be  observed  that  the  history 
of  the  appearance  and  growth  of  one  lesion  is  essentially  the  history  of 
all.  The  larger  patches  cannot  arise  as  such,  but  are  the  result  of  per- 
ipheral growth  from  a  beginning  small  lesion;  and  as  the  growth  of  the 
lesions  may  stop  at  any  time  and  remain  stationary  for  a  shorter  or 
longer  period,  or  almost  indefinitely,  it  can  readily  be  understood  how 
the  so-called  clinical  varieties  of  the  disease  are  produced.  For  in 
some  instances  the  lesions,  or  the  most  of  them,  progress  no  further 
than  pin-head  in  size,  and  then  remain  stationary,  constituting  pso- 
riasis punctata ;  in  other  cases  the}''  may  stop  short  after  having  reached 
the  size  of  drops — psoriasis  guttata ;  in  others,  as  in  the  descriptive  pic- 
ture above  given,  the  patches  develop  to  the  size  of  coins — psoriasis 
nummularis,  psoriasis  discoidea — and  remain  stationary.  In  other 
cases,  having  attained  a  certain  but  variable  size,  more  usually  small  or 
large  coin  size,  involution  changes  set  in,  and  the  central  part  of  many,  or 
the  majority  or  even  more,  begins  to  disappear,  and  there  result  a  number 
of  patches  with  clear  centers  and  a  surrounding  inflammatory  scaly  band 
— psoriasis  circinata,  psoriasis  annulata.  If  it  happens  that  several  of 
the  ring-shaped  patches  are  close  together  and  begin  to  extend  again 
peripherally,  at  the  same  time  undergoing  involution  at  the  inner  part  of 
the  ring,  coalescence  takes  place,  and  the  coalescing  portions  disappear, 
and  there  is  left  an  eruption  of  serpentine  inflammatory  scaly  bands — 
psoriasis  gyrata.1  Or  if  several  or  more  closely  situated  solid  scaly 
plaques  continue  to  increase  in  size,  they  coalesce  and  form  large  areas 
of  varying  dimensions,  sometimes  sufficiently  large  to  cover  a  part  or  an 
entire  region — psoriasis  diffusa;  when  about  joints,  the  mobility  of  the 
part  is  often  painful,  and  fissures,  somewhat  deep,  are  often  noted.  These 
diffused  areas  are  usually  markedly  infiltrated  and  of  a  somewhat  in- 
veterate character,  and  hence  the  term  sometimes  applied — psoriasis 
inveterata.  Should,  by  gradual  increase  of  old  patches  and  the  appear- 
ance of  new  lesions  in  the  interspaces,  almost  the  entire  surface  be  one 

1  Very  rarely  is  observed  a  type  which  might  be  termed  psoriasis  gyrata  in  minia- 
ture, which  Jadassohn  and  Gassman  have  described  as  small  circinate  psoriasis  (klein- 
zirzinare  psoriasis),  and  later  by  Hoffman  as  psoriasis  microgyrata.  The  gyrate  bands 
are  narrow,  scarcely  elevated,  but  slightly  (hardly  noticeably)  inflammatory,  and  the 
gyrations  are  usually  small — the  whole  having  some  resemblance  to  a  profuse  pityriasis 
rosea  in  its  stage  of  beginning  disappearance.  It  may  be  persistent  or  run  a  com- 
paratively rapid  course,  with  the  usual  tendency  to  recurrences. 


PSORIASIS 


239 


sheet  of  eruption,  the  name  psoriasis  universalis  is  applicable.     For- 
tunately, such  extensive  covering  of  the  surface  is  rarely  observed. 

In  extremely  exceptional  instances  (McCall  Anderson,  Waelsch, 
Deutsch)  there  is  displayed  on  some  patches  a  tendency  to  central 
heaping  of  the  scales,  which  may  also  be  quite  hard,  almost  horny — 
hence  the  term  psoriasis  rupioides,  psoriasis  ostreacea  ;l  in  some  of  these 
cases,  however,  there  is  an  admixture  of  fluid  (gummy  or  oily)  exudation, 
indicating  an  eczematous  or  at  least  a  seborrheic  complication  (psoriatic 
eczema,  seborrheic  psoriasis) ;  sometimes  also  with  associated  symptoms 
of  arthritis  (arthropathia  psoriatica)  and  cachexia.  When  on  the 
scalp,  this  heaped-up  scale  accumulation  may  be  quite  adherent  and 


Fig.  47. — Psoriasis  in  a  male  adult  of  several  years'  duration.  Shows  a  not  unusual 
development  on  the  elbows  in  slight  cases.  In  this  instance  the  scalp  was  also  in- 
volved, but  other  parts  were  almost  wholly  free. 

almost  horny  (Gassman).  Rarely  a  tendency  in  one  or  several  areas  to 
papillary  hypertrophy  is  noted,  giving  rise  to  the  term  psoriasis  verru- 
cosa;  such  has  been  observed  on  the  legs  (Kaposi),  on  the  extremities 
(Waelsch),  and  on  the  palmar  and  dorsal  aspects  of  the  hands  (Besnier). 
While  the  involution  begins  frequently  at  the  central  part  of  the 
patch,  and  in  a  very  perceptible  manner,  yet  this  is  by  no  means  always 
so,  for  in  many  cases  there  is  a  gradual  disappearance,  more  or  less 

1  Under  the  name  "Parakeratosis  Ostreacea   (Scutularis),"  Weiss,  Jour.  Amer. 
Med.  Assoc.,  Aug.  3,  1912,  p.  343  (case  and  histologic  illustration),  records  a  case 
having  many  of  the  features  of  this  type;  moisture  and  oozing  were  noted  underneath 
the  lesions,  and  thorn-like  projections  present  on  the  under  side  of  the  crusts  extendei 
into  the  follicular  openings. 


240 


INFLAMMA  TIONS 


uniformly,  of  the  entire  patch ;  if  examined  closely,  however,  many  such 
patches  will  show  that  the  retrogressive  change  is  slightly  more  active 
centrally  than  peripherally;  in  others  there  is  no  noticeable  difference. 
The  first  evidences  of  involution  are  lessened  hyperemia  and  lessened 
scale-production . 

In  many  cases  of  the  disease,  instead  of  beginning  with  a  somewhat 
scattered  distribution,  the  eruption  first  appears  about  the  extensor 
surfaces  of  the  knees  and  elbows,  insignificant  or  moderately  well 
marked,  and  presenting  several  or  more  small  areas.  It  may  remain 
limited  to  these  parts  for  some  months  or  longer,  without  any  disposition 
to  the  appearance  of  new  patches  elsewhere;  it  may  disappear  during 
the  summer  and  then  reappear  the  next  winter  for  a  few  years,  before 

becoming  more  general. 
As  a  rule,  after  some 
months  on  these  regions, 
lesions  begin  to  present 
on  other  parts,  few  or  in 
great  numbers,  and  finally 
present  the  picture  already 
described.  In  other  cases, 
relatively  infrequent,  the 
first  appearance  of  the 
patches  is  on  the  scalp, 
and  the  malady  may  last 
for  some  months  or  a  year 
or  more  so  limited,  and 
then  gradually  or  rapidly 
appear  on  other  parts. 
While  exceptionally  the 
scalp  is  the  sole  seat  of  the 
eruption  for  some  time, 
yet,  as  a  rule,  in  such 
cases,  if  the  elbows  and 
knees  are  closely  examined, 
two,  three,  or  more  insig- 
nificant scaly  spots  can 
usually  be  found,  although 
they  may  have  been  so 

slight  as  to  escape  the  patient's  notice;  not  infrequently,  also,  a  few 
small  insignificant  spots  can  be  found  elsewhere  on  the  limbs  and 
trunk. 

Instead  of  appearing  in  the  chronic  manner  already  described, — 
insidiously,  gradually,  or  with  moderate  rapidity, — the  disease  may 
be  acute  in  respect  to  the  outbreak,  and  within  a  few  weeks  reach  ex- 
tensive development,  several  hundred  or  more  variously  sized  patches 
presenting.  In  such  cases  the  inflammatory  element  is  usually  of  a 
more  pronounced  type,  and,  as  a  rule,  the  scaliness  less  marked,  occa- 
sionally consisting  of  scarcely  more  than  one  or  two  thin  epidermic 
films.  The  subjective  symptoms  of  burning  and  itching  may  be  present 


Fig.  48. — Psoriasis,  generalized,  of  a  common 
clinical  type,  showing  the  sharply  denned,  variously 
sized,  scaly  patches  (courtesy  of  Dr.  W.  Frick). 


PSORIASIS 


241 


to  an  annoying  degree.  After  a  while  these  cases  often  lose  the  acute 
characters,  and  then  settle  down  into  the  ordinary  clinical  type.  In 
other  instances,  after  reaching  rapid,  extensive  development,  involution 
changes  present,  and  the  disease  up  to  a  certain  degree  disappears  quite 
rapidly;  the  eruption  left,  of  slight  or  moderate  amount,  assumes  the 
slow  characters  of  the  common  clinical  cases,  and  persists  more  or  less 
indefinitely,  with  periods  of  remission  or  intermission. 

It  will  be  noted,  therefore,  that  the  disease  may  first  appear  on  one  or 
two  or  several  regions,  and  then  remain  so  limited,  but,  as  a  rule,  only 
for  a  variable  time,  and  then  present  other  patches  elsewhere;  or  that  it 
may  be  from  the  first  more  or  less  scattered,  sometimes  with  a  more 
abundant  eruption  on  certain  regions,  as  about  the  elbows,  knees,  and 
scalp.  Occasionally  most  patches  will  be  found  upon  the  legs,  on  and 
below  the  knees;  over  the  region  of  the  sacrum  is  also  a  favorite  site, 
especially  for  one  or  two 
large  areas.  On  the  scalp 
the  disease  may  present 
scattered  patches,  or  here 
and  there  confluent  areas ; 
it  is  not  uncommon  to  find 
several  or  more  just  over- 
stepping the  hairy  borders 
of  the  forehead  and  mas- 
toid  region.  There  is 
rarely  any  hair  loss.  The 
face  is  not  often  invaded, 
and,  if  so,  usually  with 
small  lesions  and  to  a  very 
slight  degree,  and  these 
are  most  commonly  found 
just  in  front  of  the  ears. 
The  palms  and  soles  usu- 
ally escape,  except  in  rare 
instances  of  more  or  less 
extensive  and  generalized 
cases;  these  parts  are 
never  the  sole  seat  of  the 
eruption.  Exceptionally 
the  palmar  lesions,  when 

present,  are  hard  and  papular,  with  but  little  if  any  scaliness  (Gaucher  and 
Hermery).  The  backs  of  the  hands  often  escape;  not  infrequently 
lesions  may  form  under  and  about  the  nails,  and  as  a  result  the  latter 
become  brittle  or  granular,  opaque,  and  sometimes  thickened;  ex- 
ceptionally one  or  more  may  be  cast  off,  but  never  permanently. 

Psoriasis  lesions  are  noted  to  form  sometimes  along  the  line  or  at 
the  points  of  mechanical  irritation  or  slight  injury;  they  are  also  seen  on 
tattoo-marks  (Heller),  on  and  about  vaccine  (Walters,  Rohe,  Hyde, 
Augagneur,  Mourier,  Heller,  and  others)  and  other  scars  (Hallopeau 
and  Gardner),  and  following  the  course  of  scratch-marks.  In  rare  in- 

16 


Fig.  49. — Psoriasis  in  a  youth  of  fifteen,  of  more 
or  less  general  distribution.  Shows  scalp  involve- 
ment, and  especially  pronounced  in  mastoid  region; 
few  small  patches  on  the  face  in  front  of  the  ear. 


242  INFLAMMA  TIONS 

stances,  too,  the  eruption  has  been,  at  first  at  least,  somewhat  limited, 
and  following  peripheral  nerve  distribution  (Thibierge,  Hallopeau  and 
Gasne),  and  even  unilateral,  on  one  arm,  starting  from  a  traumatism 
(Kuznitzky).  Psoriasis  of  the  tongue  or  other  mucous  membranes 
really  does  not  exist;  lesions,  so  called,  are  usually  those  of  leukoplakia 
buccalis;  recently,  however,  2  cases  in  which  one  or  two  lesions  extended 
from  the  skin  on  to  the  mucous  surface  have  been  recorded  (Kuznitzky, 
Sack) . 

The  eruption  may  be  scanty,  moderate  in  quantity,  or  exceedingly 
abundant,  and  may  evolve  slowly  or  rapidly.  As  to  the  inflammatory 
character,  that,  too,  varies  considerably  in  different  cases  and  some- 
times in  different  patches  in  the  same  case — from  slight  and  insignifi- 
cant to  that  of  a  marked  degree.  The  base  may,  therefore,  show  practi- 
cally no  inflammatory  thickening,  or  this  may  be  pronounced;  it  may  be 
pale  red  or  bright  or  dark  red  in  color,  and  in  those  of  dark,  sluggish  skin 
has  sometimes  a  purplish  tinge.  The  characters  of  the  scaliness  in  a 
typical  case,  in  which  the  eruption  has  been  undisturbed,  and  espe- 
cially in  those  of  dry  skin,  are,  as  a  rule,  distinctive;  the  scales  are  white 
or  grayish  white,  imbricated,  and  with  a  mother-of-pearl  luster.  In 
many  cases,  especially  in  the  working  and  dispensary  classes,  however, 
the  color  is  apt  to  be  a  dirty  gray.  As  to  the  quantity  of  scales,  this  is 
usually  abundant,  but  in  some  cases  much  more  so  than  in  others. 
In  those  who  perspire  freely,  or  who  have  frequent  recourse  to  bathing, 
the  scales,  or  the  greater  part,  are  loosened  and  rubbed  or  drop  off,  so 
that  when  the  patient  is  inspected  there  will  present  some  distinctly 
scaly  spots,  some  but  slightly  so,  and  many  entirely  free. 

In  rare  instances  the  scaliness  partakes  measurably  of  the  nature 
of  a  crust,  appearing  somewhat  as  if  the  collected  imbricated  scales 
had  been  glued  together  with  some  moist  exudation,  although  such 
does  not  in  reality  in  true  and  typical  psoriasis  ever  occur.  Exception- 
ally, however,  in  such  atypical  cases,  especially  in  patches  about  the 
lower  part  of  the  legs,  on  removing  the  scales,  the  base  is  noted  to  be 
deep  or  beef-red  in  color,  and  the  surface  presents  to  the  touch  just  a 
suspicion  of  moisture.  In  other  cases  the  scaliness  and  other  features 
of  the  disease  approach  somewhat  closely  to  those  of  an  eczematous 
eruption.  Such  examples  have  been  noted  by  most  observers,  and 
several  have  come  under  my  own  care,  and  indicate  that  midway  cases, 
or  cases  presenting  some  features  of  both  diseases,  are,  therefore,  ex- 
ceptionally to  be  met  with.  Such  instances,  and  doubtless  other  patchy 
scaly  cases  of  the  psoriatic  eruption,  in  which  the  scales  are  somewhat 
greasy  to  the  touch,  sometimes  thin  and  filmy,  and  with,  in  some  lesions,  a 
slightly  moist  or  greasy  base,  belong  chiefly  to  the  domain  of  dermatitis 
seborrhoica.  As  already  remarked,  some  of  these  might  very  properly 
be  called  psoriatic  eczema,  and  others,  seborrheic  psoriasis,  or  psoriasis  of 
a  seborrheic  type. 

The  course  of  psoriasis,  as  may  be  already  inferred,  is  in  all  instances 
essentially  chronic,  old  patches  persisting,  or  some  fading  away,  and 
new  areas  developing.  Sometimes  fluctuations  as  to  the  extent  and 
number  of  patches  are  noted,  and  occasionally  the  disease  will  partly 


PLATE  VI. 


Psoriasis  of  extensive  development  in  a  male  adult,  of  years'  duration,  showing  the  white 
silvery  character  of  the  scales  (courtesy  of  Dr.  J.  A.  Fordyce). 


PSORIASIS 


243 


or  entirely  disappear,  remain  in  abeyance  some  months  or  a  year  or 
more,  and  then  actively  present  again.  In  some  of  the  milder  cases 
there  is  a  complete,  and  in  almost  all  cases  a  partial,  disappearance  in 
warm  weather.  There  are  some  exceptions  to  this,  and  in  occasional 
instances  the  disease  is  worse  at  such  season.  There  is  never  any  de- 
structive or  atrophic  action  produced;  to  this  statement,  however,  must 
be  added  the  exceptional  cases  of  scarring  (Crocker),  of  keloidal  forma- 
tion (McCall  Anderson,  Purdon),  of  leukodermic  spots  (Hallopeau, 
Gasne,  Rille,  Caspary,  Lowenheim,  Unna),  some  of  which,  I  believe, 
however,  must  be  looked  upon  with  suspicion,  as  probably  purely  acci- 
dental or  due  to  treatment  (Besnier).  It  is  true,  in  some  instances, 
patches  will  disappear,  and  leave  for  a  short  time  a  slight  pale-red  color 
or  discoloration,  which  quickly  fades ;  exceptionally  below  the  knees  more 
positive  staining  is  noted,  which  may  continue  for  a  variable  time.  In  a 
few  recorded  instances  in  one  or  two  patches  verrucous  or  papillary  de- 
velopment has  been  observed,  and  later  epithelial  degenerative  changes 
resulted;  and  exceptionally  warty  or  horny  formations  have  been  noted, 
which  in  a  few  cases  assumed  epitheliomatous  character;  but  in  these 
instances  (Pozzi,  Cartaz,  Hebra,  White,  Rosenthal,  Hartzell,  and  others) 
these  conditions  were  doubtless  due,  as  Hartzell's  collected  cases  would 
seem  to  show,  to  prolonged  administration  of  arsenic,  as  the  drug  seems 
capable  of  provoking  or  inaugurating  such  action.  In  occasional  in- 
stances of  extensive  and  severe  type  the  disease,  after  persisting  for 
some  years,  during  which  time  it  may  be  more  or  less  variable,  finally 
develops  into  a  temporary  or  permanent  dermatitis  exfoliativa  or  a 
condition  simulating  it  (Devergie,  Camberini,  Besnier,  Crocker,  Jamieson, 
and  others).  Several  such  cases  have  come  under  my  own  observation, 
and  in  2  of  these,  as  also  observed  by  others,  there  was  associated  arthritis 
deformans;  rarely,  too,  the  nails  and  hair  fall  out  (Besnier).  Progressive 
polyarthritis  (arthropathia  psoriatica)  has  been  also  noted  in  cases  in 
which  the  skin  eruption  had  remained  of  the  average  type  and  extent.1 

Subjective  symptoms  in  psoriasis  are  absent  in  a  large  number  of 
cases.  In  some  there  is  slight  itchiness,  in  others  moderate  in  degree; 
less  frequently  it  is  intense,  either  at  irregular  times  or  continuously, 
and  constituting  the  most  troublesome  feature  of  the  disease.  In  acutely 
developing  cases  there  may  be  a  sense  of  soreness  and  tenderness.  The 
general  health  does  not  seem  to  suffer  except  in  cases  in  which  the  itch- 
ing is  sufficiently  intense  to  interfere  with  sleep.  Digestive  disturbances, 
exhausting  mental  or  physical  labor,  and  similar  factors  have  an  aggra- 
vating influence  upon  the  eruption;  on  the  other  hand,  during  serious 
acute  systemic  disorders,  as  febrile  diseases,  the  eruption  will  materially 
lessen  or  wholly  disappear. 

Etiology.2— Observation  and  clinical  analysis  (Greenough,  Pye- 

1  Wollenberg  has  recently  reported  (Berlin,  kiln.  Wochcnschr.,  Jan.  n,  1909)  a  case 
and  reviewed  the  subject  (100  cases  on  record). 

2  The  whole  subject  of  the  etiology  is  gone  over  in  the  exhaustive  investigations 
by  Schamberg  (Schamberg,  Kolmer,  Raiziss,  and  Ringer) :  "Researches  in  Psoriasis 
Preliminary  Report,"  Jour.  Cutan.  Dis.,  Oct.,  1913;  "Studies  of  Protein  Metabolism 
in  Psoriasis,"  ibid.,  Nov.,  1913;  and  "Summary  of  Research  Studies  in  Psoriasis 
Jour.  Amcr.  Med.  Assoc.,  Aug.  29,  1914;  and  in  condensed  form,  Dermatolog.  Wocft- 
enschr.,  vol.  Ivii,  1913,  and  vol.  Iviii,  1914- 


244  INFLAMMA  TIONS 

Smith,  Bulkley,  Nielsen,  and  others)  furnish  data  as  to  some  of  the 
etiologic  facts.  The  disease  constitutes  2  to  3  per  cent,  of  all  skin 
cases,  varying  slightly  in  different  countries;  is  observed  in  both  sexes, 
although  occurring  somewhat  more  frequently  in  males;  in  all  ranks  of 
society,  and  at  almost  any  age  except  earliest  infancy — although  recently 
cases  have  been  recorded  (Kaposi,  Crocker,  Elliot,  Rille,  and  others)  in 
the  first  one  or  two  years  of  life  (the  youngest  case  by  Rille,  aged  six 
days).  I  have  met  with  an  extensive  case  at  the  age  of  three.  Its  first 
appearance  is,  however,  exceptional  before  the  age  of  five,  somewhat  rare 
before  the  age  of  seven  or  eight,  and  most  common  between  the  ages 
of  fifteen  and  thirty,  and  again  relatively  infrequent  after  forty.  The 
disease  is,  of  course,  often  seen  after  this  period,  but  usually  as  a  con- 
tinuation or  a  reappearance  of  former  outbreaks.  While  some  ob- 
servers, notably  Hebra,  believed  that  it  is  generally  seen  in  those  of  ap- 
parently good  physical  condition,  my  own  experience  would  indicate 
that  it  is  much  more  common  in  those  of  poor  health  and  enfeebled 
constitution.  Season  has  usually  a  very  important  influence,  in  almost 
all  cases  the  eruption  improving  markedly  in  the  summer,  and  in  many 
of  the  lighter  cases  entirely  disappearing,  usually  to  reappear  or  get  worse 
on  the  advent  of  cold  weather,  especially  toward  the  end  of  winter.  The 
disease  is  less  common  in  countries  of  warm  climate.1 

Inherited  rheumatic  and  gouty  tendencies  are  often  of  seeming 
etiologic  import  (Bourdillon,  Gerhardt,  Bulkley,  Shoemaker,  Corlett, 
Liveing,  and  others),  and  when  pronounced,  often  suggest  the  line  of 
treatment  likely  to  be  most  successful;  in  some  extreme  cases,  more  par- 
ticularly those  cases  developing  into  dermatitis  exfoliativa,  and  in  those 
recorded  as  psoriasis  rupioides,  arthritic  symptoms,  especially  of  the 
character  of  arthritis  deformans,  have  been  associated.  Defective 
kidney  elimination,  in  such  instances  and  in  others,  is  also  sometimes 
an  element  in  those  predisposed.  Digestive  and  nutritive  disturbances 
of  all  kinds  are  certainly  provocative  as  to  recurrences  and  of  probable 
causative  influence.  An  enfeebled  state  of  the  health  is  also  predisposing ; 
in  women  who  are  subjects  of  this  disease  the  eruption  is  usually  worse  or 
recurs  during  the  latter  part  of  pregnancy  and  during  the  nursing  period. 
It  sometimes  follows  a  severe  systemic  disease.  While  it  is  true  that  the 
attacks  often  occur  in  those  of  visibly  robust  habit,  yet  a  careful  investi- 
gation will  usually  disclose  that  this  is  more  apparent  than  real;  in  such 
patients  defective  kidney  elimination,  gouty  and  rheumatic  tendency, 
digestive  disturbances,  and  in  some  not  infrequently  excessive  indulgence 
in  alcoholic  stimulants,  are  factors  of  importance.  Intemperate  drink- 
ing of  tea  and  coffee  and  excessive  use  of  tobacco  are  sometimes  apparent 
adjuvant  factors.  It  has  no  relationship  to  struma  or  syphilis,  although 
either  condition,  by  bringing  on  a  depraved  state  of  health,  could  be  of 
import  in  provoking  an  outbreak  or  recurrence  in  those  predisposed. 
Bulkley,  Schamberg,  and  others  are  convinced  that  a  high  protein  diet 
has  a  distinct  causative  influence. 

1  Bulkley  ("Notes  on  Certain  Skin  Diseases  Observed  in  the  Far  East,"  Jour. 
Cutan.  Dis.,  Jan.,  1910)  states  that  psoriasis  seems  almost  unknown  in  the  warm  cli- 
mates of  the  East. 


PSORIASIS 


245 


That  heredity  is  seemingly  an  important  factor  is  well  attested  by 
clinical  experience  (E.  Wilson  placed  it  at  30  per  cent.),  and  is  a  much 
stronger  apparent  factor  than  is  generally  believed.  The  fact  that  the 
disease  is  often  present,  but  to  a  mild  degree,  together  with  the  repug- 
nance felt  toward  publicity  as  to  skin  affections,  doubtless  frequently 
keeps  the  knowledge  of  its  existence  even  from  other  members  of  the 
family.1  But  in  the  light  of  our  present  knowledge  and  changed  views 
of  leprosy  and  tuberculosis  one  can  reasonably  ask,  I  believe,  whether 
its  frequency  in  families  is  not  just  as  much  in  favor  of  communica- 
bility — a  parasitic  cause — as  of  heredity. 

Pathology. — The  most  probable  views  entertained  as  to  the  nature 
of  the  influences  which  start  the  histopathologic  changes  are  the  para- 
sitic and  the  neuropathic.  There  is  a  growing  belief  that  the  disease 
is  parasitic,  although  as  yet  there  is  no  uniformity  of  opinion  on  this 
point.  It  is  true  Lang  believed  he  had  found  a  fungus,  and  this,  or  an 
apparently  similar  one,  was  found  by  others  (Wolff,  Eklund,  Beissel), 
but  others  again  (Neisser,  Rindfleisch,  Majocchi,  and  others)  failed 
to  corroborate  Lang,  and  Ries'  exhaustive  investigations  show  that  the 
alleged  fungus  was  an  artificial  product  consisting  of  eleidin.  Other 
findings — micrococci  (Angelucci,  De  Matei),  morococci  (Unna),  and 
"minute  circular  bodies  with  central  dark  spots  loosely  clustered  and  in 
dense  masses"  (Crocker) — are  also  recorded,  but  their  significance  is  not 
established.  So  far,  then,  it  can  be  positively  stated  that  no  specific 
organism  has  as  yet  been  demonstrated.  But,  on  the  other  hand,  the 
clinical  character  and  behavior  of  the  eruption,  as  Lang  has  pointed  out, 
are  suggestive  of  a  parasitic  origin;  and  this  view  receives  still  further 
support  in  those  cases  of  apparent  communication  (Unna,  Hammer, 
Aubert,  and  others),  and  also  in  those  in  which  the  disease  started 
from  vaccination  (Klamann,  Rohe,  Piffard,  Wood,  Hyde,  Chambard, 
and  others) ;  and  this  seems  still  further  strengthened  by  the  few  appar- 
ently successful  inoculation  experiments  on  animals  (Lassar,  Tom- 
masoli),  and  in  one  instance  on  man  (Destot).  The  fact,  too,  that  new 
psoriasis  efflorescences  are  apt  to  appear  at  points  of  abrasion  is  like- 
wise suggestive,  although  this  may  also  be  used  in  support  of  the  neurotic 
view.  Upon  the  whole,  I  believe  it  is  in  the  field  of  pathogenic  organisms 
that  the  true  exciting  agent  of  this  disease  is  to  be  found,  the  various 
factors— age,  season,  gouty  and  rheumatic  tendencies,  debility,  etc.— 
being  contributory  in  preparing  the  "soil"  for  successful  parasitic  in- 
vasion. 

The  other  favorite  theory  of  the  production  of  psoriasis  is  the  neuro- 
pathic. In  its  support  are  mentioned  the  following  clinical  observations: 
Relation  or  association  with  arthritic  disease;  heredity;  its  appearance, 
and  sometimes  starting  at  points  of  cutaneous  irritation;  its  occurrence, 
though  rare,  over  peripheral  nerve  distribution,  and  its  unilateral  dis- 
tribution, already  referred  to;  its  occurrence  during  pregnancy  and 

1  Knowles,  "Psoriasis  Familialis,"  Jour.  Amer.  Med.  Assoc.,  Aug.  10,  1912,  p.  415, 
states  that  his  examination  of  case  records  shows  that  only  rarely  is  more  than  i 
case  found  in  a  family;  this  is  contrary  to  what  has  been  the  general  belief, 
had  under  observation  in  the  past  few  years,  3  cases  in  one  family— 2  sisters  anc 
brother. 


246 


INFLAMMA  TIONS 


lactation;  the  observation  of  outbreaks,  in  those  predisposed,  after  emo- 
tional attacks  (Leloir) ;  the  association,  though  rare,  with  lessened  tactile 
and  thermic  sense  (Rendu)  in  the  patches;  the  observation,  in  some  in- 
stances, of  associated  sciatica  and  pricking  sensations  in  the  ends  of  the 
fingers  and  toes  (Hebra) — all  would  seem  to  point  toward  a  neuropathic 
origin.  The  suggestions  that  it  is  due  to  reflected  irritation  from  the 
skin  to  the  spinal  center  (Kuznitzky),  to  purely  external  mechanical 
causes  (Kobner),  that  it  is  an  infection  (Bernay  and  Piery)  due  to  auto- 
toxin  poisoning  (Tommasoli)  and  that  there  is  primarily  a  weakened  vas- 
cular tone  (Unna),  or  functionally  weak  nervous  centers  regulating  the 
nutrition  of  the  skin  ( Weyl) ,  also  bear  upon  the  neuropathic  theory,  but 
have  as  yet  but  little  basis  of  support. 

Upon  the  character  of  the  histologic  changes  evoked  investiga- 
tions (Wertheim,  Neumann,  Hebra,  Kaposi,  Auspitz,  Bosellini,  Jamie- 
son,  Robinson,  Thin,  Crocker,  Unna, 
Jarisch,  Herxheimer,  Ries,  Kopy- 
towski,  and  others)  are  fairly  well 
agreed,  although  there  is  a  difference 
of  opinion  as  to  whether  the  proc- 
ess is  primarily  a  hyperplasia  of 
the  rete  (most  strongly  supported 
by  Jamieson,  Robinson,  Thin),  with 
induced  secondary  inflammatory 
changes,  or  whether  it  originates  as 
an  inflammation  of  the  papillary 


Fig.  50. — Psoriasis,  from  a  small  le- 
sion in  early  stage,  showing  considerable 
hyperplasia  of  the  rete,  especially  in  its 
interpapillary  portion.  Blood-vessels  of 
the  papillae  are  already  more  or  less  di- 
lated (courtesy  of  Dr.  A.  R.  Robinson). 


layer.  At  all  events,  among  the 
conditions  noted  are:  A  hyper- 
plasia of  the  rete,  except  directly 
over  the  papillae;  the  latter  are 
enlarged  both  laterally  and  up- 
ward; there  is  a  dipping-down  of 
the  interpapillary  processes,  enlargement  of  the  blood-vessels;  cell  ex- 
travasation in  the  upper  corium,  expecially  in  the  papillary  layer  and 
around  the  hair-follicles,  sweat-glands  ducts,  and  the  blood-vessels. 
Serous  exudation,  cell  exudation,  and  congestion,  together  with  the 
enlargement  of  the  papillae,  furnish  the  thickened  and  elevated  inflamma- 
tory base.  The  rete  cells  undergo  rapid  keratinization,  giving  rise  to  the 
enormous  increase  of  the  horny  layer.  Recent  investigations  (Munro), 
which,  however,  lack  confirmation,  disclose  the  first  step  in  the  formation 
of  a  lesion  to  be  a  minute  erosion  of  the  epidermis,  in  which  are  noted 
collections  of  leukocytes,  producing  microscopic  miliary  abscesses, 
the  subsequent  changes  being  due  to  the  epidermic  reaction.  Nar- 
decchia  has  studied  the  disease  in  alcoholics,  and  has  found  that  the  usual 
blood-vessel  changes  of  the  latter  are  made  much  more  pronounced  by 
the  psoriatic  process. 

Diagnosis. — A  well-developed  example  of  psoriasis  can  scarcely 
be  mistaken  for  any  other  eruption.  The  scattered,  rounded,  sharply 
defined,  variously  sized,  slightly  elevated,  scaly  plaques,  with  special 
preference  for  the  extensor  surfaces,  particularly  the  knees  and  elbows, 


PSORIASIS 


247 


and  not  infrequently  the  presence  of  patches  on  the  scalp,  particularly 
just  overstepping  the  hair-border  on  to  the  forehead  and  on  to  the 
mastoid  region;  the  usually  non-involvement  or  only  slight  or  moderate 
involvement  of  the  face,  and  absence  of  eruption  on  the  palms  and  soles; 
the  invariably  dry  nature  of  the  disease,  its  course  and  its  history,  which 
often  includes  recurrences,  together  with  the  evolution  and  uniform 
character  of  the  lesions,  all  go  to  make  up  a  picture  that  is  diagnostic. 
Ill-developed,  rapidly  developing,  and  atypical  cases  may  occasionally 
give  rise  to  difficulty,  but  such  instances  are  relatively  rare.  The  disease 
is  to  be  distinguished  chiefly  from  the  papulosquamous  syphiloderm, 
eczema,  dermatitis  seborrhoica,  seborrhea,  lichen  planus,  pityriasis 
rosea,  and  tinea  circinata. 


Fig.  51— Psoriasis— from  a  chronic  patch— showing  marked  hyperplasia  of  the 
rete  extending  deeply  downward  as  interpapillary  prolongations,  thus  giving  the  papillae 
increased  length.     The  secondary  inflammatory  changes  in  the  conum  are  seen,  witt 
enlargement  of  the  blood-vessels  (a),  in  the  cutis  proper  as  well  as  the  papillae,  and  extei 
sive  (b,  b)  perivascular  cell-infiltration  (courtesy  of  Dr.  A.  R.  Robinson). 

The  papulosquamous  syphiloderm  probably  bears  the  closest  re- 
semblance. The  syphilitic  eruption,  however,  shows  no  special  prefer- 
ence for  the  extensor  surfaces;  on  the  contrary,  it  is  not  infrequently 
more  marked  on  the  flexors;  patches  are  usually  to  be  seen  upon  the 
face,  and  frequently  on  the  palms  and  soles;  lesions  are  also  frequeni 
about  the  anus  and  genitalia,  where  they  often  become  abraded,  macer- 
ated, and  moist;  they  are  usually  much  less  scaly,  and  instead  of  bright 
or  dark  inflammatory  redness,  have  a  dull  ham  or  coppery  hue: 
is  distinct  infiltration;  there  are  generally  several  or  more  characteristic 
papules  to  be  found,  which  exhibit  no  tendency  to  scale-production;  and 
not  infrequently  a  few  scattered  pustules;  the  scales  are  dirty  gray  or 


248  INFLAMMA  TIONS 

brownish  gray,  rarely  ever  shining,  white,  and  lustrous;  the  patches  usu- 
ally spring  up  the  size  they  retain  with  but  little  tendency  to  peripheral 
extension;  they  are  very  rarely  larger  than  a  dime,  or  at  the  most  a  silver 
quarter.  Moreover,  the  disease  being  a  manifestation  of  the  active  or 
secondary  stage  of  syphilis,  other  concomitant  symptoms,  such  as  sore 
throat,  mucous  patches,  glandular  enlargement,  rheumatic  pains,  falling 
out  of  the  hair,  with  often  the  history  of  the  initial  lesion,  are  one,  several 
or  all  always  present.  It  will  be  noted  that  these  various  features  and 
characters  are  materially  different  from  those  of  psoriasis.  Further, 
the  papulosquamous  syphiloderm  rarely  itches,  except  in  the  negro, 
while  psoriasis  frequently  does;  in  short,  the  presence  of  moderate  or 
intense  itching  would  bear  conclusively  against  syphilis;  its  absence, 
however,  would  have  no  weight,  inasmuch  as  it  is  not  noted  in  a  large 
proportion  of  psoriasis  cases. 

The  tuberculosquamous  syphilid  is  a  late  or  tertiary  manifesta- 
tion, which  may  occasionally  show  considerable  scaliness,  but  the  dis- 
ease is  usually  limited  to  one  or  two  regions,  forming  one  or  more  groups 
of  circinate  or  serpiginous  configuration,  and  generally  shows  ulcerative 
tendency  and  scarring  or  pigmentation  and  atrophy.  It  is  rarely  located 
on  the  favorite  psoriasis  regions,  but  is  frequently  seen  on  the  face. 

Squamous  eczema  can  also  be  confused  with  psoriasis,  but  the 
former  never  shows  such  small,  rounded,  sharply  defined  patches; 
but  a  few  areas  generally  presenting,  and  these,  as  a  rule,  large ;  it  rarely 
has  such  scattered  distribution;  it  favors  the  flexor  aspects,  and  espe- 
cially the  flexures;  the  individual  areas,  even  when  small,  usually  result 
from  an  aggregation  of  papules,  some  of  which  can  be  often  seen  at  the 
border;  or  it  arises  from  a  thickened  erythematous  patch.  The  history 
and  course  of  the  individual  areas  are,  therefore,  different;  there  is  usu- 
ally a  history  or  the  presence  of  oozing  in  eczema,  especially  if  the  dis- 
ease is  at  all  extensive;  moreover,  the  hands  and  face  frequently  show 
the  disease,  regions  which  are  only  occasionally  or  slightly  invaded  in 
psoriasis.  Eczema  is  almost  always  intensely  itchy;  psoriasis  rarely 
so,  and  often  free  from  this  symptom. 

Dermatitis  seborrhoica  (eczema  seborrhoicum)  may  show  greater 
resemblance  than  ordinary  eczema,  inasmuch  as  it  is  often  patchy  in 
character;  the  scales  are,  however,  less  abundant,  greasy,  and  the  base 
beneath  is  not  infrequently  greasy  or  moist;  moreover,  dermatitis  sebor- 
rhoica frequently  takes  its  starting-point  from  an  ordinary  seborrhea 
(dandruff)  of  the  scalp  or  of  the  eyebrows,  and  usually  involves  the  upper 
part  of  the  body  first;  the  flexures,  too,  often  show  the  disease,  and 
seborrheic  patches  with  prolongations  into  the  gland-ducts  can  be  some- 
times found  over  the  sternum  and  between  the  scapulae;  in  these  latter 
regions,  too,  the  disease  is  often  primarily  ring-like  or  segmental  in 
shape.  The  patches  in  dermatitis  seborrhoica  may  arise  the  size  they 
retain;  those  of  psoriasis  always  develop  by  peripheral  extension  from  a 
small  lesion. 

Psoriasis  of  the  scalp,  especially  when  the  inflammatory  action  is 
slight,  may  be  confounded  with  seborrhea  of  that  region,  but  from 
the  average  case  of  the  latter  it  is  distinguished  by  its  scattered  patch- 


PLATE  VII. 


Psoriasis-unusnally  marked  tendency  to  gyrate  and  circulate  variety  on  trunk  ;  on 
the  extremities  the  ordinary  scattered,  rounded  patches.      Scales  have  been  partly  n 
moved  by  bathing.     Duration,  several  years;  subject,  male  adult  aged  thirty. 


PSORIASIS 


249 


formation,  its  often  projecting  just  beyond  the  hairy  border,  and  by  the 
dry  character  of  its  scales  and  its  inflammatory  element.  Seborrhea 
is  usually  diffused  over  the  entire  scalp,  with  little  if  any  tendency  to 
patch-formation.  Moreover,  in  cases  of  psoriasis  of  the  scalp,  in  many 
instances  small  lesions  are  often  to  be  found  on  the  elbows  and  knees. 

Lichen  planus  differs  from  psoriasis  in  that  the  papular  lesions 
are  flattened,  angular  in  outline,  usually  with  central  depression,  and 
dark  red  or  violaceous  in  color.  The  lesions  rarely  increase  in  size, 
and  never  materially,  the  scaly  patches  of  the  disease  resulting  from 
the  appearance  of  new  lesions  close  to  the  old,  finally  becoming  so 
crowded  as  to  form  solid  aggregations  or  patches;  but  round  about 
such  patches,  and  usually  elsewhere,  the  typical  papule  is  always  to 
be  found.  The  patches,  too,  are  violaceous  or  purplish  in  color,  and 
show  much  more  thickening  or  infiltration  than  observed  in  psoriasis. 
Moreover,  the  flexor  surfaces  of  the  wrists  and  forearms  and  the  leg 
near  the  ankle  are  favorite  sites,  with  but  little  if  any  disposition  to 
appear  on  the  extensors  of  the  knees  and  elbows  or  upon  the  scalp. 

Pityriasis  rosea  is  a  much  less  inflammatory  disease  than  psoriasis, 
and  the  eruption  comes  out  somewhat  rapidly,  reaching  its  full  devel- 
opment in  the  course  of  one  to  two  weeks,  and  is  chiefly  limited  to  the 
trunk  and  upper  parts  of  the  arms  and  legs.  The  extensor  surfaces  are 
not  especially  favored,  and  the  elbows  and  knees  rarely  show  patches 
unless  the  eruption  is  unusually  extensive.  The  scalp  is  never  involved. 
Some  of  the  patches  tend  to  become  somewhat  circinate  almost  from 
the  beginning.  The  scaliness  is  relatively  slight,  and  the  eruption  is  of 
a  duller  color,  and  frequently  with  a  yellowish  or  salmon  tinge.  More- 
over, the  process  is  an  extremely  superficial  one;  and  the  malady  tends 
to  spontaneous  disappearance  in  the  course  of  one  to  two  months. 

The  annular  patches  of  psoriasis  due  to  the  process  of  involution 
resemble  ringworm  to  some  extent,  but  the  scaliness  is  much  greater, 
the  inflammatory  thickening  more  pronounced.  Moreover,  such  lesions 
are  usually  numerous,  and  there  are  also  found  many  other  patches  in 
which  the  clearing  of  the  center  has  not  developed.  In  ringworm  seldom 
more  than  several  patches  are  seen,  and  the  border  is  rarely  so  pro- 
nounced, and  often  is  made  up  of  contiguous  papules  or  vesicopapules. 
Moreover,  the  history  and  distribution  are  wholly  different.  In  obscure 
cases  the  microscopic  examination  of  the  scrapings  could  be  resorted  to, 
but  this  is  rarely,  if  ever,  necessary. 

Lupus  erythematosus  patches,  if  carelessly  examined,  may  sug- 
gest psoriasis,  but  the  former  is  seen  almost  always  about  the  face,  and 
seldom  elsewhere,  whereas  psoriasis  patches  on  the  face  are  rare  and 
seen  only  in  connection  with  the  disease  on  other  parts  of  the  body. 
The  patches  of  lupus  erythematosus  are,  moreover,  entirely  different 
in  history  and  character.  Psoriasis  can  scarcely  be  confounded  with 
dermatitis  exfoliativa,  or  pityriasis  rubra  pilaris,  as  their  clinical  char- 
acters, history,  and  course  are  materially  different. 

Prognosis Psoriasis  is  a  disease  in  which  an  unqualified  opinion 

as  to  the  future  cannot  be  safely  ventured.  The  prognosis  is,  as  a  rule, 
favorable  as  to  the  immediate  eruption,  and  invariably  so  in  the  earlier 


250  INFLAMMA  TIONS 

attacks.  In  fact,  almost  all  attacks  can  be  relieved,  some  more  readily 
than  others,  provided  the  patient  persists,  but  this  persistence  is,  un- 
fortunately, often  lacking.  Freedom  from  recurrences,  with  possibly 
rare  exceptions,  is  not  to  be  expected.  The  patient  should  be  clearly 
informed  on  this  point,  as  timely  measures,  as  soon  as  the  malady  again 
first  presents,  will  frequently  head  off  an  extensive  outbreak.  The  in- 
tervals may  be  long  or  short — months  or  several  years  or  more.  In 
occasional  cases,  however,  the  attack  is  scarcely  at  end  before  another 
appears.  Subsequent  attacks,  especially  when  well  advanced,  are  less 
rapidly  responsive  than  the  first  eruption.  As  later  life  is  approached, 
however,  the  disease  often  becomes  less  active,  and  may  entirely  disap- 
pear. In  some  patients  prolonged,  and  exceptionally  more  or  less  perma- 
nent, freedom  from  the  disease  is  noted.  The  health  is  rarely  materially 
affected  by  the  eruption  except  in  those  instances,  relatively  infrequent, 
in  which  itching  is  sufficiently  intense  to  deprive  the  patient  of  restful 
sleep,  and  thus  bring  about  a  condition  of  nervous  and  physical  debility. 
In  exceptional  instances,  in  severe  and  oft-recurrent  or  continuous  cases, 
the  disease  may  finally  develop  into  a  true  dermatitis  exfoliativa,  and 
necessarily  assume  a  more  serious  aspect. 

The  cooperation  of  the  patient  will  often  have  a  material  influence 
in  rendering  the  disease  less  active  and  the  attacks  less  frequent;  it 
is  a  matter  of  observation  that  whatever  depresses  or  deranges  the 
equilibrium  of  the  general  health  will  have  some  weight  in  bringing  on 
an  attack  or  making  the  eruption  worse,  and  patients  should,  therefore, 
guard  against  all  factors  which  favor  such  tendencies.  I  have  always 
pointed  out  to  young  men  with  pronounced  to  severely  marked  types  of 
this  disease,  who  have  not  yet  planned  their  life-work,  the  advantages  of 
a  permanent  transfer  to  a  warm  climate. 

Treatment.1 — Whatever  plan,  both  in  external  and  internal 
treatment,  is  instituted,  it  should  be  continued  sufficiently  long  to 
judge  of  its  probable  effects,  unless  aggravation  is  noted  to  ensue.  In 
most  cases  a  change  from  one  plan  to  another  is  often  necessary,  espe- 
cially in  the  more  extensive  and  rebellious  cases. 

1  Some  literature  concerning  constitutional  treatment:  Greve  (potassium  iodid), 
Tidsskrift  for  praktisk  Medicin,  1881,  No.  16,  abstract  of  which  is  in  Archiv,  1882,  p. 
554;  Haslund  (potassium  iodid),  ibid.,  1887,  pp.  677  and  708;  Bramwell  (thyroid), 
Brit.  Med.  Jour.,  Oct.  28,  1893,  p.  934,  and  Brit.  Jour.  Derm.,  1894,  p.  193;  G.  T. 
Jackson  (thyroid),  Jour.  Cutan.  Dis.,  1894,  p.  409  (with  bibliography);  Thibierge 
(thyroid),  Annales,  1895,  p.  760;  Paschkis  and  Grosz  (iodothyrin)  (with  report  of 
cases  and  a  critical  review  of  the  entire  literature  of  the  thyroid  treatment,  with  full 
bibliography,  including  also  that  of  potassium  iodid),  Wien.  klin.  Rundschau,  1896,  pp. 
609,  629,  646,  664;  Passavant  (meat  diet),  Archiv  fur  Heilkunde,  1867,  p.  251;  Crocker 
(salicin  and  salicylates) ,  Lancet,  June  8,  1895,  p.  193;  Brault  (mercurial  injections), 
Annales,  1895,  vol.  vi,  p.  676;  Mapother  (mercurial  treatment),  Brit.  Med.  Jour.,  Jan. 
17,  1891;  Danlos  (cacodylic  acid),  Annales,  1897,  pp.  198,  559;  Gijselman  (sodium 
cacodylate),  Wien.  klin.  Wochenschr.,  1899,  p.  363;  Rille  (sodium  cacodylate),  Monats- 
fiefte,  1899,  vol.  xxviii,  p.  140;  Murrell  (sodium  cacodylate)  (untoward  action,  letter 
communication,  Lancet,  Dec.  29,  1900;  Balzer  et  Griffin  (cacodylic  acid)  (a  resulting 
exfoliative  dermatitis),  Annales,  1897,  p.  732;  Bulkley,  "Report  of  140  Recent  Cases  of 
Psoriasis  in  Private  Practice  under  a  Strictly  Vegetarian  Diet,"  Jour.  Amer.  Med. 
Assoc.,  Aug.  26,  1911,  p.  714;  Sabouraud,  La  CHnique,  June  7,  1912,  and  Due,  ibid., 
July  5i  I9I2>  had  some  promising  effects  from  injection  of  enesol;  Winfield,  "Lactic 
Acid  and  Colonic  Irrigation  in  the  Treatment  of  Psoriasis,"  Jour.  Amer.  Med.  Assoc., 
Aug.  10,  1912,  p.  416. 


PSOHIASIS 


251 


In  the  systemic  treatment  of  psoriasis,  as  in  almost  all  of  the  chronic 
skin  diseases,  each  individual  case  must  receive  careful  study,  for  very 
often  it  is  noted  that  the  patient  is  in  need  of  treatment  fully  as  much 
for  himself  as  for  the  eruption;  all  possible  etiologic  factors  should  be 
kept  in  mind.  His  diet  should  be  supervised,  alcoholic  stimulants 
practically  withheld,  except  in  old  debilitated  subjects;  smoking  kept 
within  moderate  limits  or  interdicted,  and  an  excess  of  tea,  coffee,  and 
richly  seasoned  food  avoided.  In  many  cases  it  will  not  be  necessary 
to  interfere  with  the  diet  beyond  limiting  it  to  easily  digested  food; 
in  others,  especially  in  those  of  a  plethoric  habit,  meat  should  be  cut  down 
or  for  a  time  prohibited — Schamberg  is  convinced  by  his  research  studies 
that  a  low  protein  diet  is  of  great  value,  a  view  shared  by  Bulkley.  The 
state  of  the  nervous  system  should  be  inquired  into,  and  all  depressing 
influences  guarded  against.  In  fact,  the  patient  is  to  be  placed  in  as 
perfect  a  state  of  health  as  it  is  possible  to  attain.  Open-air  pleasures 
and  sufficient  exercise,  systematically  taken,  will,  in  some  individuals, 
have  a  material  effect  in  aiding  the  medicinal  treatment.  Living  as  much 
as  possible  in  the  sunlight  is  beneficial  (Hyde  and  Montgomery) — 
psoriasis  is  not  common  upon  exposed  parts. 

In  the  constitutional  treatment,  therefore,  in  many  instances,  each 
case  must  be  handled  upon  its  merits,  and  upon  this  basis  much  good 
can  be  done,  and  often  without  resorting  to  the  several  special  remedies, 
which,  while  of  service  in  removing  the  eruption,  are  often  detrimental 
to  digestion.  If  constipation  is  present,  it  is  to  be  corrected  by  suit- 
able laxatives,  preferably  the  salines,  and  these  are  especially  of  service 
in  the  acute  and  rapidly  developing  disease.  Indigestion  is  to  be  treated 
with  tonics,  digestives,  acids,  or  mild  alkalies,  as  may  seem  indicated, 
and  the  diet  regulated  accordingly.  Winfield  has,  on  the  basis  of  faulty 
metabolism,  treated  a  series  of  cases  with  lactic  acid  internally  and 
colonic  irrigation  with  promising  results.  Neurasthenic  conditions  are 
to  be  modified  or  removed  by  the  use  of  tonics,  such  as  strychnin,  quinin, 
iron,  and  the  sedatives,  such  as  lupulin,  asafetida,  potassium  bromid, 
and  ergot,  and,  if  deemed  necessary,  by  general  galvanization,  faradiza- 
tion, and  static  electricity.  In  gouty  conditions  the  alkalis  are  to  be 
employed,  sodium  salicylate,  potassium  bicarbonate,  potassium  acetate, 
and  liquor  potassae  being  those  most  commonly  prescribed;  potassium 
iodid  in  full  doses  also  will  act  well  in  some  gouty  cases.  If  the  general 
nutrition  is  below  par,— as,  for  instance,  in  the  attacks  of  psoriasis  occur- 
ring or  relapsing  during  pregnancy  and  lactation, — tonics,  and  espe- 
cially cod-liver  oil  and  the  hypophosphites,  should  be  advised;  the  oil, 
which  is  often  extremely  valuable,  can  be  given  in  doses  of  a  half  to  one  or 
two  teaspoonfuls,  either  pure,  in  emulsion,  or  in  capsules,  the  last-men- 
tioned method  being  ordinarily  the  most  pleasant. 

In  many  cases  of  the  disease,  however,  it  will  be  difficult  to  dis- 
cover any  material  fault  in  the  general  health,  and  dependence  is  then 
to  be  placed  on  the  special  remedies  alone.  Thus  there  are  several 
drugs  that  experience  has  shown  to  be  of  special  value.  These  are 
arsenic,  ordinary  alkalies,  sodium  salicylate,  salicin,  potassium  iodid, 
thyroid,  copaiba  and  turpentine  oils,  and  carbolic  acid.  Of  these, 


252  INFLAMMA  TIONS 

arsenic  is  the  most  valuable  and  the  most  constant  in  its  effects.  Patients 
are  met  with,  however,  who  are  intolerant  to  even  small  doses.  In 
all  fresh — first — outbreaks  of  this  disease,  if  not  of  an  acutely  inflam- 
matory character,  the  judicious  administration  of  this  drug  will  often 
bring  about  a  surprising  improvement  in  a  short  time,  and  rapidly 
cause  an  entire  disappearance  of  the  eruption.  In  old-standing  cases 
or  in  recurrent  attacks  in  those  who  have  had  no  systematic  treatment 
and  who  have  probably  never  been  regularly  treated  with  the  drug,  the 
same  favorable  effect  is  often  noted.  In  acutely  inflammatory  cases 
or  attacks,  especially  when  the  disease  is  rapidly  spreading,  the  drug 
may  do  actual  harm,  in  that  the  inflammatory  symptoms  are  increased 
and  fresh  outcroppings  stimulated.  In  recurrent  attacks  in  those  who 
have  previously  been  subjected  to  arsenical  treatment,  the  drug  seems 
to  lack  its  earlier  power  for  good,  even  large  doses  often  failing  to  influence 
the  eruption  favorably.  It  is  prescribed  in  several  forms:  as  Fowler's 
solution,  arseniate  of  sodium  solution,  arsenious  acid,  and  sodium  caco- 
dylate,  the  first  named  most  commonly.  The  dose  varies  in  different 
individuals,  the  beginning  dose  being  usually  3  minims  (0.2)  of  the 
solution  of  potassium  arsenite,  or  its  equivalent  of  the  other  preparations, 
and  increasing  slowly,  if  the  disease  is  not  being  favorably  influenced, 
to  5  minims  (0.33)  three  times  daily.  In  rare  instances  the  dose  of  10 
minims  (0.66)  and  larger  quantity  may  be  safely  reached  and  continued. 
As  a  rule,  the  dose  is  increased  until  its  good  effect  upon  the  eruption 
is  noted,  and  then  kept  at  the  same  dosage,  intermitting  for  a  day  or 
two  if  disturbing  symptoms  arise,  and  then  beginning  again  at  a  slightly 
smaller  dose,  and  increasing  up  to  the  former  quantity.  The  drug 
should  be  continued  one  or  two  months  after  the  eruption  has  disap- 
peared, but  in  somewhat  smaller  amount.  If  moderate  doses  fail  to 
benefit,  the  chances  are  that  larger  doses  will  prove  futile  also,  or  only 
benefit  the  eruption  temporarily  and  at  the  expense  of  gastric  and 
intestinal  disturbance  or  nervous  symptoms  traceable  to  the  treatment. 
The  drug,  therefore,  while  often  powerful  for  good  if  judiciously  admin- 
istered, may,  if  care  is  not  exercised,  be  productive  of  harm.  Occa- 
sionally its  prolonged  administration  in  large  dosage  produces,  in  addition 
to  possible  digestive  and  nervous  disturbance,  a  more  or  less  general 
pigmentation  of  the  skin,  which,  however,  gradually  subsides  when 
the  drug  is  discontinued;  palmar  and  plantar  epidermic  thickening  or 
callosities  and  wart-like  horny  formations  may  also  exceptionally  result, 
and  the  latter  may  even  undergo  epithelial  degeneration.  Evidences  of 
palmar  and  plantar  epidermic  thickening  from  its  administration,  should, 
therefore,  be  considered  a  signal  for  its  withdrawal  and  discontinuance. 
The  solution  of  sodium  arsenite  is,  I  believe,  less  apt  to  disturb 
the  stomach,  and  seems  equally  efficacious,  and  should  be  prescribed 
in  those  of  weak  digestion  in  preference  to  Fowler's  solution.  Arseni- 
ous acid  is  a  convenient  form,  inasmuch  as  it  can  be  readily  prescribed 
in  pills;  the  dose  should  be  at  the  start  about  ^  to  ^  of  a  grain  (0.0016 
to  0.0021),  and  increased  to  -£$  (0.0032),  and  even,  if  necessary  and 
there  are  no  centra-indications,  up  to  yT  grain  (0.0065)  or  more  three  times 
daily;  this  drug  is  also  sometimes  administered  by  hypodermic  injection. 


PSORIASIS  253 

It,  as  the  other  arsenical  preparations,  can  be  given  along  with  strychnin, 
quinin,  and  iron,  if  indicated.  A  favorite  method  of  prescribing  arsenious 
acid  is  as  the  so-called  Asiatic  pill,  made  up  of  •£$  to  y1^  grain  (0.0032- 
0.0065)  arsenious  acid  and  ^  grain  (0.033)  black  pepper,  with  acacia  or 
licorice  root  as  the  excipient. 

The  arsenical  preparations  are  usually  adminstered  by  the  mouth, 
and  this  is  the  most  convenient  method,  but  its  administration  by  sub- 
cutaneous injection  is  usually  more  rapid  in  its  results,  but  it  is  a  some- 
what painful  method,  and  requires  great  care  to  avoid  abscess  formation. 
The  solutions  of  sodium  arsenite,  potassium  arsenite,  and  sodium  caco- 
dylate  are  employed.  I  have  occasionally  used  this  method  with  ad- 
vantage in  obstinate  cases,  employing  Fowler's  solution,  sterilized,  and 
with  |  grain  (0.008)  carbolic  acid  to  each  dose  of  5  minims  (0.33),  begin- 
ning at  first  with  3  minims  (0.2),  with  4  or  5  parts  water,  and  increasing 
gradually,  giving  a  daily  injection.  Sodium  cacodylate,  administered  by 
hypodermic  injection,  in  doses  of  \  to  3  grains  (0.03-0.2),  at  intervals  of 
one  to  three  days  is  occasionally  valuable.  Salvarsan  has  also  been 
tried,  but  has  only  exceptionally  shown  special  value.1  Sabouraud  and 
Due  (loc.  tit.)  have  had  some  promising  results  from  enesol.  In  occa- 
sional instances,  as  the  result  of  arsenical  treatment,  pigmentation  is 
noted  on  the  sites  of  the  plaques  after  their  disappearance. 

The  alkalis  are  usually  most  promising  in  cases  in  which  there 
is  an  apparent  gouty  or  rheumatic  predisposition;  but,  irrespective  of 
these  conditions,  in  patients  of  plethoric  habit  and  of  apparent  robust 
health,  and  especially  in  the  markedly  inflammatory  types  and  those 
of  acute  and  rapid  development  of  the  disease,  the  administration  of 
these  remedies,  especially  liquor  potassae  (Thomson,  Bell,  Duhring), 
will  frequently  have  a  marked  influence  toward  promoting  the  disap- 
pearance of  the  eruption;  it  is  not  appropriate  for  those  of  anemic  tend- 
ency or  condition,  nor  for  those  of  enfeebled  health.  The  dose  of  liquor 
potassae  should  be,  at  first,  10  minims  (0.65)  three  times  daily,  rapidly  in- 
creasing to  20  or  even  30  minims  (1.33  to  2.),  always  being  taken  largely 
diluted.  In  established  cases  in  such  patients,  even  when  the  eruption 
is  of  a  decidedly  inflammatory  aspect,  a  prescription,  such  as  the  follow- 
ing, containing  both  the  potassium  arsenite  solution  and  liquor  potassae, 
can  often  be  used  with  advantage,  and  can  also  be  prescribed  cautiously 
in  cases  in  which  the  development  is  still  active: 

fy    Liq.  potass,  arsenit.,  f3ij-"j  (8-12.); 

Liq.  potass^,  f3iv-f5J  (16-32.); 

Aqvue  menth.  pip.,  q.  s.  ad  f  5nj  (96-). 

SIG.— A  teaspoonful  in  at  least  a  half  tumblerful  of  water  after  each  meal. 

Potassium  acetate  is  another  alkali,  as  well  as  a  diuretic,  that  has  gained 
some  reputation,  in  doses  from  of  10  to  30  grains  (0.65  to  2.)  three  times 
daily.  Sodium  salicylate  and  salicin  (Crocker)  are  occasionally  of  de- 
cided benefit,  and  not  necessarily  limited  to  those  of  arthritic  tendencies 
nor  to  any  special  class  of  cases,  although  more  valuable  in  the  arthritic, 
the  former  doubtless  by  its  alkaline  character.  Sodium  salicylate  is 
•  Schwabe,  Miinchen.  med.  Wochenschr.,  1910,  Ivii,  No.  36  (results  disappointing). 


i 


254  IN  FLAM  MA  TIONS 

given  in  dosage  from  5  to  20  grains  (0.33  to  1.33),  and  salicin,  from  10  to 
30  grains  (0.65  to  2.),  three  times  daily,  beginning  with  the  smaller  dose, 
and,  if  well  borne,  increasing.  Salicin  is  less  apt  to  disturb  digestion 
than  the  sodium  salicylate.  In  place  of  the  latter,  ammonium  salicylate 
can  be  given.  Almost  all  these  alkaline  remedies  are  diuretic,  and  this 
probably  also  measurably  aids  in  their  favorable  action. 

Potassium  iodid,  in  doses  of  from  10  to  120  grains  (0.65  to  8.)  or  more 
three  times  a  day,  has  in  recent  years  been  extolled  (Greve,  Boeck,  Has- 
lund,  Hillebrand)  as  having  a  specific  effect,  which  is  probably  partly, 
although  not  wholly,  due  to  its  alkaline  character.  While,  in  my  ex- 
perience, its  favorable  action  is  far  from  being  so  constant  as  claimed 
for  it,  it  is  occasionally  of  distinct  service.  The  larger  doses  are,  however, 
usually  required,  and,  of  course,  while  taking  such,  the  patient  needs 
careful  supervision. 

Oil  of  turpentine  (Crocker),  oil  of  copaiba  (Hardy,  Simms,  McCall 
Anderson),  and  similar  remedies  have  likewise  acted  well  in  some  cases, 
given  in  doses  of  from  10  to  30  minims  (0.65  to  2.).  They  are  best  given 
in  emulsion,  largely  diluted,  and  during  their  use  frequent  potations 
of  barley-water  or  other  diluent  should  be  taken  to  prevent  any  irri- 
tating action  upon  the  kidneys.  In  several  extensive  cases  under  my 
care  the  oil  of  copaiba  proved  effective  in  reducing  the  extent  of  the 
disease,  but  it  often  fails  absolutely.  The  wine  of  antimony  has  also  been 
commended  (Malcolm  Morris)  in  cases  of  an  acute  type  in  the  dose  of 
from  5  to  10  minims  (0.33  to  0.65)  three  times  daily;  it  should  not  be 
given  in  those  cases  in  which  there  is  general  systemic  depression,  and  its 
administration  should  always  be  carefully  watched. 

Thyroid  feeding  several  years  back  was  strongly  supported  (B  ram- 
well)  by  the  report  of  several  brilliant  cures,  but  the  experience  of 
others  (Thibierge,  Zarubin,  Jarisch,  Jackson,  and  others)  subsequently 
has  been,  upon  the  whole,  unfavorable,  and  the  remedy  is  now  rarely 
used  for  this  disease.  My  own  observations  are  in  accord  with  its  nega- 
tive action  in  most  cases,  but  it  has  been  of  service  in  a  few  instances 
in  which  other  plans  had  failed,  so  I  believe  it  is  entitled  to  be  considered 
as  a  reserve  remedy  for  trial  in  rebellious  cases.  The  dose  should  be  small 
at  first — \  to  i  grain  (0.033  to  0.065)  °f  the  desiccated  gland,  and,  if 
necessary  and  well  borne,  increasing  to  5  grains  (0.33)  or  more  three 
times  daily.  Its  use,  however,  requires  caution,  and  the  remedy  should 
be  watched  and  discontinued  if  untoward  symptoms  arise.  lodothyrin, 
an  equivalent  preparation,  has  also  been  commended  (Paschkis  and 
Grosz).  I  have  occasionally  seen  benefit  from  Donovan's  solution.  The 
subcutaneous  injection  of  mercury  has  been  commended  by  Brault  and 
Besnier. 

Carbolic  acid,  which  had  the  sanction  of  Kaposi,  has  served  me  in 
some  cases,  but  it  must  be  administered  in  full  dosage.  It  is  best  ad- 
ministered in  solution  in  glycerin  and  water  (i  to  3),  each  dram  (4.) 
containing  2  grains  (0.13)  of  chemically  pure  carbolic  acid;  beginning 
with  a  teaspoonful  (given  diluted  in  a  third  to  a  half  tumblerful  of 
water  or  more)  three  times  daily,  and  after  a  few  days,  the  same  dose  four 
times  daily,  and  so  gradually  up  to  six  times  daily;  and  then,  if  no  im- 


PSORIASIS 


255 


provemen  •  more  slowly,  adding  to  each  dose  till  20  to  30  grains  (1.25-2) 
are  given  daily.  Signs  of  toxic  action  should  be  watched  for,  but  if  the 
drug  is  pure  it  is  unusual  to  see  any  such  action.  It  is  contra-indicated 
in  those  with  kidney  disease.  Tar  is  another  remedy  that  at  one  time 
had  some  support,  and  it  probably  owes  its  alleged  favorable  action  to  its 
derivative,  carbolic  acid.  Pilocarpin  is  also  of  a  value  in  some  cases. 

The  various  alkaline  and  sulphur  springs,  especially  the  former,  are 
also  of  service,  partly  by  the  fact  that  change  to  other  scenery,  climate, 
etc.,  is  often  of  benefit  to  the  patient's  general  health,  but  also  by  the 
free  drinking  of  the  waters  and  the  frequent  baths  indulged  in. 

The  external  treatment  of  psoriasis  is  demanded  in  almost  every 
instance.  The  exceptions  are  those  cases  in  which  the  inflammatory 
symptoms  are  slight  and  the  patches  comparatively  few  in  number,  and, 
for  the  most  part,  vary  from  the  size  of  a  pin-head  to  that  of  a  pea.  In 
such  cases  a  result  is  very  often  achieved  by  the  internal  treatment, 
with  possibly  a  warm  plain  or  alkaline  bath  daily  or  three  or  four  times 
weekly.  As  a  rule,  however,  in  moderate  and  well-marked  cases  exter- 
nal treatment  is  essential;  and  even  in  instances  in  which  the  constitu- 
tional management  of  the  case  seems  to  be  bringing  about  a  favorable 
result,  external  remedies  will  materially  aid  in  shortening  the  course  of 
the  disease.  In  fact,  in  those  instances,  fortunately  not  numerous,  in 
which  constitutional  medication  has  absolutely  no  influence,  external 
measures  are  the  sole  recourse,  and  the  treatment  of  psoriasis  without  such 
aid  would  be  onty  too  frequently  disappointing.  The  primary  object  in 
view  is  to  rid  the  patches  of  the  scaliness.  In  many  cases  in  which  the 
scales  are  but  slightly  adherent  this  is  accomplished  by  the  baths  to  be 
referred  to.  In  the  mild  cases  it  is  well  to  prescribe  a  daily  ordinary  bath ; 
if  the  scales  remain  adherent  or  are  only  partly  removed,  the  bath  may  be 
made  alkaline  by  the  addition  of  sodium  carbonate,  sodium  biborate,  or 
sodium  bicarbonate,  from  2  to  6  ounces  (64.  to  192.)  to  the  bath;  a  much 
more  efficient  alkaline  bath  in  adherent  scaly  cases  is  one  made  with  sal 
ammoniac  in  the  same  proportion.  The  patient  remains  in  this  from 
ten  to  thirty  minutes,  and  rubs  himself  dry  with  a  soft  towel.  If  the 
skin  is  harsh  and  dry,  or  if  it  becomes  so  after  several  days'  use  of  the 
alkaline  baths,  an  ointment  consisting  of  petrolatum  or  lard,  or  equal 
parts  of  these,  with  from  10  to  20  grains  (0.65  to  1.33)  of  salicylic  acid  to 
the  ounce  (32.),  is  rubbed  in  after  each  bath;  if  the  lesions  are  small,  the 
ointment  is  simply  rubbed  over  the  affected  regions,  without  reference 
to  the  individual  spots,  and  the  skin  then  wiped  off.  If  some  of  the 
lesions  are  large,  into  these  the  ointment,  or  a  stronger  one,  with  20  to 
40  grains  (1.23  to  2.65)  to  the  ounce  (32.),  can  be  rubbed.  In  many  of 
the  milder  cases  this  plan,  in  conjunction  with  proper  internal  treatment, 
will  bring  about  a  disappearance  of  the  eruption.  In  such  instances  if 
there  is  any  eruption  upon  exposed  parts,  this  same  salve  can  be  used,  or, 
preferably,  as  usually  more  rapid  in  effect,  an  ointment  of  white  precipi- 
tate, from  20  to  60  grains  (1.33  to  4.)  to  the  ounce  (32.);  this  can  be 
rubbed  into  these  patches  twice  daily. 

In  the  more  severe  and  extensive  cases  this  same  plan  of  bath  treat- 
ment can  be  carried  out,  followed  by  the  general  application  of  the 


2  5  6  IN  FLA  MM  A  TIONS 

salicylated  ointment  if  necessary,  and  the  application  of  one  of  the 
stronger  remedies  to  be  referred  to,  to  the  larger  patches  individually. 
In  fact,  in  all  instances  the  baths  have  in  view,  in  addition  to  some 
possible  therapeutic  effect,  a  removal  of  the  scales,  inasmuch  as  smear- 
ing or  painting  even  an  active  remedy  over  the  scales  will  have  no  ef- 
fect upon  the  disease.  In  these  more  severe  and  more  markedly  scaly 
cases  the  above  baths,  with  frequent  anointing  with  the  salve  named,  or 
with  a  bland  oil,  as  olive  or  almond  oil,  will  often  suffice  to  remove 
the  scales,  but  it  is  sometimes  necessary  to  use  sapo  viridis  along  with 
the  baths.  Or  the  Turkish  or  home  cabinet  steam  or  hot-air  bath 
can  be  used  for  this  purpose,  these  latter  sometimes  having  a  ma- 
terial therapeutic  influence  as  well.  In  exceptional  cases  linen  rags 
or  cotton  soaked  in  oil  can  be,  during  the  interim  of  the  baths,  kept 
wrapped  around  the  worst  parts  and  enveloped  with  waxed  paper  or 
other  impermeable  dressing.  In  extreme  cases  of  markedly  adherent 
scale  accumulation,  more  especially  when  the  bath  plans  cannot  be 
conveniently  employed,  rubber-cloth  underwear  can  be  worn  for  sev- 
eral hours  daily,  which  produces  active  sweat  secretion  and  conse- 
quent softening  and  maceration.  Some  skins  are  readily  irritated  by  it, 
however;  in  others  of  sluggish  integument  such  treatment  alone,  if 
persisted  in,  will  sometimes  suffice  to  remove  the  disease;  there  is  less 
chance  of  irritation  if  a  thin  garment  is  worn  between  the  rubber  and  the 
skin.  In  cases  in  which  there  are  but  few  areas,  one  or  several  applica- 
tions of  a  3  to  6  per  cent,  alcoholic  solution  of  salicylic  acid  will  permit 
the  scales  to  be  easily  rubbed  off  or  scraped  off  with  a  curet. 

With  these  general  preliminary  remarks  as  to  the  removal  of  the 
scales,  management  of  the  milder  cases,  etc.,  the  various  more  active 
remedies  most  commonly  employed  in  the  average  cases  met  with, 
and  which  have  often  rendered  me  more  or  less  satisfactory  service, 
can  be  individually  referred  to.  Aristol  is  a  mild  one,  and  in  irritable 
cases  sometimes  valuable,  prescribed  as  a  5  to  10  per  cent,  ointment 
or  a  10  per  cent,  etheric  solution ;  if  the  latter,  it  is  painted  on  and  coated 
over  with  a  film  of  collodion,  and  repeated  wrhen  it  becomes  detached. 
In  some  instances  I  have  used  on  the  larger  patches  iodin  tincture  full 
strength  or  diluted  with  alcohol,  depending  upon  the  sensitiveness  of  the 
skin;  this  is  painted  on  as  a  light  coating  and  rapidly  dries;  if  desired,  over 
this  can  be  painted  a  coating  of  collodion.  While  this  treatment  is  being 
carried  out  with  these  larger  areas  the  general  plan  already  outlined  can 
be  continued;  the  painting  is  renewed  as  soon  as  the  film  or  iodin  coating 
has  come  off,  provided  there  is  no  irritation,  in  wrhich  event  the  repainting 
is  postponed.  When  the  patches  show  no  reaction  from  the  iodin 
painting  and  no  improvement,  two  or  three  coats  can  be  put  on  at  the  one 
time.  It  sometimes  acts  satisfactorily. 

Tar,  in  its  various  forms  and  varieties,  has  long  been  in  use  as  an 
external  remedy  in  the  treatment  of  psoriasis,  and,  all  things  consid- 
ered, it  is  an  extremely  valuable  one.  In  rare  instances  of  extensive 
application  toxic  symptoms  from  absorption  have  arisen,  but  these 
subside  rapidly  upon  withdrawal  of  the  drug.  Although  I  use  tar 
freely  in  the  cases  of  psoriasis  in  the  skin  wards  of  the  Philadelphia 


PSORIASIS 


257 


Hospital,  I  have  never  observed  such  an  accident.  Its  positive  odor 
makes  it  somewhat  objectionable  for  every-day  practice,  but  this  does 
not  hold  as  an  objection  to  the  coal-tar  preparation,  and  with  this 
latter  the  odor  soon  disappears.  This  preparation,  too,  will  often  agree 
where,  from  sensitiveness  of  the  skin  or  idiosyncrasy,  the  other  tar 
applications  irritate.  It  is  much  less  active,  however,  than  the  wood- 
tars,  but  in  mild  and  moderate  cases  it  has  often  proved  of  benefit. 
The  proprietary  preparation  is  known  under  the  name  of  liquor  car- 
bonis  detergens,  but  an  equally  good  or  superior  one  can  be  made  from 
the  formula  given  under  Eczema,  and  is  the  one  most  commonly  used 
\>y  my  Philadelphia  colleagues  and  myself.  It  may  be  applied  as  an 
ointment,  2  drams  (8.)  to  the  ounce  (32.)  of  simple  cerate,  or  with  lanolin 
and  simple  cerate;  or  it  may  be  rubbed  in  as  a  wash,  diluted  with  several 
parts  of  water;  the  pure  solution  may  sometimes  be  used  without  pro- 
ducing irritation.  Another  method  of  employing  this  coal-tar  solution, 
which,  however,  makes  a  much  stronger  application,  is  as  a  mixture  with 
an  equal  quantity  of  Vleminckx's  solution  (liquor  calcis  sulphuratae), 
another  active  psoriasis  remedy,  diluting  with  from  one  to  several  parts 
of  water  as  may  be  required;  occasionally  it  may  be  used  pure.  When 
this,  or  either  singly,  is  used  as  a  wash,  a  mild  ointment  should  be  ap- 
plied after  each  application,  otherwise  the  skin  tends  to  become  harsh  and 
dry. 

The  other  tar  preparations — the  vegetable,  or  wood,  tars — may  be 
prescribed  in  various  ways.  The  most  common  one  is  as  the  official 
tar  ointment,  at  first  weakened  with  lard  or  petrolatum — 2  parts  of 
tar  ointment  to  6  parts  of  the  diluent,  and  if  necessary  gradually  in- 
creasing the  proportion,  sometimes  finally  using  the  pure  tar  ointment; 
this  is  the  most  active  probably,  but  the  most  offensive  as  to  odor  and 
color.  Another  form,  and  that  most  frequently  prescribed,  is  as  the  oil 
of  cade  (oleum  cadinum)  or  the  oil  of  birch  (oleum  rusci),  i  or  2  drams 
(4.  to  8.)  to  the  ounce  (32.)  of  lard,  petrolatum,  or  simple  cerate.  In 
other  cases  the  tar  oil,  the  oil  of  cade,  or  oil  of  birch,  weakened  with  i  or 
2  parts  of  alcohol  or  liquid  petrolatum,  may  be  used.  The  application 
selected  is  to  be  thoroughly  rubbed,  in  small  quantity,  into  the  affected 
areas,  the  excess  wiped  off,  and  a  dusting-powder  applied.  Another 
mode  of  employing  tar  which  may  occasionally  be  used  with  satisfaction 
is  in  the  form  of  a  paint,  i  dram  (4.)  of  the  oil  of  tar,  oil  of  cade,  or  oil  of 
birch  to  the  ounce  (32.)  of  collodion.  The  quantity  of  oil  contained  in  the 
formula  makes  it  dry  with  comparative  slowness,  but  the  dressing  is  effi- 
cient in  some  instances,  and  remains  adherent  from  one  to  several  days. 

Chrysarobin  (chrysophanic  acid)  has  an  important  place  in  the  exter- 
nal treatment  (Squire)  of  this  disease.  The  advantage  of  this  remedy  is  its 
rapidity  of  action.  It  is  adapted  to  cases  in  which  the  patches  are  com- 
paratively few  and  large,  or  to  the  larger  patches  in  extensive  cases.  Its 
disadvantages  are  that  it  stains  both  the  garments  and  the  skin,  the  former 
permanently,  the  latter  temporarily;  it  occasionally  excites  a  mild  or 
severe  dermatitis  in  the  surrounding  skin.  The  patient  should  be  cau- 
tioned against  carrying  the  application  to  the  eyes,  as  conjunctivitis  of 
varying  severity  may  thus  be  provoked;  it  should,  therefore,  not  be  em- 
17 


258  IN  FLA  MM  A  TIONS 

ployed  for  patches  of  psoriasis  on  the  face  or  the  scalp.  If  carefully  used, 
however,  and  in  the  paint  or  film  forms,  these  untoward  effects,  except 
staining,  rarely  present  to  an  annoying  degree.  Accidental  irritation  does 
not,  however,  necessarily  mean  the  giving  up  of  this  plan  of  treatment; 
as  soon  as  it  subsides  it  can  be  cautiously  resumed,  and  if  there  is  no 
further  irritation,  continued. 

Chrysarobin  is,  on  the  whole,  the  most  powerful  local  remedy  we  have 
in  the  treatment  of  psoriasis,  and  if  propery  used,  frequently  removes 
the  eruption.  It  is  to  be  usually  employed  as  a  powdery  film  or  as  a 
paint,  the  latter  being  the  less  active.  Its  efficacy  is  sometimes  enhanced 
by  the  addition  of  salicylic  acid. 

In  its  use  as  a  powdery  film  (Besnier)  the  drug  is  mixed  with  chloro- 
form, i  to  2  drams  (4.  to  8.)  to  the  ounce  (32.);  or  it  may  be  used  as  a 
saturated  solution,  chloroform  taking  up  about  40  grains  (2.65)  to  the 
ounce  (32.).  The  patches,  freed  from  scaliness,  as  before  applications 
of  all  remedies,  are  freely  painted  over,  giving  two  or  three  coatings. 
The  chloroform  evaporates  and  leaves  behind  a  thin  layer  of  the  powder; 
over  this,  to  fix  it  and  keep  it  in  place,  are  painted  a  few  coatings  of  flexible 
collodion  or  of  plain  collodion,  or  a  mixture  of  the  two;  the  plain  is  apt  to 
be  too  hard  and  stiff,  the  flexible  sometimes  less  adherent.  Or  liquor 
gutta-percha  (traumaticin)  can  be  used  for  this  purpose,  as  originally  ad- 
vised, but  is  not,  in  my  judgment  so  satisfactory.  When  the  films  be- 
come detached  or  considerably  cracked  or  loosened,  baths  are  renewed, 
the  films  rubbed  or  picked  off,  and  a  new  coating  made.  As  soon  as  the 
tendency  to  scaliness  ceases  and  the  skin  of  the  patches  becomes  pale  and 
normal  the  application  is  discontinued.  This  is  a  satisfactory  method  for 
large,  stubborn  patches.  Staining  of  the  surrounding  skin  follows,  but  to 
a  much  less  extent  than  when  a  chrysarobin  salve  is  used. 

The  method  of  using  chrysarobin  as  a  paint  is  probably  the  most 
common  one.  The  drug  is  prescribed  in  collodion  or  in  solution  of 
gutta-percha,  48  grains  (3.2)  or  more  to  the  ounce  (32.)  (Auspitz);  the 
application  is  rendered  somewhat  more  active  by  the  addition  of  a 
proportion  of  salicylic  acid  (G.  H.  Fox),  but  with  this  addition  it  is 
not,  as  a  rule,  so  comfortably  borne  in  those  with  delicate  skin.  The 
compound  formula  with  collodion  is  usually  as  follows: 

fy     Chrysarobini,  5j  (4-); 

Acidi  salicylici,  gr.  x-xx  (0.65-1.33); 

Athens,  f3j  (4.); 

Olei  ricini,  n#v  (0.33) ; 

Collodii,  q.  s.  ad  £5  j  (32.). 

The  ether  and  oil  are  sometimes  omitted,  but  this  formula  is  probably 
more  satisfactory.  I  have  also  found  it  more  efficient  and  less  apt  to 
stain  the  clothing  when  a  coating  of  plain  or  flexible  unmedicated  col- 
lodion is  painted  over  it. 

This  mixture  is  painted  on  the  diseased  areas  with  a  camel's  hair 
brush.  It  quickly  dries  into  a  thin  film,  which  adheres  firmly.  It  usu- 
ally remains  somewhat  longer  intact  than  the  films  formed  when  the 
method  previously  described  is  employed.  The  application  should  be 
repeated  every  few  days,  or  as  soon  as  the  films  become  detached; 


PSORIASIS 


259 


when  they  begin  to  crack,  they  can,  as  a  rule,  be  readily  pulled  off. 
Underlying  scales,  if  any,  should  first  be  removed,  or  as  soon  as  the 
films  are  partly  detached  the  baths  can  be  temporarily  resumed,  until  the 
patches  are  again  free  from  scaliness,  and  then  the  paintings  repeated. 
In  another  method  of  applying  chrysarobin  as  a  paint  a  solution  or  mix- 
ture is  made  with  liquor  gutta-perchae,  according  to  the  following  for- 
mula: 

J$.     Chrysarobini,  5j  (4.); 

Acidi  salicylici,  gr.  x-xx  (0.65-1.33); 

Liquor  gut ta-perchas,  f§j [(32.). 

This  makes  a  thin  film  which  is  quite  adherent,  but  does  not  dry  quite 
so  rapidly  as  when  collodion  is  used  as  the  excipient,  and  in  my  experi- 
ence is  less  satisfactory.  The  last  two  paints  give  rise  to  less  staining 
of  the  surrounding  skin  than  does  the  powdery  film  already  referred  to. 
Chrysarobin  was  originally  prescribed  as  an  ointment;  this  is  the 
most  positive  but  the  least  agreeable  form  of  application,  as  it  dis- 
colors everything  with  which  it  comes  in  contact.  It  is  prescribed 
ordinarily  in  the  strength  of  from  40  to  60  grains  (2.65  to  4.)  to  the 
ounce  (32.),  of  benzoated  lard.  A  small  quantity  is  to  be  rubbed  in 
vigorously  once  or  twice  daily,  the  excess  being  wiped  off  and  rice-flour 
or  starch-flour  dusted  over  the  part.  After  a  time  the  tendency  to 
scaliness  lessens  and  finally  ceases,  the  surrounding  skin  becomes  slightly 
or  deeply  stained  of  a  mahogany,  or  bronze  tint,  and  the  diseased  area 
or  patch  itself  becomes  pale  and  normal.  The  method  of  treatment 
with  chrysarobin  ointment  is  called  for  in  cases  presenting  obstinate  and 
rebellious  patches,  and  in  which  the  other  methods  of  using  this  drug 
have  failed.  It  is  also  cheaper  than  the  other  plans,  and  for  this  reason 
well  adapted  for  hospital  practice. 

The  chrysarobin  treatment  is  to  be  discontinued  as  soon  as  patches 
to  which  it  has  been  applied  become  pale  or  distinctly  whitish,  as  this 
usually  indicates  a  disappearance  of  the  disease  in  such  areas;  should  a 
tendency  to  hyperemia  or  scale-formation  present,  it  is  to  be  resumed. 
Pyrogallol  (pyrogallic  acid)  is  another  remedy  (Jarisch)  of  some 
value,  and  one  that  has  been  employed  for  some  years  in  the  treat- 
ment of  the  disease.  It  is  not  so  rapid  in  its  effects  as  chyrsarobin, 
but  it  stains  the  skin  less  and  rarely  excites  cutaneous  inflammation  unless 
used  in  too  great  strength;  the  linen  is  permanently  discolored.  It 
should  not  be  applied  to  too  large  a  surface  at  one  time,  as  there  is  a 
possibility,  as  demonstrated  by  a  few  recorded  cases,  of  toxic,  and  even 
fatal,  action  from  absorption  (Besnier,  Vidal,  Nejsser).  The  drug  is 
commonly  employed  in  the  form  of  an  ointment.  It  is  prescribed  with 
benzoated  lard  or  petrolatum,  in  the  strength  of  from  20  to  60  grains 
(1.33  to  4.)  to  the  ounce  (32.).  This  is  well  rubbed  into  the  patches  once 
or  twice  daily,  wiping  off  the  excess  and  applying  over  the  parts  an  in- 
different dusting-powder. 

/3-naphthol  is  another  valuable  drug  (Kaposi)  in  some  cases,  but 
it  takes  a  lower  rank  than  any  of  the  remedies  thus  far  named.  It  is 
a  clean  remedy,  and  is  usually  prescribed  in  the  strength  of  from  20  to 
60  grains  (1.33  to  4.)  to  the  ounce  (32.)  of  ointment.  Very  often  in 


260  INFLAMMATIONS 

working  strength  it  produces  considerable  burning  at  the  time  of  appli- 
cation and  for  some  minutes  afterward.  Resorcin  in  ointment  form,  5 
to  10  per  cent,  strength,  is  also  serviceable  in  some  cases.  Gallaceto- 
phenone  is  likewise  employed  in  this  disease,  in  the  form  of  an  ointment 
in  the  strength  of  from  \  dram  to  i  dram  (2.  to  4.)  to  the  ounce  (32.) ;  so, 
also,  is  anthrarobin  in  the  same  proportion.  Sulphur  is  only  occasion- 
ally of  service,  applied  as  a  5  to  20  per  cent,  ointment.  As  an  ointment 
base  for  these  various  remedies  lard,  or  equal  parts  of  petrolatum  and 
lard,  or  with  10  per  cent,  of  lanolin,  can  be  employed.  In  those  of  sen- 
sitive skin  using  the  zinc-oxid  ointment  or  Lassar's  paste  as  the  base,  will 
lessen  the  irritating  effects  of  the  various  stronger  drugs  named. 

In  psoriasis  of  the  scalp  the  treatment  is  somewhat  different  from  that 
employed  when  the  disease  is  seated  upon  other  parts.  Chrysarobin  and 
pyrogallol  are  rarely  used  in  psoriasis  thus  situated,  and  when  employed, 
always  in  the  form  of  ointments;  the  pyrogallol  salve  is  sometimes  of 
distinct  service,  but  should  not  be  used  in  those  with  blonde  hair,  as  it 
stains  perceptibly.  White  precipitate,  /?-naphthol,  and  tar  are  the  main- 
stays in  the  treatment  of  the  disease  here.  White  precipitate  in  ointment, 
5  to  15  per  cent,  strength,  is  the  most  commonly  employed  and  is  usually 
efficient.  Salicylic  acid  in  the  form  of  an  ointment,  from  \  to  i  dram 
(2.  to  4.)  to  the  ounce  (32.),  is  also  valuable  in  some  cases.  The  tarry 
oils  and  ointments  are  sometimes  employed,  and  are  most  serviceable 
applications,  especially  the  vegetable  tars,  but,  owing  to  their  odor,  their 
use  can,  as  a  rule,  only  be  insisted  upon  if  the  others  fail  to  make  an 
impression;  the  oil  of  cade,  either  pure  or  weakened  with  i  to  3  parts  of 
alcohol,  olive  oil,  or  liquid  petrolatum,  is  the  most  satisfactory.  The 
scaliness  is  best  removed  by  frequent  shampooing  with  the  tincture  of 
sapo  viridis. 

Affected  nails  are  to  be  treated  with  the  free  use  of  ointments,  of  the 
milder  and  non-staining  class  of  remedies  mentioned,  such  as  /9-naphthol, 
white  precipitate,  salicylic  acid,  and  sulphur.  Tarry  ointments  are  of 
service  here,  too,  but  are  disagreeable.  The  parts  should  be  enveloped 
in  the  selected  ointments  as  continuously  as  circumstances  permit. 
The  nails  should  be  kept  trimmed,  and  rough  or  projecting  parts  gently 
ground  or  scraped  down  with  pumice,  file,  or  knife.  An  occasional  soak- 
ing in  an  alkaline  solution  of  borax  or  sodium  bicarbonate,  i  to  5  grains 
to  the  ounce,  is  often  of  advantage,  the  ointment  application  being  re- 
applied  immediately  afterward. 

Psoriasis  spots  or  patches  on  exposed  parts,  more  particularly  on 
the  face,  are  best  treated  with  ointments  of  white  precipitate,  naphthol, 
or  liquor  carbonis  detergens,  inasmuch  as  they  are  cleanly  and  usually 
efficient. 

For  the  rather  rare  acutely  developing,  markedly  irritable  cases,  the 
external  applications  must,  in  the  beginning  at  least,  be  of  the  mildest 
character  possible.  Sometimes  a  bran  or  gelatin  bath,  followed  by  plain 
cold  cream  or  petrolatum,  with  or  without  3  or  4  grains  (0.2  to  0.265) 
of  salicylic  acid  to  the  ounce  (32.),  will  furnish  relief  and  answer  the  de- 
mands until  the  disease  has  become  more  sluggish.  The  salicylic  acid 
paste  is  one  of  the  safest  and  most  soothing  applications.  In  extreme 


ECZEMA  26l 

cases  of  cutaneous  irritability  the  most  comforting  application  is  one 
consisting  of  equal  parts  of  lime-water  and  almond  oil,  with  \  to  5  grains 
(0.035  to  0.33  of  carbolic  acid  to  the  ounce  (32.).  The  calamin-zinc-oxid 
lotion  or  liniment  is  also  useful  in  such  instances. 

Regarding  the  several  new  remedies  or  modifications  of  old  remedies 
introduced  in  recent  years,  clinical  trials  do  not  place  them  so  high  as 
those  already  in  use.  Among  these  may  be  mentioned  pyrogallol  mon- 
acetate  and  chrysarobin  triacetate,  known  also  respectively  as  eugallol 
and  eurobin  (Kromayer,  Bottstein),  and  oxidized  pyrogallol  (Unna). 
These  are  usually  prescribed  in  ointment  form,  2  to  10  per  cent,  strength; 
eugallol  and  eurobin  also  in  chloroform  or  acetone,  the  former  in  10  to 
50  per  cent,  strength,  and  the  latter  i  to  20  per  cent. 

Among  the  new1  methods,  I  can  speak  favorably  of  the  influence 
of  both  light  baths  and  the  Rontgen  rays.  The  most  efficient  light  is 
that  of  the  sun,  but  this  is  rather  unreliable  and  somewhat  imprac- 
ticable. Next  in  value,  and  readily  obtainable,  is  the  arc  light.  Baths 
of  light  from  numerous  incandescent  lamps  are  also  of  some  value,  but 
not  so  efficient  as  the  arc  light.  Repeated  exposures  at  intervals  of  two 
to  four  in  five  days  to  the  Rontgen  rays,  at  a  distance  of  6  to  1 2  inches 
from  the  tube,  have  in  my  experience  proved  serviceable  in  removing 
obstinate  areas  of  the  disease;  the  tube,  of  a  vacuum  equal  to  i-  to  2-inch 
spark,  should  be  moved  from  place  to  place — not  being  kept  more  than 
three  to  ten  minutes  in  one  region.  Occasionally,  in  obstinate  places,  the 
time  of  exposure  can  be  cautiously  lengthened  or  the  distance  shortened. 
Undue  risk  is  not,  however,  justifiable  in  a  disease  of  this  character,  so 
that  x-ray  treatment  is  best  reserved  for  large  rebellious  areas.  Like  all 
remedies  or  methods,  however,  the  light  baths  or  Rontgen  rays  do  not 
ensure  against  relapse. 

ECZEMA 

Synonyms.— Tetter;  Salt  rheum;  Fr.,  Eczeme;  Eczema;  Ger.,  Eczema;  Ekzem; 
Eczem;  Nassende  Flechte;  Salzfluss. 

Definition.— An  acute,  subacute,  or  chronic  catarrhal  inflamma- 
tory disease,  characterized  in  the  beginning  by  the  appearance  of  ery- 
thema, papules,  vesicles,  or  pustules,  or  a  combination  of  these  lesions, 
with  a  variable  amount  of  infiltration  and  thickening,  terminating  either 
in  discharge  with  the  formation  of  crusts  or  in  desquamation,  and  accom- 
panied by  more  or  less  intense  itching  and  a  feeling  of  heat  or  burning. 

Symptoms So  protean  a  disease  may  have  almost  any  beginning 

form,  and  often  tends  to  change,  especially  into  consecutive  or  secondary 
types— eczema  squamosum  and  eczema  rubrum.  As  a  rule,  however, 
when  once  established,  its  type  or  predominant  type  is  apt  to  remain 
throughout.  It  may  begin  as  one  or  more  slightly  or  marked  inflamma- 
tory erythematous  areas,  which  soon  show  slight  or  moderate  scalmess; 
or,  instead  of  dry  erythematous  areas,  the  skin  shows  inflammatory  red- 
ness and  swelling  beset  with  pin-point-sized  vesicles  which  discharge  and 
form  crusts;  or  the  beginning  lesions  may  be  small  papules,  usually  aggre- 

1  An  interesting  paper  in  this  connection  is  that  by  Hyde,  "The  Influence  of  Light- 
hunger  in  the  Production  of  Psoriasis,"  Brit.  Med.  Jour.,  Oct.  6,  1906. 


262 


INFLAMMA  TIONS 


gated,  and  often  so  closely  packed  that  a  confluent  patch  results,  later 
tending  to  scaliness  or  vesicular  formation.  The  beginning  lesions  may 
also  be  pustular,  or  become  rapidly  so,  and  dry  to  crusts.  Not  infre- 
quently the  beginning  type  may  be  of  a  mixed  character.  These  are  the 
several  primary  types  of  the  disease, — erythematous,  papular,  vesicular, 
and  pustular, — and  all  eczema  cases  begin  with  the  presentation  of  one  or 
other  of  these  types  or  a  mixture  of  two  or  more.  The  erythematous  is 
usually  least  likely  to  show  lesions  of  other  types.  The  papular  variety 
often  exhibits  vesicles  as  well,  and  the  vesicular  variety  not  infrequently 
seropurulent  or  purulent  lesions.  And  when  the  disease  is  somewhat 
extensive  in  distribution,  the  several  types  may  sometimes  be  found  on 


Fig.  52. — Eczema  of  erythematosquamous  variety  of  several  months'  duration; 
deep  red  color;  moderate  scaliness;  considerable  thickening  and  infiltration,  and  accen- 
tuation of  the  lines  and  folds  of  the  skin — this  last  especially  marked  about  the  eyes. 

different  regions.     As   clinically  met  with,  a  pure  type,  except  the 
erythematous,  and  less  often  the  papular,  is  not  frequently  observed. 

Eczema  is  eczema,  however,  whatever  its  variety,  and  the  various 
type  names  should  not  be  allowed  to  confuse ;  type  name  simply  signifies 
the  lesion  or  predominant  lesion  or  condition  present,  and  does  not  mean 
necessarily  the  entire  absence  of  other  lesions  or  conditions;  if  the  pre- 
dominance is  not  overwhelming,  the  type  is  usually  designated  mixed. 
The  eruption  made  up  of  an  intermingling  is  not  infrequent,  and  some- 
times the  beginning  of  the  outbreak  is  of  ill-developed  character;  thus  is 
explained  the  terms  erythematopapular,  erythematosquamous,  papulo- 
squamous.  vesicopapular,  vesicopustular,  etc.  Although  these  are  some- 


PLATE  VIII. 


Eczema. 


ECZEMA 


263 


times  used  to  designate  eruptions  of  mixed  nature,  they  are  more  com- 
monly employed  to  signify  that  the  lesions  are  of  transitional  or  midway 
character,  as,  for  instance,  the  last  two  terms  signifying  that  the  papules 
tend  to  vesiculation,  and  that  the  vesicles  are  not  purely  serous,  but  con- 
tain some  admixture  of  pus,  and  so  on.  Moreover,  very  often  the  disease 
does  not  continue  as  one  of  the  beginning  types,  but  frequently  develops 
into  what  are  known  as  secondary  or  consecutive  forms.  Of  these  the 
most  common  are  eczema  squamosum  or  squamous  eczema,  character- 
ized by  moderate  or  marked  scaliness;  and  eczema  rubrum  or  eczema 
madidans,  characterized  by  a  confluent,  reddened,  raw-looking,  inflamed, 
weeping  surface,  with  crusting,  but  which  may  be  at  times  partly  or  al- 
most completely  dry.  These  and  other  types  will  be  referred  to  in  con- 
nection with  the  description  of  the  lesional  varieties. 

The  distribution  of  eczema  may  be  more  or  less  general,  or,  as  is  usu- 
ally the  case,  it  may  be  limited  to  one  or  several  regions  and  even  to  a 
very  small  area.  It  may  be  more  or  less  continuous  in  its  extent,  or  it 
may  be  distinctly  patchy;  exceptionally,  as  in  the  eczema  nummulare  of 
Devergie,  the  patches  may  be  variously  coin-sized,  vesicular  or  vesico- 
papular,  but  usually  with  the  margin  flattening  and  merging  into  the 
surrounding  healthy  skin.  This  nummular  or  herpetoid  type  occurs  on 
both  trunk  and  extremities.  An  apparently  similar  or  closely  similar 
type  is  that  recurrent,  small,  rounded  or  ovalish  patchy  vesicopapular  and 
vesicular  type  more  or  less  confined  to  the  dorsal  aspects  of  the  hands  and 
forearms,  with  often  the  lesions  discrete  and  slightly  apart,  as  in  zoster 
patches  and  dermatitis  herpetiformis;  these  cases  are  not  uncommon  and 
are  rebellious  and  troublesome.1  Doubtless  some  of  these  patchy  cases, 
especially  acute  in  character  and  vesicular,  usually  about  the  hands  and 
feet,  are  due  to  the  ringworm  fungus;  such,  for  example,  as  reported  by 
Whitfield  and  Sabouraud  (see  Ringworm). 

No  part  of  the  body  is  exempt.  At  different  ages  different  regions 
show  the  disease  much  more  frequently  than  others.  Thus  in  infants 
and  young  children  the  face  and  face  and  scalp  are  most  usually  the 
seat  of  the  malady;  and  in  some  of  strumous  diathesis  there  seems  a  spe- 
cial disposition  for  the  eczema  to  be  about  the  orifices  of  the  mouth,  ear, 
nose,  and  eyes — its  assumed  association  with  struma  leading  some  ob- 
servers to  name  it,  without  sufficient  foundation,  tuberculous  or  scrofu- 
lous eczema.  As  active  working  life  is  approached  and  continues,  the 
fingers,  hands,  and  forearms  are  most  commonly  affected,  and  not 
infrequently  the  scrotal  and  anal  regions  in  the  male,  and  the  vulva  in  the 
female;  whereas  in  older  life,  past  forty  or  fifty,  the  disease  is  seen  rela- 
tively much  more  frequently  on  the  lower  part  of  the  legs,  and  also 
upon  the  face.  In  some  cases  of  long-continued  eczema  of  the  fingers, 
and  also  sometimes  in  association  with  the  disease  elsewhere,  the  nails 
are  observed  to  share  in  the  disease;  they  crack  and  break  easily,  are  dry 
and  often  crumbling.  The  flexures  of  the  knees,  elbows,  axillae,  are  not 
infrequent  sites  for  the  eruption,  and  age  does  not  seem  to  exercise  much 
influence  upon  the  election  of  these  regions,  although  these  are  not  com- 

1  Pollitzer,  "A  Recurrent  Eczematoid  Affection  of  the  Hands,"  Jour.  Cutan.  Dis., 
Dec.,  1912,  p.  716  (with  illustrations),  has  recently  reported  a  series  of  these  cases. 


264  INFLAMMA  TIONS 

mon  situations  in  infancy  and  early  childhood.  This  tendency  of  the 
disease  to  affect  certain  parts,  taken  together  with  the  age  of  the  patient 
and  the  chronicity,  is  often  an  important  element  in  diagnosis. 

The  character  of  the  eruption  as  regards  the  activity  of  the  inflam- 
matory process  may  be  of  the  acute,  subacute,  or  chronic  type.  These 
terms  are,  in  eczema,  somewhat  confusing,  inasmuch  as  acute  and 
chronic  are  also  employed  with  their  usual  meaning  in  connection  with 
the  course  of  the  disease  as  regards  dtiration.  Exceptionally  eczema  is 
observed  to  run  an  acute  course,  ending  in  several  weeks  or  a  month  or 
two;  and  in  such  instances  the  disease  is  almost  always  of  a  markedly 
inflammatory  or  acute  grade,  and  such  cases  are  in  the  true  sense  examples 
of  acute  eczema.  As  a  rule,  however,  the  course  of  eczema  is  always 
chronic,  and  almost  all  cases  can  be  classed  as  chronic  eczema,  but  the 
grade  of  the  process  may  be  acute,  subacute,  or  chronic  (sluggish)  through- 
out. 

Often  the  disease  is  of  chronic  type  and  course,  with  acute  or  sub- 
acute  exacerbations;  in  some  cases  it  may  disappear  spontaneously  for 
a  shorter  or  longer  time,  more  especially  in  temperate  or  mild  weather. 

The  subjective  symptoms  of  eczema  are  almost  always  troublesome, 
consisting  of  itching,  burning,  pricking,  or  stinging,  or  a  mixture  of  these 
several  sensations;  and  exceptionally  hyperesthesia  and  pain.  Itching 
is  the  most  common,  and  is  rarely  missing;  if  so,  its  place  is  usually  taken 
by  one  of  the  other  symptoms  named.  The  itching  may  vary  in  degree 
from  slight  to  intense,  and  it  may  be  constant  or  frequently  intermittent. 
The  rubbing  and  scratching  which  it  usually  provokes  either  during  full 
consciousness  or  when  asleep  often  have  considerable  influence  in  modi- 
fying the  type  of  the  disease — an  erythematous  or  papular  eczema  may 
be  partly  changed  into  a  moist  oozing  form,  and  the  vesicular,  by  second- 
ary infection,  into  pustular  lesions. 

Constitutional  disturbances  as  a  part  of  the  disease  are  never  ob- 
served except  in  acute  generalized  forms  and  in  the  acute,  markedly 
inflammatory  and  edematous  eczema  of  the  face,  when  there  may  be 
preceding  and  accompanying  febrile  and  other  symptoms,  which,  how- 
ever, soon,  as  a  rule,  abate  and  disappear ;  followed  often  with  a  fall  of 
\  to  i  degree  below  the  normal  temperature.  On  the  other  hand,  an 
intercurrent  febrile  disease,  such  as  typhoid,  etc.,  usually  leads  to  a  dis- 
appearance of  the  eczema,  which,  however,  generally  recurs  as  soon  as 
the  constitutional  malady  has  run  its  course. 

In  occasional  cases  of  eczema  complications  are  met  with,  such  as 
blebs  (rarely),  furuncles,  impetiginous  and  ecthymatous  pustules,  and 
abscesses;  these  are  purely  accidental,  and  are  not  a  part  of  the  disease 
process.  They  are  due  to  accidental  infection  by  pyogenic  cocci,  the 
excoriations  and  the  weakened  or  destroyed  horny  layer  affording 
favorable  opportunities  for  inoculation.  For  the  most  part  these  lesions 
are  met  with  in  debilitated  subjects.  Enlargement  of  the  neighboring 
lymphatic  glands  is  also  at  times  noted,  especially  in  infants  and  young 
children,  and  more  particularly  with  the  vesicular  and  pustular  types, 
usually  the  latter.  In  eczema  rubrum  of  the  leg,  in  adults,  and  especially 
older  patients,  varicose  veins  are  often  seen  in  association  and  are  of 


ECZEMA  265 

etiologic  importance  (eczema  varicosum) ;  in  such  cases  there  is  a  tend- 
ency, due  to  the  same  cause,  to  the  development  of  leg  ulcer  (ulcus  vari- 
cosum). Other  cutaneous  diseases  are  occasionally  encountered  in 
association  with  eczema  or  during  its  course,  but  such  occurrences  are 
purely  a  matter  of  coincidence — eczema  is  in  no  sense  protective  against 
other  affections. 

Essential  Characters. — Before  taking  up  the  lesional  varieties  of  the 
disease,  the  essential  conditions  or  characters  of  eczema,  in  the  main  to 
be  inferred  from  what  has  already  been  said,  may  be  more  distinctly 
referred  to.  Exudation  is  invariable,  slight  in  the  exudative  congestion 
of  the  erythematous  type,  although  it  may  also  in  this  variety  be  con- 
siderable; more  intense  and  often  minutely  circumscribed,  producing 
papules,  vesicles,  and  pustules,  and  serous  and  seropurulent  discharge. 
There  are  noted  also  redness  due  to  hyperemia,  thickening  and  infiltra- 
tion, and  often  variable  scaliness  or  crusting.  There  is  distinct  tendency 
to  the  formation  of  one  or  more,  often  diffused,  areas,  with  irregular  and 
ill-defined  borders,  the  disease  shading  off  almost  imperceptibly,  as  a  rule, 
into  the  surrounding  unaffected  skin;  often  with,  especially  when  about 
the  joints,  a  disposition  to  cracking  or  fissuring  of  the  skin.  It  will  also 
be  observed  that  fluid  exudation  on  to  the  surface  (eczema  humidum, 
moist  eczema,  moist  tetter,  salt  rheum,  weeping  eczema),  formerly 
considered  a  sine  qua  non  of  the  disease,  is  not  always  present;  the  parts 
are  often  noted  to  be  dry  and  scaly  (eczema  siccum,  dry  eczema,  dry 
tetter).  To  these  various  features  are  added  the  subjective  symptoms, 
of  variable  intensity.  Several  or  more  of  these  are  always  to  be  found  in 
every  case,  sometimes  comparatively  insignificant,  sometimes  pronounced. 

As  stated,  the  primary  or  elementary  varieties  are  so  named  from 
the  fact  that  the  eruption  is  made  up  of  one  type  of  lesion,  or  that  there 
is  an  overwhelming  preponderance  of  such.  These  are  also  called  lesional 
varieties.  These,  as  well  as  those  of  secondary  or  consecutive  types, 
deserve  special  description. 

Eczema  Erythematosum. — The  most  common  site  for  erythema- 
tous eczema  is  the  face,  and  more  especially  in  middle-aged  and  old 
people.  It  is,  however,  also  not  infrequently  met  with  in  the  flexures, 
on  the  back  of  the  neck,  hands,  and  occasionally  on  other  parts,  and 
exceptionally  as  a  generalized  eruption.  It  begins  as  one  or  more  small 
or  large,  irregularly  outlined  hyperemic  macules  or  patches,  pale  or  bright 
red  in  color,  accompanied  by  more  or  less  itching  and  burning.  At  first 
it  may  be  ill  defined  and  insignificant,  but  from  time  to  time,  and  either 
gradually  or  rapidly,  it  tends  to  spread,  and  its  features  to  become  more 
pronounced;  the  redness  becomes  more  conspicuous,  the  skin  somewhat 
thicker,  and  shows  scaliness,  usually  branny  in  character,  but  sometimes 
consisting  of  thin,  epidermic,  flake-like  exfoliation.  It  may  remain  as 
ill-defined  patches,  or,  from  enlargement  and  often  the  arising  of  new  areas, 
confluence  takes  place,  and  the  eruption  is  then  diffused  over  a  partner 
a  whole  of  a  region.  The  face  is  often  thus  involved,  although  not  in- 
frequently it  may  be  more  or  less  limited  to  the  forehead,  and  sometimes 
to  the  region  surrounding  the  eyes. 

When  the  disease  is  fully  developed,  the  skin  is  observed  to  be  harsh 


266 


INFLAMMA  TIONS 


and  dry,  of  a  reddish  color,  frequently  with  a  violaceous  and  yellowish 
tinge,  and  sometimes  mottled;  the  color  and  inflammatory  process  be- 
coming less  marked  toward  the  healthy  surrounding  skin,  into  which  the 
disease  merges  almost  imperceptibly.  It  is  thickened,  infiltrated,  and 
slightly  scaly,  with,  at  times,  here  and  there,  a  tendency  to  the  formation 
of  one  or  more  moist  or  oozing  areas,  which  are  usually  the  result  of  rub- 
bing and  scratching.  In  consequence  of  the  latter,  too,  punctate  and 
linear  scratch-marks  and  excoriations  may  often  be  seen  scattered  over 
the  affected  region.  In  most  cases,  however,  the  whole  area  or  region  re- 
mains dry,  and  continues  so  throughout,  with  possibly,  at  intervals,  the 
appearance  of  provoked  circumscribed  oozing,  which  soon  disappears. 

The  process  often  varies  within 
slight  or  moderate  limits,  becom- 
ing at  times  less  pronounced,  and 
at  others,  especially  after  exposure 
to  wind  or  indulgence  in  rich  food 
or  alcoholic  stimulants,  much  ag- 
gravated. Exceptionally  its  course 
may  be  acute,  the  disease  after 
several  weeks  tending  to  disap- 
pear; in  such  cases,  which  are, 
however,  rare,  the  face  is  the  re- 
gion generally  involved,  and  the 
inflammatory  process  usually  be- 
gins abruptly  and  is  of  an  intense 
character,  the  process  being  some- 
what simulative  of  an  erysipelatous 
outbreak.  With  few  exceptions, 
however,  the  course  is  chronic,  al- 
though often  fluctuating,  and  some- 
times partly  abating,  and  occasion- 
ally entirely  disappearing,  but,  as 
a  rule,  for  a  short  time  only.  Even 
after  complete  disappearance  as 
the  result  of  treatment  or  spon- 
taneously, it  is  exceedingly  liable 
to  relapse,  probably  more  strik- 
ingly so  than  is  observed  with  the 
other  varieties  of  the  disease.  Very 
often  the  scaliness  becomes  much 
more  pronounced  and  practically 

the  disease  is  then  representative  of  the  squamous  type— eczema  squa- 
mosum.  In  rare  cases,  when  involving  the  face,  the  eruption  surround- 
ing the  mouth,  and  extending  outward  one  or  more  inches,  is  erythem- 
atosquamous,  with  superficial  furrows  or  cracks,  sometimes  in  num- 
bers, converging  toward  the  lips,  especially  to  the  angles;  from  the 
effort  of  the  patient  to  hold  the  mouth  more  or  less  fixed,  to  prevent 
fissuring,  the  orificial  opening  seems  small.  Occasionally  in  patchy 
erythematous  disease  about  the  hands  and  fingers,  the  hyperemic  element 


Fig-  53.— Eczema  of  erythematosqua- 
mous  type,  in  a  woman,  of  a  year's  dura- 
tion, involving  both  legs. 


ECZEMA 


267 


is  almost  wanting,  the  eruption  consisting  of  slight  thickening,  insignifi- 
cant scaling,  and  considerable  fissuring.  In  many  of  these  erythematous 
cases,  in  fact,  the  terms  erythematosquamous  and  fissured  would  be 
likewise  applicable. 

In  the  flexures  from  friction,  and  the  natural  moisture  of  the  parts, 
the  surface  frequently  is  abraded,  and  a  mucoid  secretion,  often  observed 
in  erythema  intertrigo,  is  noted — eczema  mucosum,  eczema  intertrigo. 
This  condition  is  not  uncommon  at  the  scrotal,  femoral,  natal,  and  inter- 
digital  folds,  and  also  under  the  mammae.  As  already  stated,  however, 
erythematous  eczema,  particularly  when  on  the  face,  is  apt  to  remain  as 
such,  for  a  shorter  or  longer  time,  with,  in  the  majority  of  cases,  a  tendency 
to  considerable  scaliness,  and  thus  evolving  into  squamous  eczema.  In 
a  few  instances  the  skin  becomes  more  inflamed,  the  surface  abraded  and 
oozing,  and  often  crusted,  and  the  type  known  as  eczema  rubrum  is  tem- 
porarily or  more  or  less  permanently  established.  Papules,  vesicles, 
and  pustules,  lesions  of  the  other  primary  types,  are  rarely  seen  in  the 
erythematous  cases,  especially  those  of  limited  distribution. 

A  few  words  should  be  said  in  regard  to  generalized  erythematous 
eczema  (eczema  universale),  as  this  is  the  type  the  generalized  disease 
usually  presents.  It  is  rare.  It  begins  rather  suddenly,  with  the 
appearance  of  small  and  large  erythematous  plaques,  which  rapidly 
enlarge,  and,  together  with  others  that  form,  soon  result  in  confluence, 
and  practically  cover  the  entire  integument,  with  sometimes  here  and 
there  small  free  spaces.  Concomitantly  with  the  outbreak,  and  some- 
times for  several  hours  or  a  day  or  two  preceding,  the  patient  often 
feels  unwell,  chilly,  and  suffers  with  malaise  and  slight  flushings  of  heat, 
with  usually  slight  febrile  action  developing.  Immediately  at  the  time 
of  outbreak,  if  acute  and  abrupt,  there  may  be  considerable  temper- 
ature elevation.  As  a  rule,  such  symptoms,  when  present,  abate  as 
soon  as  the  eruption  has  developed,  but  exceptionally  chilliness  and 
febrile  action,  especially  the  latter,  with  evening  exacerbation,  may 
continue  for  several  days  or  longer;  later,  in  these  general  cases,  there 
may  be  more  or  less  continuous  slight  temperature  depression.  The 
eruption  presents  the  usual  symptoms  of  the  erythematous  type,  as 
observed  in  the  limited  form,  the  surface  being  reddish,  and  soon  slightly 
branny  or  scaly,  with  often  a  tendency  to  crack  aboutthe  joints.  Almost 
always,  sooner  or  later,  on  certain  parts  of  the  surface,  especially  on  one 
or  more  of  the  flexures,  the  moist  exudation  of  eczema  is  exhibited.  Itch- 
ing is  present  to  a  slight  or  severe  degree,  as  a  rule  intermittently;  prob- 
ably as  troublesome  a  symptom  is  burning,  and  sometimes  a  feeling  of 
tension.  The  malady,  for  most  of  the  surface  at  least,  usually  runs  an 
acute  course,  tending  to  disappear,  sometimes  after  one  or  two  exacer- 
bations, in  several  weeks  to  a  few  months,  but  usually  leaving  behind, 
however,  a  more  or  less  persistent  involvement  of  one  or  several  regions, 
most  commonly  the  lower  part  of  the  legs. 

Eczema  Papulosum.— Papular  eczema,  lichen  simplex  of  former 
authors,  and  sometimes  called  eczema  lichenoides  and  lichen  eczema- 
todes,  is  observed  most  frequently  upon  the  flexor  aspects  of  the  limbs, 
although  it  is  not  uncommon  upon  the  trunk.  As  with  all  other  forms 


268  INFLAMMA  TIONS 

of  the  disease,  it  may  be  encountered  elsewhere,  but  the  face,  ears,  hands, 
and  fingers  seldom  show  this  variety.  In  my  experience,  in  its  purest 
type  it  is  more  common  in  adults.  The  eruption  may  be  sparse  and 
limited  to  a  small  region,  or  it  may  be  more  or  less  extensive,  involving 
a  greater  part  of  the  integument.  The  lesions  appear  suddenly  or  in- 
sidiously, usually  in  numbers,  and  consist  of  discrete,  aggregated,  or 
closely  crowded  reddish,  pin-head-sized,  acuminated,  or  rounded  papules; 
when  in  numbers  and  close  together,  there  is  often  a  good  deal  of  diffused 
infiltration.  The  aggregations,  especially  on  the  arms,  often  form  rounded 
or  orbicular  patches  (formerly  called  lichen  circumscriptus). 

It  is  not  uncommon,  here  and  there,  to  find  a  variable  number  of 
lesions  so  crowded  that  a  solid  patch  is  formed,  red,  inflammatory,  and 


Fig.  54. — Papular  eczema  in  male  adult,  of  two  months'  duration,  limited  to  the  back. 

thickened,  with  usually  several  or  more  outlying  discrete  papules.  These 
patches  sometimes  show  slight  or  moderate  scaliness.  It  is  not  unusual, 
too,  for  some  of  the  papules  to  show  slight  apex  vesiculation  (formerly 
called  lichen  agrius),  and  sometimes  to  develop  into  vesicles;  and  often 
the  latter  lesions,  commonly  few  or  in  moderate  numbers,  are  found  aris- 
ing primarily  as  such  along  with  the  much  more  numerous  papules. 
Occasionally  the  lesions  are  distinctly  follicular  in  origin  (eczema  follicu- 
lorum,  follicular  eczema).  The  papules  are  persistent,  lasting  for  days 
or  weeks,  and  if  disappearing,  replaced  by  fresh  lesions.  In  fact,  often 
there  is  a  tendency  to  irregular  appearance  and  disappearance,  and  also 
to  crop-like  exacerbations.  Sometimes  the  papules  are  minute  and 
punctiform  in  character;  in  other  cases  they  are  quite  large  to  small 


ECZEMA 


269 


pea  in  size,  rather  irregularly  rounded  at  the  base,  and  may  be  slightly 
flattened  on  top,  and  when  on  the  scrotum  and  lower  part  of  the  legs  are 
likely  to  be  dark  red  or  even  violaceous  in  color,  bearing  some  resem- 
blance to  the  larger  lichen  planus  papules. 

Papular  eczema  is  persistent  and  obstinate,  and  usually  much  more 
itchy  than  other  types;  excoriations,  scratch-marks,  and  small  blood- 
crusts  are  often  observed,  bearing  evidence  of  its  pruritic  character. 
It  often  maintains  its  papular  form  throughout,  but  there  is  frequently 
a  tendency  in  some  to  become  vesicles,  and  this  tendency  is,  I  think, 
expecially  observed  in  children.  In  many  cases  where  solid  patches  from 
overcrowding  of  the  lesions  have  resulted,  scaliness  becomes  a  feature, 
and  the  disease  becomes  an  example  of  the  papulosquamous  or  squamous 
type,  although  it  is  common  to  find  discrete  papules,  especially  near  the 
periphery  of  the  scaly  area  or  areas;  such  areas  are  not  uncommon  on  the 
lower  part  of  the  legs.  When  the  crowded  lesions  are  overirritated  by 
rubbing  and  scratching,  and  especially  if  there  is  a  tendency  to  vesicula- 
tion,  the  surface  becomes  abraded  and  oozing,  and  eczema  rubrum  is 
evolved. 

Eczema  Vesiculosum. — The  vesicular  variety  may  occur  upon  any 
portion  of  the  surface,  but  it  is  most  usually  seen  upon  the  face  of  infants 
and  young  children  (crusta  lactea,  or  milk  crust,  of  older  writers),  and 
in  older  people  upon  fingers  and  hands,  neck,  and  flexor  surfaces,  especially 
near  the  joints.  As  an  acute  outbreak  it  is  also  observed  on  the  face  of 
adults.  It  may  be  limited  to  one  region,  or  several  regions  may  be 
simultaneously  affected,  or  one  rapidly  after  the  other.  It  is  rather 
rare  as  a  wide-spread  eruption. 

It  usually  appears  somewhat  acutely,  by  the  appearance  of  red- 
dened, more  or  less  diffuse,  patches,  upon  which  rapidly  develop  numer- 
ous closely  crowded  pin-point  vesicles,  rounded  or  acuminated,  con- 
taining clear  or  slightly  opaque  fluid,  and  which  tend  to  become  pin- 
head-sized  or  slightly  larger,  and  so  closely  packed  that  in  places  practical 
coalescence  results.  In  fact,  solid  sheets  of  eruption  are  often  thus 
formed.  In  some  cases  the  disease  is  markedly  acute,  and  consider- 
able swelling  and  edema  (eczema  cedematosum),  occasionally  with  scanty 
vesiculation,  are  present,  and  when  on  the  face,  especially  in  adults,  the 
attack  may  at  first  bear  resemblance  to  erysipelas.  The  vesicles  soon 
mature  and  rupture  spontaneously,  or  are  broken  by  rubbing  or  scratch- 
ing, and  a  partly  vesicular  and  partly  oozing  surface  ensues,  on  which 
irregular  crusting  of  a  yellowish  or  honeycomb  character  forms.  Be- 
neath this  more  or  less  continuous  oozing  takes  place,  and  in  some 
places  new  vesicles  are  formed;  or  the  disease  process  in  the  course  of 
days  or  several  weeks  may  decline,  the  crusts  be  cast  off,  sometimes  to 
be  quickly  followed  by  a  new  abundant  crop  of  vesicles,  and  the  same 
course  be  gone  through.  Later,  lesions  are  apt  to  be  less  numerous,  and 
at  times,  instead  of  appearing  crop-like,  they  appear  irregularly.  Scat- 
tered papules,  vesicopapules,  and  exceptionally  vesicopustules  or  pustules 
are  frequently  to  be  seen  mixed  in  with  the  vesicles,  or  more  generally 
about  the  borders  of  the  involved  areas.  In  some  cases  the  discharge, 
after  rupture  of  the  first  outcropping  of  vesicles,  is  so  profuse  that  new 


2/0 


INFLAMMA  TIONS 


vesicles  can  scarcely  be  formed,  and  the  surface  remains  for  a  time  an 
oozing  one,  with  here  and  there  scattered,  imperfect  vesiculation.  The 
eruption,  when  appearing  and  behaving  as  described,  rarely  remains  long 
the  vesicular  type,  but  the  parts  become  thickened  and  infiltrated,  the  sur- 
face oozing  and  crusted,  thus  evolving  into  and  constituting  eczema  rubrum. 
In  other  cases  the  disease  begins  insidiously,  especially  when  on 
the  fingers  and  hands,  the  lesions  being  scattered,  with  a  tendency  for 
two,  three,  or  more  to  form  in  close  proximity;  sometimes  the  contents 

are  absorbed,  sometimes — and 
this  most  frequently  —  the 
lesions  rupture  or  are  broken, 
exude,  and  dry  over  with  a 
thin  crust,  which  may  fall  off 
spontaneously,  leaving  healthy 
skin  beneath,  or  maybe  pushed 
off  by  new  vesiculation  be- 
neath; or,  especially  where 
lesions  are  crowded  together 
in  groups,  the  underlying  part 
becomes  somewhat  thick  and 
infiltrated,  and  for  a  time — a 
day  or  two — the  surface,  after 
vesicular  rupture,  oozes,  and 
constitutes  a  small  patch  of 
eczema  rubrum.  These  small 
areas  are  similar  to  those  aris- 
ing from  grouped  or  coalescent 
papules  with  vesicular  capping. 
If  lesions  are  observed  in  the 
palms  and  on  the  anterior  as- 
pect of  the  fingers,  they  are 
often,  especially  the  former, 
noted  to  be  at  first  some- 
what deep  seated,  sometimes 
milky  in  appearance,  and 
showing  slight  resemblance  to 
beginning  pompholyx  lesions. 
In  such  cases,  too,  some  of  the  efflorescences  are  clearly  papular,  and  at 
times  with  a  few  scattered  seropurulent  or  purulent  lesions  instead  of 
pure  vesicles.  In  other  cases  the  entire  eruption  is  vesicopapular;  the 
lesions  are  often  readily  broken  or  rubbed  off,  but  they  do  not  present 
clearly  formed  or  perceptible  vesiculation.  In  other  instances,  at  one 
time  the  vesicles  predominate,  and  at  another  period  the  papules,  so  that 
a  precise  type  designation  is  not  possible.  Occasionally  the  eruption  is 
mixed  vesicular  and  pustular.  Exceptionally  the  vesicular  character 
gradually  disappears,  leaving  infiltrated  areas  which  are  persistent  and 
become  scaly,  thus  going  into  the  squamous  form.  This  termination  is, 
however,  exceptional— the  usual  one,  if  it  takes  place,  is  into  eczema 
rubrum,  as  already  referred  to. 


Fig.  55. — FoLlicular  (sycosiform)  eczema. 


ECZEMA 


2/1 


^  subjective  symptoms  are  troublesome,  but  rarely  so  intense 
as  in  papular  eczema;  a  feeling  of  burning  and  tension  is  apt  to  be  more 
predominant  than  itching,  although  at  times,  and  in  some  cases  con- 
stantly, this  latter  may  be  present  to  an  annoying  degree.  Fissur- 
ing,  especially  at  the  affected  joints,  is  sometimes  in  this,  as  in  other 
types,  a  feature  of  the  case,  but  if  present  at  all,  is  usually  slight,  and 
rarely  to  such  an  extent  as  in  other  varieties.  The  course  of  the  disease, 
as  can  readily  be  inferred  from  the  foregoing  description,  is  usually 
chronic,  with  often  acute  exacerbations.  In  exceptional  cases,  however, 
the  disease  is  acute  both  in  character  and  its  course. 

Eczema  Pustulosum. — Pustular  eczema,  known  also  under  the  name 
of  eczema  impetiginosum,  is  seen  most  commonly  on  the  scalp  and  face, 
especially  in  children  and  young  people,  and  more  particularly  those 
who  are  ill  nourished  and  strumous.  In  adults  it  is  occasionally  seen 
about  the  bearded  face,  and  on  the  thighs  and  lower  part  of  the  legs 
(eczema  sycosiforme).  The  pustular  type,  is,  however,  probably  the 
least  common  of  the  several  varieties;  although  a  pustular  eczema  of 
the  scalp,  especially  of  the  occipital  region  in  girls  and  women,  usu- 
ally of  the  dispensary  class,  due  to  pediculi,  is  not  infrequent.  It  is 
similar,  although  usually  less  actively  inflammatory,  in  its  symptoms 
to  eczema  vesiculosum,  with  which  it  is  sometimes  associated.  In  fact, 
there  is  often  an  admixture  of  both  types.  The  lesions  are  either  pus- 
tular from  the  start  or  develop  from  pre-existing  vesicles,  as  a  rule  in- 
creasing somewhat  in  size.  There  is  a  marked  tendency  ordinarily 
to  rupturing  of  the  lesions,  the  discharge  drying  to  thick  yellowish, 
brownish,  and  sometimes  greenish  crusts  (eczema  crustosum).  On  the 
scalp  it  is  noted  exceptionally  that  the  lesions  are  so  numerous  and  so 
crowded  that  considerable  epidermic  undermining  results,  and  the 
seropurulent  or  purulent  discharge  is  so  profuse  (eczema  ichorosum)  that 
the  denuded  surface  presents.  The  neighboring  lymphatic  glands  are 
usually  considerably  enlarged,  especially  in  young  subjects. 

In  adults  there  is  a  tendency  for  the  pustules  to  be  seated  in  or 
about  the  hair-follicles  (eczema  folliculorum,  eczema  sycosiforme,  follic- 
ular  eczema),  to  be,  in  fact,  sycosiform,  and  when  on  the  legs,  they  are 
often  scattered,  although  occasionally  grouped.  Some  are  distinctly 
papular  in  the  beginning.  In  this  region,  too,  they  are  usually  larger 
than  when  on  the  face  and  scalp,  and  some  approach  the  size  of  small 
impetigo  lesions.  In  extremely  rare  instances  this  sycosiform  type 
may  involve  the  entire  hairy  system,  being  virtually  a  sycosis,  although 
with  intense  itching  and  other  symptoms  of  eczema. 

In  recent  years  there  has  been  a  growing  belief  that  many  of  the  cases, 
especially  those  in  the  class  of  vesicopustular,  pustular  or  impetiginous 
eczema,  are  in  reality  cases  of  infectious  eczematoid  dermatitis1  due  to 

1  Engman,  "Dermatitis  Infectiosa  eczema toidcs,"  Amer.  Med.,  1902-03,  vol.  iv,  p. 
769;  Fordyce,  "Infectious  Eczematoid  Dermatitis;  Possible  Influences  of  Anaphylaxis 
in  Skin  Reactions,"  Jour.  Cutan.  Dis.,  March,  1911,  p.  129  (with  illustrations:  and 
discussion);  Bruck  and  Hidaka,  Archiv,  Feb.,  1910,  c,  p.  165  (abstract  m  Jour.  Cutan. 
Dis.,  1911,  p.  188),  "Biologische  Untersuchungen  iiber  die  Rolleder  Staphylokokken 
bei  Ekzemen"),  found  that  staphylococci  in  cases  of  eczema  can  produce  biologic 
reactions  which  consist  in  an  increase  in  the  agglutinins  as  well  as  the  antilysir 


27  2  INFLAMMA  TIONS 

pathogenic  pyogenic  cocci.  In  these  cases  the  eczematoid  eruption 
frequently  follows  or  is  coincident  with  some  pyogenic  process,  such  as 
occurs  in  scabies,  infected  wounds  or  traumatisms,  impetigo,  ecthyma, 
furuncles,  abscesses,  pus  discharges,  etc. 

The  course  of  pustular  eczema  is  chronic,  with  exacerbations,  but 
not  so  persistently  so  as  other  varieties.  The  subjective  symptoms 
may  be  slight,  with  intermittent  attacks  of  itching  of  variable  degree, 
or  the  itching  may  be  almost  constant.  Soreness  and  burning  are 
also  sometimes  complained  of. 

Eczema  Rubrum. — This  is  a  secondary  or  consecutive  type,  evolving 
from  the  primary  or  elementary  varieties,  as  has  been  already  referred 
to  in  describing  the  latter.  It  is  evolved  most  commonly  from  the 
moist  lesional  types,  but  on  the  legs  it  frequently  follows  also  the  ery- 
thematous  form.  It  is  a  common  clinical  variety,  and  may  be  seen  on 
any  part  of  the  surface,  but  is  not  uncommon  about  the  face  and  scalp 
in  infants  and  children,  and  quite  frequent  on  the  legs  in  middle-aged 
and  old  people.  It  is  a  weeping  or  oozing  form,  but  not  constantly 
so,  and  is  chronic  and  persistent,  with,  as  a  rule,  but  slight  variation. 
Its  features  are  considerable  infiltration  and  thickening,  often  with 
swelling,  and  sometimes  with  intermittent  edema,  and  with  variable 
degrees  of  redness — not  always  bright  red,  as  the  name  might  suggest. 
The  surface  is  usually  oozing,  which  may  be  slight  or  marked,  and  hence 
there  may  be  slight  or  considerable  crusting  produced  from  time  to  time; 
in  the  markedly  oozing  type  (eczema  madidans)  of  the  leg  (weeping 
leg),  the  surface  is  commonly  free  from  any  general  crusting,  the  surface 
being,  as  a  rule,  raw  looking,  acutely  inflammatory  in  appearance,  with 
the  oozing  very  diffused  over  the  surface,  or  in  the  form  of  thickly  set 
minute  drops.  As  with  all  eczematous  oozing,  it  is  sticky  in  character. 
Often  the  exudation  may  lessen,  and  slight  crusting  ensue;  occasionally 
in  these  cases  the  exudation,  though  not  profuse,  may  be  seropurulent 
and  quite  thick,  and  result  in  places  in  the  formation  of  adherent,  heaped- 
up  crusting  (eczema  crustosum). 

In  other  cases  the  surface  is  free  from  any  evident  discharge,  but  to 
the  touch  the  surface  is  noted  to  be  perceptibly  moist  or  sticky.  In  other 
instances,  at  times,  even  perceptible  moisture  is  wanting,  and  the  surface 
presents  a  reddish,  glazed  appearance,  being  deprived  of  a  great  part  or  the 
entire  horny  layer.  The  infiltration,  thickening,  redness,  diffused  char- 
acters, are,  however,  common  to  all,  and  exceptionally  the  first  twro  may 
be  so  considerable  as  to  suggest  mildly  or  moderately  developed  ele- 
phantiasis. In  the  cases  with  marked  varicosity  (varicose  eczema,  eczema 
varicosum),  the  leg  ulcer  (ulcus  varicosum)  is  not  infrequently  associated. 

Frequently  at  the  borders  of  the  area,  or  near  by,  some  elementary 
lesions  are  to  be  observed,  showing  from  which  primary  type  the  dis- 
content of  the  blood,  and  further  that  the  chronicity  and  severity  of  the  eczema 
influence  these  antibody  productions;  it  is  evident,  therefore,  that  staphylococci  cannot 
be  regarded  as  harmless  parasites  in  cases  of  eczema;  Sutton,  "Uber  die  Moglickeiten 
von  Venvandtschaftsbeziehungen  zwischen  der  Dermatitis  infectiosa  Ekzematoides, 
der  Dermatitis  repens  und  der  Acrodermatitis  perstans,"  Monatshfftc,  191 1,  Band  53, 
believes  there  is  an  etiologic  identity  in  these  conditions  and  equally  influenced  by 
vaccine  therapy  (case  and  histologic  illustrations). 


ECZEMA 


273 


ease  has  evolved.    The  subjective  symptoms,  especially  itching    are 
usually  troublesome. 

Eczema  Squamosum.— Squamous  eczema  is  a  not  uncommon 
secondary  or  consecutive  clinical  type,  developing  most  usually,  as  a 
chronic  form,  from  the  erythem- 
atous  and  closely  aggregated 
papular  types.  It  may,  how- 
ever, evolve  from  other  primary 
varieties,  and  all  these,  as  well 
as  eczema  rubrum,  in  fact,  go 
through  a  slight  or  moderate 
scaly  stage  when  declining,  or 
during  periods  of  lessened  ac- 
tivity. It  may  be  seen  on  any 
part  of  the  surface,  but  is  most 
frequently  observed  on  the  scalp, 
back  of  the  neck,  palms,  and  the 
legs.  Other  forms  may  also  be 
present,  as  in  all  the  other  varie- 
ties— for  instance,  on  the  leg, 
where  it  often  evolves  from  the 
papular  variety,  where  the  pap- 
ules are  closely  crowxied,  scattered, 
and  aggregated;  papules  may  be 
near  by  or  more  or  less  remote. 
It  may  be  present  as  one  large 
area,  or  there  may  be  several 
patches;  they  are  red  and  scaly, 
with  the  border  fading  gradually 
into  the  unaffected  skin.  Ex- 
ceptionally the  areas  are  more  or 
less  sharply  circumscribed,  and 

in  rare  instances  are  somewhat     F'i?-  5.6.— Squamous  eczema,  with  tendency 

,1        j.  .  ,  in  lower  part  to  eczema  rubrum. 

numerous;     the    disease   picture 

seems,  in  reality,  to  represent  features  of  both  eczema  and  psoriasis 
(eczema  psoriasiforme,  psoriatic  eczema). 

There  is  usually  a  good  deal  of  infiltration  and  thickening,  espe- 
cially when  it  follows  the  papular  variety.  The  scaliness  is  somewhat 
variable,  in  some  cases  considerable,  in  others  slight;  and  the  amount 
often  varies  materially  from  time  to  time  in  the  same  case.  This  is 
due  partly  to  frequency  of  washing,  to  intermittent  or  continuous  treat- 
ment, or  entire  lack  of  it,  as  well  as  to  the  activity  of  the  sweat  secretion. 
The  scales  are  dry,  thin,  or  massed  and  imbricated,  in  color  whitish  to 
brownish  yellow;  occasionally  they  seem  to  partake  slightly  of  the  nature 
of  a  crust,  being  somewhat  moist  or  greasy,  as  if  there  had  been  an  insig- 
nificant admixture  of  a  fluid  exudation,  often  probably  oily  in  character 
(dermatitis  seborrhoica,  q.  v.).  When  about  the  joints,  and  not  infre- 
quently on  the  fingers  and  palm,  there  is  usually  a  marked  tendency  to 
fissuring.  Itching  is  slight  or  intense,  and  sometimes  variable.  This 

18 


274  INFLAMMATIONS 

variety  of  the  malady  pursues  a  chronic  course,  as,  in  fact,  do  almost  all 
other  forms  of  eczema. 

Eczema  Fissum. — This  is  an  important  and  not  uncommon  clinical 
type,  known  also  as  fissured  eczema,  eczema  rimosum,  and  eczema 
rhagadiforme.  It  is  especially  common  about  the  ringers  and  hands. 
The  conspicuous  symptom  is  a  marked  tendency  to  fissuring  or  crack- 
ing of  the  skin,  and  usually  deep  in  character  and  painful.  It  is  com- 
monly a  part  of  an  erythematous  or  patchy  squamous  eczema  of  the 
parts  named,  the  fissuring  constituting  the  most  conspicuous  and  trouble- 
some symptom.  Indeed,  sometimes  the  skin  seems  scarcely  reddened 
or  scaly,  merely  slightly  or  moderately  thickened,  smooth  and  dry, 
and  without  scaliness;  in  other,  somewhat  exceptional  cases,  the  skin, 
especially  at  the  finger  ends,  is  apparently  even  thinner  than  normal,  pale, 
glossy,  red,  and  atrophic  in  appearance,  and  inelastic,  fissures  forming 
from  time  to  time.  The  condition  known  as  chapping  or  chaps  is  an 
extremely  mild  example  of  the  fissured  variety,  although  such  cases  can 
scarcely  be  called  eczematous;  more  frequently,  indicating  a  dry  and 
poorly  nourished  condition  of  the  skin,  in  subjects  eczematously  inclined. 
Eczema  fissum  is  more  or  less  persistent,  the  tendency  to  fissuring  varying 
considerably,  often  according  to  the  state  of  the  weather,  frequently 
disappearing  spontaneously  in  the  summer  months. 

Other  clinical  or  name  varieties  are  to  be  noted,  due  to  some  pecu- 
liarity of  the  disease  process  or  to  some  developmental  tendency.  Thus, 
rarely  there  is  observed  a  scarcely  evident  erythematous  type,  in  which 
the  outer  epiderm  shows  superficial  cracks,  extending  only  to  the  rete,  the 
latter  being  bared,  and  appearing  as  pale-red  or  red  lines,  often  crossing 
at  right  angles  or  irregularly.  In  some  places  the  epiderm,  just  at  the 
edges  of  the  cracks,  is  slightly  detached  and  may  turn  upward.  These 
thin  cuticular  filmy  scales  are  quite  adherent,  except  at  the  borders  just 
mentioned.  Occasionally  minute,  scarcely  macroscopically  visible 
vesiculation  can  be  noted.  The  peculiar  appearance  is  such  as  would 
convey  the  impression  that  the  outer  epiderm  had  been  too  small  for  the 
body,  and  that  the  cracking  had  thus  resulted.  It  bears  resemblance 
also  to  crackled  china.  It  is  rare,  usually  occurring  on  the  trunk  or  thighs. 
It  is  commonly  quite  extensive,  and  is  observed  in  neurotic  subjects. 
Occasionally  chilliness  is  not  unusual,  especially  when  disrobing.  Burn- 
ing, sometimes  associated  with  hyperesthesia,  is  probably  more  com- 
plained of  than  itching.  This  variety  is  variously  known  as  crackled 
eczema,  furrowed  eczema,  and  eczema  craquele. 

Another  type  of  eczema — eczema  sclerosum — is  occasionally  en- 
countered about  the  legs,  especially  the  region  of  the  ankle,  usually 
developing  from  the  squamous  type,  particularly  that  following  upon 
aggregated  large  papules.  The  skin  is  noted  to  be  thickened,  infil- 
trated, hard,  and  almost  horny,  and  somewhat  elevated,  and  some- 
times rather  sharply  defined.  This  type  is  also  observed  in  limited 
patches  on  the  palms,  fingers,  and  on  the  soles.  In  such  cases  acci- 
dental, forcible  flexing  of  a  finger- joint  near  or  above  which  a  patch 
may  be  situated  wrill  cause  deep  fissuring.  Sometimes,  on  the  palms 
and  flexor  surface  of  the  fingers  and  also  on  the  soles,  this  form  of  the 


ECZEMA 


2/5 


disease  approaches  closely  to  tylosis  or  callositas,  and  hence  the  name, 
eczema  tyloticum.  Instead  of  the  surface  of  a  sclerous  patch,  near  the 
ankle,  being  more  or  less  flattened,  it  may  be  rough  and  uneven,  showing 
papillary  hypertrophy,  or  crowded,  wart-like  projections — eczema 
verrucosum.  In  rare  instances,  usually  as  a  small  area,  the  eruption 
is  moist  and  papillomatous  and  frambesiform  (Beco,  Huber).1 

The  term  parasitic  eczema  (eczema  parasiticum)  is  a  yet  somewhat 
vague  term;  it  is  applied,  often  without  sufficient  reason,  to  those  cases 
of  eczematous  aspect  in  which  the  disease  is  patchy  and  sharply  or 
slightly  circumscribed  in  outline.  As  a  rule,  however,  the  term  is  not 
applied  to  the  eczematous  irritation  produced  by  such  animal  para- 


Fig.  57. — Eczema  rubrum,  of  considerable  duration,  involving  face,  ears,  and  neck; 
showing  a  good  deal  of  thickening  and  crusting  (courtesy  of  Dr.  M.  B.  Hartzell). 

sites  as  lice,  fleas,  etc.,  although  it  might  very  well  be.  The  nummular 
eczema  of  Devergie,  and  the  recurrent  rounded  small  eczematous  patches 
frequently  seen  on  back  of  fingers,  hand,  and  forearm,  are  suggestive 
clinically  of  an  active  parasitic  factor,  but  most  investigations  have  been 
negative.  The  ringworm  fungus  is  known  to  be  capable  of  producing 
manifestations  in  which  all  the  ordinary  features  of  ringworm,  except 
being  sharply  defined  and  circumscribed,  are  absent,  the  patch  or  patches 
in  other  respects  being  distinctly  eczematous— usually  vesicopapular, 

1  J.  Beco,  "Uncas  d'eczema  impetigineux  d'apparence  frambcesoide,"  Annales  de  la 
Societe  Medico-Chirurgicale  de  Liege,  1894,  xxxiii,  p.  218;  Alfred  Huber,     Penfolhcu- 
litis  suppurativa  und  framboesiforme  Vegetationen  im  Anschlusse  an  i-kzem 
case  illustrations),  Archiv,  1899,  vol.  xlix,  p.  57- 


2  76  I  NFL  AM  MA  TIONS 

squamous,  or  of  the  eczema  rubrum  type;  the  genitocrural  region, 
axillae,  hands,  fingers,  face,  and  feet,  especially  about  the  toes,  are  some- 
times the  seat  of  such  eczematoid  manifestations  of  the  ringworm  fungus 
invasion,  as  recently  emphasized  by  the  observations  of  Sabouraud  and 
Whitfield.  Eczema  marginatum,  to  be  considered  under  the  head  of 
Ringworm,  is  a  typical  example.  Fungi  other  than  that  of  ringworm  have 
also  been  found  occasionally  in  circumscribed  eczema  areas,  but  as  yet 
the  subject  is  chaotic,  and  alleged  examples  are  relatively  few.  There 
are  such  possibilities,  however,  as  the  occasional  eczematous-looking 
patches  due  to  the  ringworm  fungus  would  indicate.  Such  cases  are  not, 
I  believe,  judged  by  my  own  observations,  so  rare  as  commonly  believed. 
The  designation  "parasitic"  is  also  sometimes  applied  to  those  cases  illus- 
trative of  the  type  known  as  seborrheic  dermatitis  (dermatitis  sebor- 
rhoica),  which  is  elsewhere  described. 

Etiology.1 — Eczema  stands  first  in  frequency  among  skin  dis- 
eases for  which  advice  is  sought.  It  constitutes,  in  this  country,  not 
less  than  one-third  of  all  cases;  in  Europe  it  is  much  less  frequent,  rela- 
tively, at  least,  as  other  skin  diseases  uncommon  with  us  are  compara- 
tively frequent  abroad.  It  is  met  with  in  both  sexes  and  at  all  ages, 
although  it  is  probably  least  observed  between  the  ages  of  six  and  fifteen. 

In  studying  the  etiology  of  the  disease  many  factors  must  be  con- 
sidered. The  first  which  naturally  suggests  itself  is  the  question  of 
heredity.  Eczema  can  scarcely  be  said,  without  much  reservation, 
to  be  hereditary,  for  such  evidence  is  lacking  in  a  large  proportion  of 
the  cases.  In  many  patients,  however,  there  is  an  inherited  tendency, 
but  this  alone  probably  is  never  responsible,  but  such  individuals,  if 
subjected  to  other  contributory  and  exciting  factors,  will  often  present 
the  disease.  Doubtless  it  would  be  more  correct  to  state  that  some 
individuals  are  born  with  irritable  and  easily  excited  skin,  and  therefore 
this  organ  is  readily  susceptible  to  internal  or  external  pathogenetic  stim- 

1  Valuable  and  suggestive  papers  bearing  mainly  upon  etiology  and  pathology,  some 
of  which  also  include  eczema  seborrhoicum :  Bronson,  "Eczema:  Its  Pathology  and 
Principles  of  Treatment,"  Jour,  Cutan.  Dis.,  1883,  p.  129;  Unna,  "On  the  Nature 
and  Treatment  of  Eczema,"  Brit.  Jour.  Derm.,  1890,  p.  231;  "Meine  bisherigen  Be- 
funde  iiber  den  Morococcus,"  Monatshefie,  1899,  vol.  xxix,  p.  106;  Bulkley,  "On  the 
Causes  of  Eczema,"  Med.  Record,  April  4,  1891;  Breda;  "Das  Ekzem  und  seine  Natur," 
Archiv,  1894,  vol.  xxix,  p.  179;  Hutchinson,  "The  Nature  of  Eczema,"  Clinical  Journal, 
London,  1895,  vol.  vi,  p.  275;  Schwimmer,  "Ueber  die  Natur  des  Ekzems,"  Wicn.  med. 
Wochenschr.,  Nos.  30,  34, 1894;  Bowen,  "Modern  Theories  and  Treatment  of  Eczema," 
Boston  Med.  and  Surg.  Jour.,  Oct.  10,  1895;  Leredde,  "Etiologie  et  pathologic  de 
1'eczema,"  Presse  medicale,  May  8,  1897,  and  "L'origine  parasitaire  de  1'eczema," 
Annales,  1899,  vol.  x,  p.  30;  L'eczema,  maladie  parasitaire,  Masson  &  Co.,  Paris,  1898; 
Torok,  "L'eczema-est-il  une  maladie  parasitaire?"  Annales,  Dec.,  1898;  Malcolm 
Morris,  "What  are  We  to  Understand  by  Eczema?"  Brit.  Jour.  Derm.,  1898,  p.  359 
(and  discussion  by  Beatty  and  Colcott  Fox);  Leslie  Roberts,  "A  Contribution  to  the 
Study  of  Eczema,"  Brit.  Jour.  Derm.,  1899,  pp.  7  and  66;  Brocq,  "La  question  des 
eczemas,"  Annales,  Jan.,  Feb.,  and  March,  1900;  Sabouraud,  "Essai  critique  sur 
1'etiologie  de  1'eczema,"  Annales,  April,  1899,  p.  305;  Galloway  and  Eyre,  "A  Study 
of  Certain  Staphylococci  producing  White  Cultures  found  in  Eczema,"  Brit.  Jour. 
Derm.,  Sept.,  1900;  Veillon,  "Recherches  bacteriologiques  sur  1'eczema,"  Annales, 
1900,  p.  683;  Fordyce,  "The  Modern  Conception  of  Eczema,"  Jour.  Amer.  Med.  Assoc., 
June  13,  1903,  p.  1621;  Brocq,  Annales,  1903,  p.  77,  and  Graham  Chambers  (etiology 
and  treatment),  Brit.  Med.  Jour.,  Oct.  6,  1906;  Johnston,  "Speculations  as  to  the 
Causation  of  Eczema,"  Jour.  Cutan.  Dis.,  Jan.,  1913,  p.  •$  (a  presentation  and  review 
of  modern  theories). 


ECZEMA 


277 


uli  or  excitants.  It  is  a  well-known  fact  that  certain  external  irritants 
will  provoke  a  dermatitis  in  a  large  number  of  those  exposed,  whereas  in 
most  of  these  it  will  be  simply  a  passing  dermatitis;  in  others — usually 
a  small  minority — it  turns  out  to  be  a  true  persistent  eczema  which  has 
been  provoked;  what  this  necessary  something  is  which  is  present  in  such 
individuals  and  not  in  others,  and  not  constantly  present  in  many  of 
these,  is  the  unknown  quantity  in  eczema  of  which  we  are  still  ignorant. 
All  that  we  know  is  that  a  great  many  factors,  both  constitutional  and 
local,  have  an  influence  hi  calling  this  "unknown  quantity,"  condi- 
tion, or  "soil,"  whatever  it  may  be  termed,  into  existence,  of  which  an 
inherited  cutaneous  irritability  is,  in  many  instances,  an  important  one. 
It  has,  moreover,  been  noted  that  blonde  and  florid  persons,  who  are 
usually  apt  to  have  dry  and  thin  skin,  belong  much  more  numerously 
in  the  "eczema  class"  than  do  those  of  dark  hair  and  complexion;  and,  as 
a  rule,  the  disease  is  much  more  common  in  those  of  an  active,  nervous 
temperament  than  in  those  of  rather  sluggish  or  phlegmatic  habit.  Sex 
exercises  but  little  weight,  although  statistics  give  the  preponderance  to 
males,  doubtless  due  to  the  fact  that  men  are  more  subjected  to  ex- 
ternal irritants  or  causes.  Age  has  but  little,  if  any,  material  influ- 
ence, although  the  disease  is  frequent  during  the  first  several  years  of 
life,  relatively  uncommon  from  this  time  to  maturity,  and  then  be- 
coming again  frequent. 

The  possibility  of  contagiousness  is  a  matter  which  requires  men- 
tion, and  which  has  been  much  discussed,  but  until  recent  years  there 
was  but  one  conclusion,  and  that  was  negative,  without  qualification. 
That  is  the  view  still  predominantly  held  to-day,  and  is  in  accord  with 
my  own  experience.  There  are  doubtless  fungi  and  other  organisms, 
among  which  is  the  ringworm  fungus,  that  are  capable  of  giving  rise  to 
eczematous  or  eczematous-looking  patches,  usually  those  of  circumscribed 
character,  and  such  would  naturally  be  communicable. 

The  acceptance  of  the  presence  of  micro-organisms  as  the  essential 
cause  of  the  disease— a  growing  belief — would  naturally  carry  with 
it  the  possibility  of  contagiousness,  at  least  under  favoring  conditions, 
but  as  yet  the  findings  are  too  scanty  and  lacking  in  uniformity  to 
warrant  such  conclusion.1 

The  various  etiologic  factors  of  eczema  can  be  conveniently  divided 
into  two  classes:  internal,  predisposing,  or  constitutional,  and  external 
or  exciting.  Either  can  doubtless  act  independently  of  the  other,  more 
particularly  the  external,  but  in  a  large  number  of  cases  both  are  necessary. 

Constitutional  Causes. — These  are  varied,  and  include  all  systemic 
states  or  conditions,  passing  or  persistent,  which  bring  about  impaired 
or  depressed  vitality,  and  which  interfere  with  proper  nutrition,  assimi- 
lation, and  excretion.  Experience  has  taught  that  gouty  and  rheu- 
matic subjects  are  especially  liable  (Bazin,  Garrod,  Duckworth,  Bulk- 
ley,  Bird,  Mapother,  Duhring,  Piffard,  Whitfield,  Watraszewski,  and 
many  others)  to  the  disease,  and  they  seem,  in  some  instances,  almost 

1  For  status  of  this  question,  see  interesting  papers  and  discussion  in  Trans,  of  Sec- 
tion Derm,  and  Syph.,  XIII.  Internal.  Med.  Congress,  Paris,  1900;  and  also  other  papers 
already  referred  to. 


2/8  INFLAMMATIONS 

interchangeable — gout  or  rheumatism  in  the  progenitors,  the  same  or 
eczema  in  those  of  the  succeeding  generation.  Uric  acid  diathesis,  or 
lithemia,  being  a  factor  in  many  cases  (gouty  eczema),  defective  kidney 
elimination,  in  consequence  of  which  the  overproduced  uric  acid  is  locked 
up,  is  an  added  important  element  in  such  patients.  It  is  now  gen- 
erally, and  doubtless  more  justly,  believed  that  these  conditions  (gout 
and  rheumatism)  have  only  an  associated  relationship,  and  not  causa- 
tive— they  as  well  as  eczema  often  being  due  to  the  same  or  similar 
underlying  cause. 

Digestive  debility,  dyspepsia,  and  its  frequent  accompaniment,  con- 
stipation, must  also  be  given  a  high  place  in  discussing  the  causes  of 
the  disease — in  fact,  in  my  experience  stand  first  in  importance,  such 
conditions  often  bringing  on  an  eczematous  attack  in  those  of  eczema- 
tous  tendency,  and  which  responds  rapidly  as  soon  as  perfect  or  rela- 
tively perfect  digestion  has  been  re-established.  Important  an  etiologic 
factor  as  it  is  in  adults,  it  is  even  of  greater  influence  in  eczema  of  infants 
and  children.  Diet,  therefore,  may  be  said  to  have  an  important  bear- 
ing, not  only  by  directly  provoking  digestive  irregularity,  but  indirectly 
when  food  is  taken  in  excessive  quantity,  by  overloading  the  system 
with  unnecessary  supply.  Faulty  or  incomplete  metabolism,  either 
directly  or  by  leading  to  the  development  of  intestinal  toxins,  is  probably 
an  important  element  in  some  cases.1  General  debility,  from  whatever 
cause,  is  sometimes  the  last  contributing  factor  necessary  to  bring  on  an 
outbreak.  This  debility  may  often  be  due  to  assimilative,  nutritive,  or 
nervous  influence — from  overwork,  physical  or  mental,  probably  more 
potential  when  resulting  from  the  latter.  The  constitutional  state  desig- 
nated struma  is  to  be  regarded  (Trousseau,  Sangle,  Hutchinson,  Unna, 
and  others)2  as  an  important  factor  in  some  cases,  especially  in  children. 

In  some  cases  it  may  be  of  reflex  origin  (Kroell,  Abramitcheff,  Kroch, 
Eddowes,  and  others).  To  such  factors  may  be  ascribed  some  in- 
stances of  eczema  seen  in  association  with  dentition  in  infants — the 
so-called  tooth  rash,3  although  many  of  these  cases  are  more  likely 
due  to  a  coexistent  digestive  disturbance.  In  children,  too,  intestinal 
parasites,  doubtless  both  by  reflex  impression  and  direct  action  on  the 
process  of  digestion,  seem  to  have  at  times  an  etiologic  bearing.  Like- 
wise, the  occasionally  observed  etiologic  agency  of  an  adherent  pre- 
puce indicates  nerve  relationship.  The  relation  of  the  nervous  system 
to  skin  nutrition  is,  indeed,  a  close  one,  and  nervous  shock,  hysteria, 
neurasthenia,  and  like  conditions  sometimes  have  a  direct  determining 
influence  (Meyer,  Tilbury  Fox,  Schwimmer,  Bulkley,  Duhring,  Morris, 
Kromayer,  and  others),  and  their  existence  always  renders  the  disease 

1  Johnston  (loc.  cit.),  by  a  process  of   exclusion,  reaches  the  opinion  that  "the 
causation  of  eczema  may  be  narrowed  down  to  a  derangement  of  the  nitrogen  metab- 
olism neither  anaphylactic  nor  a  defective  synthesis  of  urea,  but  occurring  where  for 
the  moment  biochemistry  cannot  demonstrate  it.     Color  is  lent  to  the  theory  by  the 
appearance  in  its  course  of  allergic  phenomena  and  urinary  evidence  of  incomplete 
desamidation.     Perhaps  the  fault  lies  in  a  failure  of  protein — splitting  in  the  intestinal 
wall  or  the  blood  stream  before  the  tissues  select  their  store  of  amino-acid  nitrogen." 

2  Sangle,  "Etude  sur  I'ecz6ma  scrofuleux,"  These  de  Paris,  1880.  No.  161. 

3  Hall  ("Etiology  of  Infantile  Eczema,"  Brit.  Jour.  Derm.,  1908,  p.  6)  found  that  in 
over  four-fifths  of  the  cases  dentition  had  not  begun  when  the  rash  first  appeared. 


ECZEMA 


2/9 


more  rebellious.  It  is  probably  by  the  disturbing  action  on  the  ner- 
vous system  that  vaccination  in  children  eczema  tously  inclined  occa- 
sionally provokes  the  disease.  The  presence  of  eczema  should  not, 
as  a  rule,  however,  in  average  cases,  be  an  obstacle  to  this  procedure,  for 
experience  teaches,  while  it  is  occasionally  an  exciting  and  aggravating 
factor,  it  likewise  sometimes  influences  the  disease  favorably. 

Among  other  less  active  predisposing  causes  which  indicate  defect- 
ive kidney  elimination,  and  which  also  aid  in  bringing  about  a  debili- 
tated condition,  are  to  be  mentioned  albuminuria,  diabetes  mellitus 
(eczema  diabeticorum),  and  diabetes  insipidus — the  dry  skin  resulting 


Fig.  58. — Eczema  of  crackled  variety,  in  a  neurotic  old  man  past  sixty,  and  of 
several  months'  duration,  involving  the  surface  more  or  less  generally,  but  more  espe- 
cially the  trunk,  arms,  and  thighs.    The  skin  is  not  thickened— simply  of  a  slightly 
erythematous  character,  harsh  and  dry,  with  the  corneous  layer  crackled,  the  t 
superficial,  disclosing  the  red  rete. 

from  the  last  two  is  probably  a  factor  of  importance.  Liyeing1  directs 
attention  to  the  occasional  presence  of  eczema,  especially  in  old  people, 
in  those  with  saccharine  urine  due  usually  to  overfeeding  without  com- 
pensatory work  or  exercise  and  to  defective  assimilation,  and  not  neces- 
sarily indicative  of  true  diabetes  mellitus.  Functional  and  organic  uter- 
ine disorders  and  nerve  injuries  (Bowlby,  Cavafy,  Nikolski,  Brouardel, 
Oulmont  and  Touchard,  and  others)  have  in  some  cases  had  etn 
bearing  and  are  additional  evidences  of  the  action  of  the  nervous  sys- 
tem. This  frequent  relationship  has  given  rise  to  the  term  neurotic 
eczema.  Malarial  poisoning  is  also  occasionally  an  important  factor. 
!Liveing,  Lancet,  1881,  i,  p.  4"- 


280 


INFLAMMA  TIONS 


Eczema  certainly  seems  in  some  cases  to  bear  relationship  to  the 
mucous  membranes;  thus  an  association  with  asthma  is  now  and  then 
met  with,  the  two  maladies,  usually  existing,  getting  worse  and  improv- 
ing simultaneously.  Exceptionally  it  has  been  noted  by  some  observers 
that  an  improvement  of  one  was  followed  by  aggravation  of  the  other; 
such  instances  have  rarely  come  under  my  notice.  It  is  barely  possible 
that  the  stomachic  and  intestinal  catarrh  frequently  associated  with 
eczema — probably  a  catarrhal  inflammation  of  the  skin — is  in  real- 
ity the  same  disease  process  and  due  to  the  same  causes;  although 
the  fact  that  the  cure  or  relief  of  the  digestive  trouble  by  treatment 
addressed  to  it  alone  favorably  influences  the  skin  eruption,  does  not 
seem  to  support  this  view;  on  the  contrary,  this  seems  to  show  more 
positively  merely  an  etiologic  relationship. 


Fig.  59. — Eczema  of  thickened,  sclerous,  and  verrucous  variety,  in  a  man  aged 
about  thirty-five,  limited  to  regions  shown,  and  of  several  years'  duration.  Deep 
brownish-red  color,  with  purplish  tinge,  and  bearing  some  clinical  resemblance  to  hyper- 
trophic  lichen  planus  patches.  Previous  history  of  eczema. 


External  Causes. — In  a  large  number  of  cases  an  external  factor 
in  the  production  cf  the  disease  cannot  be  discovered,  and  probably 
does  not  exist.  On  the  other  hand,  there  are  cases  of  eczema  which 
are  persistent,  owing  to  the  fact  that  the  external  exciting  cause  re- 
mains unknown  or  unsuspected,  but  which,  if  finally  discovered  and 
removed,  brings  about  rapid  recovery.  All  the  agencies  capable  of 
bringing  on,  by  their  local  irritant  or  weakening  action,  erythema  or  der- 
matitis, referred  to  under  these  heads,  are  also  capable,  in  some  persons, 
of  provoking  a  veritable  eczema,  especially  when  long  continued  or 
repeatedly  acting.  In  most  individuals,  as  has  already  been  stated, 
nothing  more  than  a  passing  erythema  or  a  variable  dermatitis  is  pro- 
duced, and  in  many  persons  the  action  is,  with  most  of  such  substances, 


ECZEMA  28l 

practically  negative;  in  short,  as  before  referred  to,  there  is  an  unknown 
something  which  makes  some  people  susceptible,  while  others  are  unin- 
fluenced, be  this  heredity,  depraved  or  perverted  health,  faulty  metabo- 
lism, defective  excretion,  or  some  inherent  or  acquired  state  of  the  skin 
itself,  which  may  be,  and  probably  is,  a  sensitization  of  the  skin  brought 
about  by  some  internal  or  external  factor.  Diseased  conditions  of  the 
skin,  such  as  long-persistent  seborrhea  and  ichthyosis,  sometimes  lead 
to  the  complication  or  development  of  an  eczema. 

Among  the  more  common  external  causes  are  to  be  mentioned 
excessive  use  of  water  and  soap,  especially  strong  soaps,  dyes  and  dye- 
stuffs,  chemical  irritants,  mustard  and  other  medicinal  plasters,  and 
drugs;  trade  articles,  such  as  sugar,  flour,  tobacco,  pastes,  polishing 
materials,  and  the  like.  It  is  a  matter,  too,  of  common  observation  that 
most  of  the  causes  may  be  acting  for  a  long  time  without  provoking 
any  irritation,  when  suddenly  or  gradually  some  underlying  condition 
supervenes  or  the  resisting  power  of  the  skin  has  been  finally  overcome 
(or  the  weakened  skin  is  no  longer  able  to  protect  itself  against  parasitic 
invasion  (?)),  and  an  eczema  results.  This  is  seen  over  and  over  again 
with  certain  occupations  (so-called  trade  eczemas,  occupational  eczema, 
occupational  dermatoses),  and,  as  a  rule,  when  this  vulnerability  is 
established,  it  remains  more  or  less  permanently.1  In  this  class,  with  ec- 
zema of  the  hands  and  sometimes  the  forearms,  we  find  grocers — grocers' 
itch  or  eczema;  bakers,  from  flour  and  yeast — bakers'  itch  or  eczema; 
washerwomen — washerwomen's  eczema;  stonecutters,  bricklayers,  past- 
ers, bookbinders,  printers,  dyers,  chemists,  surgeons  (surgeons'  eczema, 
surgical  eczema,  nurse's  eczema,  from  use  of  antiseptics),  wood-workers, 
furriers,  photographers,  etc. 

Exposure  to  extreme  cold  (Hyde,  Corlett),2  more  especially  to  cold 
winds,  is  a  not  uncommon  external  factor  in  some  instances,  and  aggra- 

1  Leloir,  "Dermite  professionnelle  specale  (eczema  des  fileurs  et  varouleurs  de  lin)," 
Annales,  1885,  p.  129;  Blaschko,  "Die  Berufsdermatosen,"  Deutsch.  med.  Wochenschr., 
1889,  p.  925,  and  "GewerblichenHautkrankheiten,"  Handbuch  der  Arbeiterkrankheiten 
(Th.  Weyl-Gustav  Fischer,  1908) ;  Herxheimer,  "Ueber  die  gewerblichen  Erkrankungen 
der  Haul,"  Deutsch.  med.  Wochenschr.,  1912,  No.  i;  Jacquet  and  Jourdanet,  Annales, 
1911— full  abstract  in  Jour.  Cutan.  Dis.,  1911,  p.  564,  "Etiologic  Study  of  Occupational 
Eczema" — think  digestive  disturbance  combined  with  occupation  causative;  Fordyce, 
"Occupational  Skin  Diseases,"  Publication  No.  17,  A.  A.  L.  L.,  New  York  City,  June, 
1912;  and  "Occupational  Diseases  of  the  Skin,"  Med.  Record,  Feb.  3,  1912;  Lefebre, 
"Eczema  of  Spinners  and  Flax-soakers,"  abstract  in  Brit.  Jour.  Derm.,  1889,  vol.  i, 
p.  140— original  paper,  These  de  Lille,  1888;  Purdon,  "Note  on  the  Eczema  of  Bleach- 
ers," Brit.  Jour.  Derm.,  1891,  p.  82;  Lassar,  "Das  Ekzem  der  Chirurgen,"  Dermatolog. 
Zeitschrift,  1894,  vol.  i,  p.  424;  Stillmark,  ibid.,  St.  Petersburg  med.  Wochenschr.,  1894, 
p.  451;  Merzbach,  "Ueber  Gewerbeczeme,"  ibid.,  1896,  vol.  iii,  p.  161;  Hall,  "Derma- 
titis Occurring  in  the  Silver  and  Electroplating  Trades,"  Brit.  Jour.  Derm.,  1902,  p.  121; 

The  external  origin  of  eczema,  particularly  the  occupational  eczemas,  based  on  a 
study  of  4142  cases,  is  exhaustively  presented  by  Knowles,  Jour.  Cutan.  Dis.,  Jan., 
1913,  p.  ii ;  with  bibliography;  who  found  25  per  cent,  of  eczema  cases  to  be  of  definite 
external  origin.  Other  references  to  such  cause  will  be  found  under  '  Dermatitis 
venenata."  , 

2  Corlett,  "Cold  as  an  Etiologic  Factor  in  Diseases  of  the  Skin,  with  a  Report  of  14 
Cases"  (i  colored  plate  and  2  half-tone  cuts),  Jour.  Cutan.  Dis.,  1894,  p.  457- 
cases  eczematous  in  aspect,  Dr.  Corlett  considers  distinct  from  this  disease  and  suggests 
the  name  "dermatitis  hiemalis";  and  second  paper,  "A  Recurrent  Disease  of  the  bkin 
Associated  with  High  Winds  and  Cold  Weather,"  Corlett  and  Cole,  Amer.  Jour.  Med 
Sci.,  June,  1912,  p.  710— full  and  detailed  description,  and  histopathologic  study,  witt 
illustrations. 


282  INFLAMMATIONS 

vating  in  almost  all  cases.  In  fact,  season  often  has  a  considerable 
influence,  the  cold  wintry  windy  weather  materially  adding  to  the 
number  of  patients,  whereas  as  summer  weather  approaches  the  disease 
with  many,  especially  if  mild  or  only  moderately  developed,  disappears 
entirely.  There  are  exceptions  to  this,  for  occasionally  the  malady  is 
worse  in  hot  weather ;  this  is  more  especially  true  of  eczema  in  regions 
where  heat,  perspiration,  and  friction  are  pronounced,  as  about  the  geni- 
talia,  anus,  axillae,  etc. 

Exposure  to  heat-rays,  but  probably  more  especially  to  the  actinic 
rays,  of  the  sun,  is  a  source  in  susceptible  people,  sometimes  producing 
erythema  solare,  and  in  others,  particularly  if  repeated,  a  more  persistent 
irritation,  or  eczema  solare.  The  #-ray  is  also  capable  of  calling  forth 


Fig.  60. — A  distinctly  eczematous  area  of  a  few  months'  duration,  somewhat 
rounded  and  well-defined,  which  might  be  truly  called  "parasitic  eczema,"  the  ring- 
worm fungus  was  found. 

an  eczema-like  process;  as  a  rule,  this  is  an  evanescent  affair,  and  scarcely 
justifies  the  name  of  eczema,  but  exceptionally  a  persistent  eczema  re- 
sults. 

Eczema  resulting  from  dye-stuffs,  usually  anilin  dyes,  is  not  only  met 
with  as  a  trade  eczema,  but  not  infrequently  an  eczema  of  the  legs  will 
be  due  to  the  irritation  from  the  dye  in  the  socks  or  stockings,  and  a  body 
eczema  is  occasionally  observed,  explainable  on  a  similar  basis.  The 
material  sometimes  put  in  hat-bands  will  provoke  an  eczema  of  the 
forehead.  Among  such  possible  similar  causes  are  to  be  sought  an 
explanation  of  some  etiologically  obscure  cases.  To  not  a  few  persons 
the  wearing  of  a  rough  woolen  undergarment  next  the  skin  is  not  per- 
missible on  account  of  the  cutaneous  irritation  excited;  this  leads  to 
scratching,  and  the  latter  to  congestion  and  possibly  to  an  eczema.  Mus- 
tard and  other  rubefacient  plasters,  stimulating  liniments,  and  blisters 


ECZEMA 


283 


should  be  used  with  considerable  caution  in  those  eczematously  inclined, 
for  sometimes  there  results  an  outbreak  which  proves  persistent  and  re- 
bellious. Eczema  of  the  genital  region  in  infants  is  often  observed,  and 
the  cause  is  usually  to  be  found  in  the  repeated  wetting  by  the  urine,  as 
well  as  from  the  irritant  action  of  its  products.  The  eczema  of  diabetics 
of  these  parts,  observed  more  especially  in  women,  has  as  the  immediate 
exciting  cause  the  irritating  diabetic  urine. 

In  speaking  of  so-called  parasitic  eczema,  it  is  there  stated  that  at 
times  the  ringworm  fungus  is  responsible  for  what  clinically  seems 
to  be,  and  doubtless  is,  an  eczema;  it  is  probable  that  this  and  other  similar 
fungi  found  from  time  to  time  by  different  observers  may  have  a  much 
wider  causative  influence  than  is  generally  supposed.  I  have  met  with 
several  instances  of  persistent  eczematous  areas,  in  which  the  ringworm 
fungus,  or  closely  similar  fungus,  was  found.  Various  micro-organisms, 
as  pus-cocci,  morococci,  and  others,  have  been  described,  but,  as  already 
stated,  there  has  been  no  conclusive  uniformity  in  the  findings,  and  their 
presence  probably  has  no  etiologic  significance  beyond,  possibly,  as  with 
the  pus-cocci,  a  modification  or  complication  of  the  eczematous  picture. 
The  irritation  provoked  by  the  various  animal  parasites,  as  pediculi  and 
the  acari  scabiei,  together  with  the  resulting  irritation  produced  by 
scratching,  often  gives  rise  here  and  there  to  eczematous  areas.  Other 
animal  parasites,  such  as  bed-bugs,  fleas,  and  the  like,  in  susceptible  sub- 
jects may  also  be,  exceptionally,  etiologic  factors. 

Among  drug  irritants,  which  are  also  essentially  chemical  irritants, 
must  be  mentioned,  in  the  first  place,  iodoform.  The  sometimes  un- 
toward action  of  this  drug,  more  especially  when  used  as  a  powder,  is 
referred  to  under  Dermatitis  Venenata.  It  at  times  not  only  is  responsible 
for  a  passing  dermatitis,  but  occasionally  it  is  the  starting  factor  in  a 
most  persistent  eczema  (iodoform  eczema),  and  is  a  drug  which  should 
never  be  employed  in  individuals  eczematously  inclined.  Another 
local  application,  rather  frequently  employed,  capable  of  exciting  the 
disease,  is  mercurial  ointment  (eczema  mercuriale).  These  and  many 
other  drugs,  as  already  intimated,  in  certain  susceptible  individuals, 
produce  either  an  artificial  dermatitis,  which  usually  soon  passes  away,  or 
which  evolves  into  a  true  persistent  eczema— the  latter  in  those  who  are 
especially  prone  to  this  disease.  The  same  may  in  such  subjects  result 
from  so-called  rhus  poisoning,  the  dermatitis  or  eczema  proving  rebellious. 

Pathology. — The  investigations  of  most  observers  and  the  clin- 
ical evidence  point,  I  believe,  pretty  conclusively  to  the  catarrhal 
nature  of  the  disease — in  other  words,  that  it  is  a  catarrhal  inflam- 
mation of  the  skin.  The  acceptance  of  an  inherently  weak  or  debili- 
tated skin  from  various  causes,  and  the  action  of  varied  pathologic 
epithelial  stimuli  or  irritants  (Roberts,  Brocq,  Fordyce,  and  others), 
either  from  within  or  without,  or  from  both,  best  explain  the  disease 
process.  The  grosser  parasites,  micro-organisms  (Unna,  Leredde),  or 
their  products  (Brockhardt,  Bender,  and  Gerlach),  thermic,  actinic, 
chemical,  toxinic,  and  other  irritating  agents,  may,  therefore,  be  at  times 
contributory  or  even  distinctly  pathogenic  in  provoking  the  skin  to  the 
reactionary  inflammatory  process  we  call  eczema.  Sabouraud,  Torok, 


284 


INFLAMMA  TIONS 


Jadassohn,  Neisser,  and  others  believe  the  disease  amicrobic,  although 
admitting  that  micro-organisms  may  be,  as  they  undoubtedly  are,  of 
import  in  the  evolution  or  later  changes  in  the  morbid  process.  Unna 
no  longer  holds  to  the  specific  coccus — the  morococcus — which  is  now 
generally  considered  to  be  the  staphylococcus  epidermalis  albus.  The 
symptom  of  itching  might  suggest  a  primary  nerve  involvement  as  re- 
sponsible for  the  cutaneous  phenomena,  and  nerve  changes  have  occa- 
sionally been  noted  (Colmiatti,  Leloir),  but  it  is  much  more  probable  that 


Fig.  61. — Eczema,  sluggish,  deep-seated,  vesicular  type,  with  scattered  lesions  and 
somewhat  thickened  corneous  layer,  commonly  seen  on  the  fingers;  section  from  palmar 
surface  of  a  finger  (low  magnification):  a,  a,  Represents  a  vesicle  in  the  earliest  ob- 
servable stage;  the  mucous  layer  in  the  lighter  part  shows  molecular  changes,  and  cor- 
responds to  the  area  of  inflammation  in  the  papillary  layer  of  the  corium  below.  The 
papillae  show  marked  serous  exudation,  dilated  blood-vessels,  and  invasion  of  leuko- 
cytes (courtesy  of  Dr.  A.  R.  Robinson). 

this  is  wholly  secondary.  The  neurotic  or  trophoneurotic  basis  of  the 
pathologic  changes  has  had,  however,  and  still  has,  many  supporters, 
as  referred  to  when  discussing  etiology. 

The  pathologic  anatomy1  of  eczema  has  been  considerably  studied 

1  Literature  bearing  upon  pathologic  anatomy,  more  especially  consulted  in  addi- 
tion to  that  to  which  references  were  previously  given:  Leloir,  "Contribution  a  1'etude 
de  la  formation  des  pustules  et  des  vesicules  sur  la  peau  et  les  muqueuses"  (with 
bibliography),  Archives  de  physiologic,  1880,  vol.  vii,  p.  307;  and  "Contribution  a 
1'etude  des  affections  cutanees  d'origine  trophiques,"  ibid.,  1881,  vol.  viii,  p.  391; 
"Anatomic  pathologique  de  1'eczema,"  Annales,  1890,  p.  465;  Suchard,  "Des  modifica- 
tions et  de  la  desparition  du  stratum  granulosum  de  I'epidermis  dans  quelques  maladies 
de  la  peau,"  Archives  de  physiologic,  1882,  vol.  ix,  p.  205;  Gaucher,  "Note  sur  1'anatomie 
pathologique  de  1'eczema,"  Annales,  1881,  p.  263;  Rindfleisch,  A  Manual  of  Pathologic 
Histology,  New  Sydenham  Soc'y  Translation,  1872,  vol.  i,  p.  349;  Neumann, Zur  Kennt- 
niss  der  Lymphgefasse  der  Haul  des  Menschen  und  der  Sdugethiere,  Vienna,  1873,  p.  28; 
text-books,  almost  all  of  which  present  cuts — Tilbury  Fox,  Neumann,  Kaposi,  Robin- 
son, Crocker,  Jarisch,  Unna  ("Histopathology"),  Duhring  (Cutaneous  Medicine,  part  ii), 
Macleod  (Pathology  of  the  Skin), 


ECZEMA 


285 


in  recent  years  (Simon,  Hebra,  Wedl,  Rindfleisch,  Kaposi,  Riemer, 
Neumann,  Biesiadecki,  Robinson,  Crocker,  Unna,  Leloir,  Gilchrist, 
and  others) .  There  is  a  difference  of  opinion  as  to  whether  the  earliest 
changes  take  place  in  the  epithelium  or  in  the  papillary  layer,  and  by 
such  observers  that  both  possibilities  are  to  be  admitted.  The  same 
difference  of  opinion  exists  as  to  the  formation  of  the  vesicle,  its  anatomic 
seat  being  the  middle  or  upper  layers  of  the  rete ;  according  to  investiga- 
tions, the  earliest  and  most  frequent  formation  of  vesicles  is  within  an 
epithelial  cell  by  alteration,  dropsical  degeneration,  and  expansion;  and 
some  are  formed  between  the  epithelial  cells.  The  pustule  is  a  similarly 
developed  formation,  with  the  addition  of  leukocytes.  The  earliest,  and 
possibly  histologically  characteristic,  symptom  of  eczema  is  parenchy- 


Fig.  62.— Eczema  rubrum,  weeping  variety  (low  magnification)':  p,  p,  Shows 
marked  hypertrophy  of  interpapillary  processes  of  the  epiderm;  a,  a,  thinning  in  some 
places  over  the  papillae,  but  one  layer  of  cells  at  b;  c,  enlarged  papillae;  d,  d,  d,  d,  dilated 
blood-vessels;  s,  s,  sweat-ducts,  showing  no  change.  In  the  corium  small  mononuclear 
cells  present  in  great  number,  with  increased  number  of  connective-tissue  cells  (courtesy 
of  Dr.  T.  C.  Gilchrist). 

matous  edema  of  the  transitional  epithelium;  there  is,  in  consequence,  a 
broadening  of  the  prickle  layer,  and  these  changes  are  noted  before  there  is 
any  epithelial  growth.  The  edema  is  also  especially  observed  in  the  granu- 
lar layer,  and,  as  a  direct  or  indirect  result,  granulation  ceases  or  is  re- 
tarded, and  proper  keratinization  is  interfered  with.  The  serous  satura- 
tion of  the  whole  epidermis,  which  in  reality  occurs,  leads  sooner  or  later 
to  variable  epithelial  growth.  Along  with  these  phenomena,  or  as  con- 
tended, and  probably  rightly,  by  the  majority  of  observers,  preceding 
and  causing  such,  are  to  be  observed  a  congestion  and  dilatation  of  the 
vessels  of  the  papillary  layer,  with  consecutive  diapedesis  of  leukocytes, 
and  serous  exudation  from  the  blood-vessels;  in  consequence  the  papillae 
and  adjacent  parts  of  the  corium  are  enlarged,  distended,  and  infiltrated, 
and  in  some  instances  the  deeper  parts  are  also  involved  in  the  serous  exu- 


286 


INFLAMMA  TIOiVS 


date.  In  the  latter  cases  considerable  surface  swelling  is  noted  in  the 
more  chronic  disease.  As  a  result  of  the  epithelial  proliferation  referred 
to,  and  also  of  the  serous  and  cell  exudation  and  connective-tissue  cell  pro- 
liferation, together  with  dilatation  and  engorgement  of  the  vessels  of  the 
upper  corium,  considerable  thickening  and  infiltration  ensue.  In  some 
instances  these  changes  are  limited,  primarily  at  least,  to  the  follicles, 
especially  the  hair-follicles,  and  are  perifollicular,  giving  rise  to  papular 
elevations.  In  those  cases  in  which  the  papillae  are  much  enlarged  and 
elongated  a  wart-like  or  papillomatous  aspect  is  given  to  the  disease. 
In  acute  confluent  vesicular  eczema  and  in  eczema  rubrum  the  edematous 
exudation  is  so  great  and  rapid  as  to  destroy  and  cast  off  the  corneous 
layer,  laying  bare  the  rete. 


Fig.  63. — Eczema,  chronic  squamous  variety,  in  a  colored  woman  (low  magnifica- 
tion); the  inflammatory  process  involves  the  epidermis  and  upper  part  of  the  corium, 
the  former,  especially  the  rete  (r),  being  much  hyper trophied,  the  lower  half  of  the 
corium  and  the  glandular  structures  remaining  practically  normal:  s,  Scaling  corneous 
layer;  g,  granular  layer;  p,  p,  papillae,  showing  but  little  alteration;  »,  D,  blood-vessels 
surrounded  by  collection  of  granulation-cells,  numerous  mast-cells,  and  pigment-cells; 
d,  part  of  a  sweat-duct  (courtesy  of  Dr.  T.  C.  Gilchrist). 

It  will  be  observed  from  the  above  that  the  process  is  distinctly 
an  inflammatory  one,  with  the  predominance  of  serous  exudation; 
and  is  characterized  in  all  cases  by  hyperemia,  serous  exudation,  and 
usually  also  by  blood-vessel  dilatation,  epithelial  and  connective-tissue 
cell  proliferation,  varying  in  degree  according  to  the  intensity  and  dura- 
tion of  the  disease ;  the  rete  and  papillary  layers  are  especially  involved, 
although  in  severe  and  chronic  cases  the  lower  part  of  the  corium,  and 
even  the  subcutaneous  tissue,  may  share  in  the  process.  The  congestion 
and  exudation  lead  to  increased  activity  of  the  epiderm,  resulting  in 
scaling.  In  long-continued  chronic  eczema,  especially  of  the  legs,  the 
changes  are  still  more  emphasized,  with  pigmentation,  increased  thicken- 
ing of  all  parts  of  the  affected  integument,  and  an  accentuation  of  the 
natural  lines  and  furrows;  the  papillae,  blood-vessels,  and  lymphatics 
are  considerably  enlarged,  and  in  extreme  cases  the  sebaceous  glands, 


ECZEMA  287 

sweat-glands,  and  hair-follicles  suffer  obliteration  or  degeneration,  as 
noted  in  elephantiasis. 

The  peculiar  gummy  or  sticky  exudation  of  eczema  is  made  up  chiefly 
of  serum  and  the  fluid  resulting  from  dropsical  degeneration  of  the 
rete  cells.  It  is  clear,  light  yellowish  in  color,  neutral  or  feebly  alkaline 
in  reaction,  and  deposits  flocculent  albumin  when  subjected  to  the  usual 
tests;  this  secretion,  when  dry,  gives  rise  to  the  yellowish,  gummy,  or 
candied-looking  glaze  or  crust  often  observed  in  this  malady;  linen  or 
other  material  wet  with  it  is  stiffened  when  dry.  The  darker  crusts  of  the 
disease  are  due  to  the  admixture  of  blood,  pus,  and  dirt. 

,  Diagnosis. — The  diagnosis  of  eczema  seems  to  be  a  field  of  great 
difficulty  to  students  and  practitioners,  and  yet,  if  the  usual  features — 
redness,  thickening  or  infiltration  of  variable  degree,  the  often  mixed 
character  of  the  eruption,  scaling  or  crusting,  and,  in  many  cases  fluid 
exudation  of  a  sticky  nature,  the  tendency  to  be  confluent  and  to  form 
areas,  together  with  the  subjective  symptom,  itching,  and  the  not  un- 
common disposition  to  fissuring — are  kept  in  mind,  error  need  rarely 
occur.  Add  to  this  picture  a  more  or  less  chronic  course,  and  the  above 
group  of  symptoms,  in  readily  excluding  many  other  diseases,  becomes 
almost  pathognomonic.  Cases  seen  shortly  after  the  outbreak,  thus 
lacking  chronicity  as  a  feature,  might  be  more  difficult,  but  as  the  disease 
often  begins  insidiously  and  slowly, — cases  coming  on  rapidly  and  running 
an  acute  course  are  somewhat  rare, — by  far  the  large  majority  do  not  seek 
medical  aid  for  several  weeks  after  the  onset.  The  value  of  these  various 
factors  is  still  further  strengthened  if  the  favorite  locations  of  eczema  are 
remembered,  as  the  hands,  face,  scalp,  back  of  the  ears,  genitalia,  flex- 
ures, legs,  etc.  Judged  by  my  own  experience,  practitioners  in  venturing 
upon  diagnosis  in  an  untried  field  usually  favor  a  rare  disease  rather  than 
a  common  one — if  there  is  to  be  any  guessing  done  or  jumping  at  con- 
clusions, it  should  naturally  be  in  the  direction  of  the  greater  chances  of 
being  right.  Eczema  is  a  frequent  disease,  and  a  large  part  of  dermato- 
logic  practice  is  made  up  of  its  cases,  and  in  that  of  the  general  physician 
it  is  probably  even  relatively  larger;  the  specialist's  statistics  of  this  dis- 
ease are  apt  to  be  reduced  by  the  much  greater  number  of  cases  of  rare 
diseases  which  naturally  gravitate  to  him.  Combining  all  these  diagnos- 
tic factors, — symptoms,  region,  chronicity,  frequency, — one  is  then  pre- 
pared to  say  that  in  children  under  the  age  of  four  or  five  an  itchy  inflam- 
matory eruption  of  the  face  or  scalp  of  any  duration  is  usually  an  eczema; 
the  same  of  an  eruption  on  the  hands  of  a  working  adult;  the  same 
of  that  on  the  leg,  and  to  a  less  extent  of  that  on  the  face,  of  the  middle- 
aged  and  old;  the  same  of  that  about  the  genitalia  and  anus  of  a  matured 
adult;  the  same  of  that  observed  in  the  various  flexures,  etc.  It  is  not 
intended,  by  any  means,  that  these  statements  should  be  taken  as  abso- 
lute, for  other  diseases  do  occur  on  such  regions,  but  relatively  so  much 
less  frequently  that  such  knowledge  has  value  in  reaching  a  diagnosis. 

In  the  differential  diagnosis  many  diseases  must  be  considered,  but 
of  the  more  common  affections  the  most  important  and  those  most  likely 
to  be  confounded  with  eczema  in  private  practice  are  psoriasis  and  sebor- 
rhea,  and  in  public  practice  the  same  and  scabies,  pediculosis,  and  im- 


2  88  INFLAMMA  TIONS 

petigo  contagiosa.  The  differences  between  these  and  eczema  will  first 
be  pointed  out,  and  then  other  maladies  which  may  also  at  times  bear 
resemblance  follow  in  alphabetic  order.  Among  these  latter  those  dis- 
eases in  which  itching  is  a  factor  should  be  more  particularly  considered 
in  the  differentiation,  such  as  pruritus,  urticaria,  sometimes  miliaria, 
and  also  the  rarer  affections,  lichen  planus  and  dermatitis  herpetiformis. 

Psoriasis. — Psoriasis,  even  though  the  eruption  be  scanty,  is  of  more 
or  less  general  distribution:  eczema  is  more  likely  to  be  limited  to  one 
or  two  regions;  psoriasis  patches  are  variously  sized,  rounded,  and 
sharply  defined:  eczema  is  usually  in  one  or  more  large,  irregular  areas, 
and  shades  gradually  into  the  surrounding  skin;  psoriasis  favors  the 
extensor  surfaces,  especially  the  regions  of  the  knees  and  elbows:  eczema 
the  flexures;  psoriasis  lesions  are  uncommon  upon  the  face  and  hands, 
and  then  usually  only  as  a  part  of  a  more  or  less  generalized  eruption, 
whereas  eczema  is  frequently  seen  upon  these  parts  and  often  only  there ; 
psoriasis  is  probably  never  limited  to  a  single  region,  except  the  scalp, 
and  this  rarely:  eczema  is  frequently  so  limited;  the  scaliness  of  eczema  is, 
as  a  rule,  slight:  that  of  psoriasis,  more  or  less  abundant;  eczema  fre- 
quently shows,  or  gives  a  history  of,  vesicles  or  gummy  oozing:  psoriasis 
is  always  dry;  psoriasis  lesions,  when  the  scales  are  removed,  disclose  a 
reddish,  filmy,  or  membranous-looking  surface,  which,  if  scraped,  shows 
minute  blood-drops :  in  squamous  eczema  the  uncovered  surface  is  usually 
hard,  thickened,  and  rough;  psoriasis  patches  begin  as  small  lesions  and 
increase  in  size  by  peripheral  extension:  scaly  eczema  patches,  which 
most  resemble  psoriasis,  arise  most  frequently  from  overcrowding  of 
papules  producing  a  solid  area,  and  usually  characteristic  papules  are 
to  be  found  at  the  periphery;  in  psoriasis  eruption  it  is  not  uncommon 
to  find  a  few  ring-shaped  patches  with  clearing  center:  in  eczema  this 
rarely,  if  ever,  occurs.  Psoriasis  lesions  on  the  palms  may  resemble  closely 
squamous  eczema,  but  the  former  malady  is  never  limited  to  this  region, 
but  is  seen  here,  and  that  rarely,  only  in  conjunction  with  the  characteris- 
tic areas  on  other  parts. 

Psoriasis  of  the  scalp  and  squamous  eczema  of  this  region  have,  in 
appearance,  much  in  common,  but  the  former  is  here  also  usually  seen 
as  well-defined  and  always  dry  scaly  patches,  and  eczema  as  more  or  less 
diffused  and  sometimes  in  places  moist;  psoriasis  patches  are  often  noted 
to  overlap  the  hairy  border  on  to  the  forehead  and  mastoid  region,  and  if 
close  together,  present  a  wavy  or  festooned  edge,  sharply  defined,  as 
elsewhere:  eczema,  if  it  oversteps  the  scalp,  generally  does  so  as  a  diffused 
eruption,  fading  gradually  into  the  normal  skin,  and  often  presenting, 
as  it  approaches  the  ear,  especially  behind  the  ear  in  the  fold,  moist  exuda- 
tion; further,  while  psoriasis  may  in  rare  instances  be  limited  to  the  scalp, 
in  most  of  the  so-called  scalp  limitation  cases  usually  a  few  insignificant 
spots  may  be  seen  on  the  elbows  and  knees. 

In  eczema  itching  is  practically  invariable:  in  psoriasis  it  may  or 
may  not  be  present;  its  absence  would,  therefore,  throw  the  balance  in 
favor  of  psoriasis,  while  its  presence  would  have  but  little  significance, 
although,  as  a  rule,  even  in  itchy  psoriasis  cases,  the  itching  is  rarely  so 
intense  as  in  eczema. 


ECZEMA  289 

Seborrhea. — Seborrhea  is  sometimes  confounded,  but  in  this  there  is 
entire  absence  of  infiltration  and  thickening  and  of  other  signs  of  inflam- 
mation common  to  eczema;  moreover,  the  scales  of  seborrhea  are  greasy 
and  oily,  rather  soft  and  unctuous  to  the  touch,  and  when  on  non-hairy 
parts,  as  the  nose  and  breast,  occasionally  show  slight  prolongations  into 
the  follicles;  the  underlying  skin  is  usually  pale  and  sluggish  looking, 
while  in  eczema,  on  the  other  hand,  the  scales  are  dry  and  brittle,  and  the 
underlying  skin  is  red,  infiltrated,  and  often  rough  and  hardened;  often, 
too,  in  eczema  a  removal  of  scales  or  crusts  discloses  a  part  of  the  surface 
with  'the  characteristic  gummy  oozing,  whereas  in  seborrhea  it  is  greasy 
or  oily.  In  seborrhea  of  the  scalp,  its  most  usual  situation,  if  long  con- 
tinued it  is  often  accompanied  with  falling  of  the  hair:  in  eczema  this  is 
seldom  noted.  The  itching  is  rarely  marked  in  seborrhea,  and  sometimes 
wanting,  while  in  eczema  it  is  more  or  less  constant  and  troublesome.  At 
times,  however,  the  seborrheic  disease  has  ingrafted  upon  it,  or  appar- 
ently so,  the  eczematous  process,  and  thus  shows  mildly  inflammatory 
symptoms;  such  cases  are  described  under  Dermatitis  Seborrhoica,  under 
which  the  differential  points  of  this  latter  from  ordinary  eczema  will  be 
given. 

Scabies. — The  eruption  of  scabies  is  in  many  respects  somewhat 
eczematous,  due  to  parasitic  irritation,  and  in  cases  of  any  duration  the 
conditions  observed  in  some  parts,  especially  about  the  hands,  in  the 
neighborhood  of  the  elbow,  axillae,  and  natal  folds,  may  present  distinct 
eczematous  areas.  Even  in  such  extreme  cases,  however,  the  matter  of 
differential  diagnosis  is  usually  readily  solved.  The  distribution  of 
scabies  is  so  characteristic  as  to  be  almost  pathognomonic.  It  is  not 
localized  to  a  region  or  two,  as  eczema  commonly  is,  but  the  lesions  are 
usually  scattered  and  discrete,  and  consist  often  of  a  mixture  of  papules, 
vesicles,  small  and  large  pustules,  between  the  fingers,  palms,  and  dorsum 
of  hands,  about  the  wrists,  region  of  the  elbow- joint,  axillary  folds,  nipples 
in  women,  lower  abdomen,  genitalia,  and  inner  sides  of  the  thighs,  and 
often  on  the  legs  and  feet — a  distribution  and  eruptive  characters  wanting 
in  eczema.  Moreover,  the  papules,  vesicles,  and  pustules  of  eczema  are 
small,  acuminated,  or  rounded,  those  of  scabies  somewhat  linear,  and  often 
markedly  so,  and  many  of  the  lesions,  especially  the  pustular,  larger  in 
size.  The  presence  of  the  burrow,  or  cuniculus,  usually  and  most  com- 
monly to  be  found  on  the  inner  sides  of  the  fingers,  and  sometimes  upon 
the  covering  wall  of  the  vesicular  and  pustular  lesions,  would  be  decisive. 
Moreover,  a  history  of  contagion  is  often  attainable  in  scabies,  and  fre- 
quently two  or  three  members  of  the  family  are  affected.  In  extremely 
mild  cases  of  the  malady,  kept  so  by  constant  bathing,  and  gener- 
ally observed  in  private  patients,  the  lesions  are  usually  ill-defined 
papules,  vesicopapules,  and  vesicles,  and  may  be  few  in  numbers,  but 
the  characteristic  distribution  is  present.  Then,  too,  the  face  and  scalp, 
except  sometimes  in  infants  and  very  young  children,  are  never  involved 
in  scabies,  and  are  commonly  so  in  more  or  less  generalized  eczema. 
The  pruritus  of  scabies  is  most  troublesome  at  night,  and  often  com- 
paratively absent  during  the  daytime:  in  eczema  this  difference  is  not 
usually  so  marked.  Scabies  cannot  remain  limited  to  the  region  on 

19 


290  INFLAMMA  TIONS 

which  it  first  presents,  but  is  progressive  and  becomes  generally  distrib- 
uted: eczema  often  is  confined  to  one  or  two  regions,  and  rarely  is  found 
so  generally  scattered. 

Pediculosis. — An  eczematoid  eruption  of  a  papular,  papulopustular, 
and  pustular  character,  about  the  scalp,  especially  posteriorly,  and 
about  the  pubic  region,  should  always  lead  to  suspicion  of  pediculi 
as  the  cause;  the  suspicion  aroused,  it  is  an  easy  matter  to  determine 
the  point  by  the  presence  or  absence  of  ova,  or  nits,  on  the  hair-shafts. 
This  is  sufficient,  but  the  pediculi  can  also  usually  be  found  hidden 
in  the  deeper  meshes  of  the  hair  on  the  scalp,  and  the  crab-louse  on 
or  close  to  the  skin,  clinging  to  the  hair  in  the  pubic  region.  In  addition 
to  the  pubic  region,  the  crab-louse  also  causes,  but  infrequently,  similar 
irritation  about  the  axillae,  and  sometimes  in  other  regions  where  there 
is  short  hair,  as  in  hairy  individuals  about  the  breast,  legs,  etc.  In 
extremely  rare  instances  also  an  eczematous  irritation  of  the  eyelids  and 
of  the  eyebrows  has  been  found  to  be  due  to  the  crab-louse  on  these  parts, 
but  here,  as  in  other  situations  above  named,  the  finding  of  the  nits 
attached  to  the  hairs  will  solve  the  problem.  Pediculosis  corporis,  if  of 
long  duration,  and  especially  in  the  tramp  class,  gives  rise  to  distinct  ec- 
zematous irritation,  with,  however,  accentuation  on  those  parts  against 
which  the  clothing  comes  in  closest  contact,  as  across  shoulders,  neck, 
and  upper  back,  around  the  waist,  and  down  the  outer  sides  of  the  thighs 
— a  distribution  not  observed  in  ordinary  eczema.  Even  if,  in  many 
cases,  the  eruptive  lesions  and  excoriations  are  scanty,  the  same  distri- 
bution is  noted,  and  is  usually  characteristic.  Then,  too,  parallel  linear 
scratch-marks  of  some  length  are  more  frequently  noted  in  pediculosis 
corporis  than  in  any  other  itchy  disease.  The  pediculi  are  often  to  be 
found  in  the  clothing,  but  unless  in  great  numbers  are  usually  hidden  in 
the  seams,  in  which  places  they  are  to  be  sought  for. 

Impetigo  Contagiosa. — It  is  only  when  impetigo  lesions  are  close 
together  and  coalesce,  forming  a  crusted  area,  that  a  resemblance  to 
eczema  is  shown.  Even  then  the  nature  of  the  lesions  from  which 
the  area  resulted,  as  usually  disclosed  by  the  history,  and  also  by  the 
presence  of  characteristic  discrete  lesions,  will  prevent  error.  The 
vesicles  and  pustules  of  eczema  are  usually  pin-point  to  pin-head  in 
size,  with  tendency  to  spontaneous  rupture;  those  of  impetigo  are 
pea-  to  dime-sized,  and  exceptionally  larger,  and  tend  to  dry  to  crusts 
without  breaking.  In  the  latter  disease  there  is  often  a  history  of 
contagion. 

Acne  and  Acne  Rosacea. — Ordinarily  acne  can  scarcely  be  confused 
with  papular  or  pustular  eczema,  as  in  the  former  disease  the  lesions 
are  always  discrete,  larger,  and  their  origin  from  a  plugging  up  of  the 
sebaceous  gland  outlet  is  usually  evident.  Acne  rosacea  with  a  sebor- 
rheic  element  can  show  a  rough  resemblance,  but  here  the  hyperemia, 
with  no  infiltration,  often  associated  acne  lesions,  and  the  dilated  capil- 
laries, will  prevent  error — such  conditions  are  not  observed  in  eczema; 
moreover,  acne  rosacea  is  usually  limited  to  the  nose  and  immediate  neigh- 
borhood: eczema,  on  the  other  hand,  is  apt  to  be  diffused  over  the  face, 
and  never  remains  limited  for  any  length  of  time  to  the  rosacea  regions. 


ECZEMA 


291 


Dermatitis. — Inflammation  of  the  skin  of  artificial  origin  is  often 
similar  in  symptomatology  to  that  of  eczema,  and  may,  indeed,  be  con- 
sidered identical,  and  therefore  is  to  be  differentiated  chiefly  by  the 
acuteness  of  the  attack,  history  as  to  the  cause,  its  short  course  and 
rapid  disappearance.  It  is  also  usually  limited  to  the  parts  subjected 
to  the  irritant.  In  many  cases  of  artificial  dermatitis  the  very  violence 
of  the  symptoms  is  suggestive.  In  rhus  poisoning  the  history  of  exposure, 
the  part  affected,  the  intensity  of  the  process  in  many  cases,  and  some- 
times the  presence  of  large  vesicles  and  blebs,  would  ordinarily  preclude 
confusing  it  with  eczema.  Rhus  plants,  however,  like  other  external  irri- 
tants, may  be  the  exciting  factor  in  eczema,  and  the  violent  early  symp- 
toms give  way  to  those  of  the  eczematous  disease ;  this  result,  fortunately, 
rarely  happens  except  in  those  with  distinct  predisposition  to  the  latter 
malady. 

Dermatitis  Exfoliativa. — This  disease  is  almost  invariably  general- 
ized, and,  as  a  rule,  shows  very  little  infiltration  and  thickening,  and 
is  usually  always  dry  and  with  abundant  exfoliation;  eczema  is  prac- 
tically never  over  the  entire  surface,  but  in  sheets  or  areas,  and  more 
marked  in  its  favorite  places,  exhibits  a  good  deal  of  infiltration  and 
thickening,  slight  or  moderate,  and  often  intermittent,  scaliness,  and 
shows  often,  especially  in  the  flexures,  characteristic  gummy  oozing. 
Moreover,  in  many  cases  of  dermatitis  exfoliativa  there  are  symptoms 
of  constitutional  disturbance,  and  in  eczema  such  would  be  exceptional; 
the  subjective  symptom  of  itching  is  much  more  marked  in  eczema,  and 
is  usually  intense,  whereas  in  cases  of  dermatitis  exfoliativa  it  may 
occasionally  be  troublesome,  but  is  often  slight,  and  sometimes  wanting, 
the  feeling  being  more  of  burning  and  tension.  There  is  no  doubt,  how- 
ever, that  exceptionally  extensive  eczema,  of  usually  long  duration,  may, 
as  well  as  psoriasis,  evolve  into  a  true  dermatitis  exfoliativa. 

Dermatitis  Herpetiformis. — The  cases  of  dermatitis  herpetiformis 
which  could  be  confused  with  eczema  are  rare,  and  to  be  found  only 
in  those  cases  in  which  the  vesicular  and  papular  lesions  are  small, 
but  in  this  disease  the  herpetic  character  of  the  eruption— the  tendency 
to  small  groups  and  the  absence  of  distinct  tendency  to  spontaneous 
rupture — is  different  from  eczema.  Moreover,  its  variable  course,  with 
often  change  of  type  or  sprinkling  of  lesions  of  other  types,  as  blebs,  ery- 
thematous  and  bullous  rings,  and  other  symptoms  common  to  erythema 
multiforme,  is  not  observed  in  eczema. 

Erysipelas.— Eczema  can  be  mistaken  for  this  disease  only  when 
markedly  acute,  with  considerable  edema 'and  swelling,  but  there  are 
sufficient  points  of  difference.  In  erysipelas  the  character  of  the  onset, 
its  method  of  spread  usually  from  one  point,  the  shining-  glazed-looking 
red  surface,  and,  above  all,  the  well-defined  elevated,  often  as  if  chopped 
off,  border,  frequently  the  presence  of  blebs,  and  the  accompanying  con- 
stitutional disturbance,  are  different  from  the  symptoms  of  eczema. 
In  this  latter  there  is  rarely  febrile  action,  except  at  the  very  beginning  of 
the  acute  outbreak,  and  this  not  always;  the  eruption  often  appears  simul- 
taneously at  several  points,  with  ill-defined  borders,  its  surface  is  some- 
times beset  with  minute  vesicles,  which  usually  break  and  discharge  the 


292  INFLAMMA  TIONS 

characteristic  sticky  fluid,  different  from  the  serum  from  the  broken  blebs 
in  erysipelas.  The  swelling  and  deep-seated  character  of  the  process  in 
erysipelas  persist  until  the  disease  has  reached  its  acme — usually  some 
days:  in  eczema  the  violence  of  the  onset  generally  abates  within  twenty- 
four  to  forty-eight  hours,  and  then  the  disease  assumes  the  ordinary 
features.  Eczema  is  usually  intensely  itchy,  whereas  the  subjective  symp- 
toms in  erysipelas  are  apt  to  be  a  feeling  of  tension,  soreness,  and  burning, 
rarely  itching. 

Erythema. — There  is,  as  a  rule,  no  difficulty  in  distinguishing  eczema 
from  the  various  erythemata.  In  the  milder  erythemata — erythema 
simplex  and  the  other  hyperemias — there  is  absence  of  distinct  inflam- 
mation, the  process  being  simply  a  congestion,  though  sometimes  insig- 
nificant, scarcely  perceptible  exudation,  but  with  the  absence  of  eczema 
features.  Erythema  intertrigo,  when  with  a  macerated  surface,  resembles 
eczema,  but  the  secretion  is  not,  as  that  of  eczema,  sticky,  nor  does  it 
stiffen  linen  as  the  latter  does;  nor  is  there  any  infiltration.  Still,  ery- 
thema intertrigo  persisting  and  neglected  does  sometimes  evolve  into  a 
true  eczema.  The  lesions  of  erythema  multiforme — papules,  tubercles, 
nodes — are  much  larger  than  those  of  eczema,  and  with  little  tendency  to 
become  confluent;  the  erythematous  patches  are  sharply  marginate  or 
annular,  conditions  not  observed  in  eczema.  Scaliness  is  not  noted  in 
the  erythemata  except  occasionally,  and  then  only  as  an  almost  imper- 
ceptible branniness  or  a  thin  filmy  exfoliation;  in  eczema  scaliness  is 
common  and  often  pronounced.  Moreover,  the  erythemata  rarely  itch 
to  any  degree. 

Favus. — This  disease,  when  well  defined  in  its  earliest  existence,  can 
scarcely  be  mistaken  for  eczema,  as  the  yellow,  mortar-like,  cup-shaped 
discs  are  pathognomonic.  The  scalp  is  its  usual  region,  and  here,  after 
the  disease  has  lasted  for  some  time  and  been  neglected,  and  the  crusting 
massed  and  dirty,  it  bears  some  resemblance  to  squamous  eczema,  but  the 
hair  involvement,  as  shown  by  the  dead-looking,  lusterless  hair,  the  broken 
hairs,  and  the  irregular,  patchy  hair  loss,  is  never  seen  in  the  latter  dis- 
ease. Moreover,  if  the  crusts  are  removed,  atrophic  or  scar-like  tissue 
is  disclosed,  another  condition  entirely  foreign  to  eczema.  In  obscure  or 
questionable  cases,  which,  however,  are  rarely  met  with,  the  microscopic 
examination  of  the  crusts  will  disclose  the  fungus  if  the  disease  be  favus. 

Herpes. — Herpes  simplex,  whether  the  lesions  are  about  the  lips  or 
face  or  about  the  genitalia,  can  scarcely  be  confused  with  eczema; 
herpes  presents  a  grouping  of  vesicles,  often  upon  a  hyperemic  base,  with 
little,  if  any,  disposition  to  spontaneous  rupture :  eczema  vesicles  are  much 
smaller,  usually  closely  crowded,  and  generally  over  considerable  area, 
with  no  tendency  for  special  grouping,  and,  as  a  rule,  soon  break  and  dis- 
charge a  gummy  fluid;  the  process  in  herpes  is  acute  in  course,  disappear- 
ing usually  in  several  days  or  one  or  two  weeks :  eczema  is  almost  always 
persistent;  in  herpes  itching  is,  as  a  rule,  absent,  or  so  slight  as  to  give  rise 
to  no  complaint:  in  eczema  it  is  generally  intense  and  constant.  The 
same  reasons,  with  slower  evolution  and  disappearance  of  the  vesicles, 
which  are  also  larger,  in  great  measure  suffice  to  prevent  confusion  between 
herpes  zoster  and  eczema;  moreover,  the  limitation  of  zoster  to  one  side 


ECZEMA 


293 


of  the  body  or  region,  its  appearance  as  erythematous  and  inflammatory 
patches,  surmounted  by  groups  of  pin-head-  to  pea-sized  vesicles,  and  its 
distribution  over  the  course  of  a  nerve  are  entirely  wanting  in  eczema. 
Herpes  zoster  comes  on  suddenly  and  is  often  preceded  and  accompanied 
by  neuralgic  pain:  eczema  is  never  neuralgic,  and  often  insidious  in  its 
appearance. 

Lichen  Planus. — The  irregular  base,  flattened  top,  with  often  central 
depression,  and  the  dark-red  or  violaceous  color  and  the  glistening 
surface  of  lichen  planus  papules  usually  suffice  to  distinguish  them 
from  the  rounded  or  acuminated,  bright-red  papules  of  eczema.  The 
lesions  of  lichen  are,  as  a  rule,  slow  in  appearance  and  are  persistent,  and 
always  papules,  and,  when  disappearing,  leaving  brownish  or  purplish 
stains:  those  of  eczema  generally  present  acutely,  and  are  less  apt  to 
persist  as  such,  often  showing  a  tendency  to  vesiculation,  and  rarely 
leave  discoloration.  The  solid  scaly  areas  of  lichen  planus  resulting  from 
an  overcrowding  of  the  lesions  bear  resemblance  to  scaly  eczema,  espe- 
cially that  evolving  from  papular  eczema,  but  the  lichen  plaques  are  darker 
red  and  usually  purplish  in  color  and  sharply  defined:  those  of  eczema 
bright  red,  and  generally  fade  off  gradually  into  the  surrounding  skin; 
moreover,  in  lichen  planus  scattered,  characteristic,  discrete  papules 
are  almost  always  to  be  found  at  the  edges  of  the  patch  or  near  by,  which 
would  serve  for  differentiation. 

Lupus  Erythematosus. — There  is  a  resemblance,  on  casual  inspection, 
between  squamous  eczema  and  this  disease;  but  in  lupus  erythematosus 
the  sharply  defined  border,  the  firmly  adherent  but  less  abundant  scali- 
ness,  and  often  the  evident  involvement  of  the  sebaceous  glands,  as  shown 
by  the  distended  and  scaly  plugging  of  the  ducts,  and  in  most  cases  the 
tendency  to  central  atrophy  of  the  patch,  are  sufficient  points  of  differ- 
ence from  the  conditions  observed  in  eczema,  in  which  glandular  duct  in- 
volvement, sharp  border,  and  atrophy  are  wanting.  If  the  scales  are 
removed  in  lupus  erythematosus  or  are  scanty,  the  patch,  pale  or  deep  red 
in  color,  is  apt  to  have  a  dirty-white  dotted  look,  due  to  the  accumulation 
in  the  ducts.  Moreover,  lupus  erythematosus  is  usually  a  strikingly 
chronic  and  slow  process,  often  taking  months  for  the  formation  of  a  dime- 
or  quarter-dollar-sized  area.  The  subjective  symptoms  of  lupus  ery- 
thematosus are  slight  or  absent,  whereas  in  eczema  usually  troublesome. 
Ordinary  eczema  rarely  shows  the  peculiar  distribution  common  with 
lupus  erythematosus— across  the  nose,  and  spreading,  wing-like,  on  to  the 
cheeks.  When  not  so  distributed,  the  above  differences  will,  however,  be 
sufficient  to  distinguish. 

Miliaria.— The  vesicular  variety  of  miliaria  cannot  well  be  mistaken 
for  eczema,  as  the  lesions,  though  they  may  be  numerous,  are  discrete 
and  remain  so,  with  no  tendency  to  confluence,  and  little,  if  any,  to  spon- 
taneous rupture,  and  the  contained  fluid  is  not  of  sticky  character,  fea- 
tures just  the  opposite  of  those  observed  in  vesicular  eczema.  The 
papular  variety  of  miliaria  possesses  greater  resemblance,  but  here  the 
discrete  character,  the  sudden  advent,  and  usually  after  profuse  sweating 
or  heat  exposure,  distinguish  it  from  papular  eczema.  Moreover,  in 
vesicular  and  papular  eczema,  when  the  lesions  are  as  crowded  as  generally 


294  INFLAMMATIONS 

observed  in  miliaria,  there  are  usually  underlying  inflammatory  swelling 
and  perhaps  infiltration,  conditions  not  observed  in  the  latter  disease 
either  hi  its  papular  or  vesicular  varieties.  Besides,  eczema  itches 
greatly:  miliaria  rarely  to  as  great  a  degree,  and  is  sometimes  absent,  the 
subjective  symptoms  being  more  a  feeling  of  pricking,  tingling,  and  burn- 
ing. Miliaria  runs  a  rapid  course,  and  if  the  cause  ceases  to  act,  disap- 
pears hi  several  days  to  one  or  two  weeks:  eczema,  although  it  may  be 
acute  in  coming,  is  apt  to  evolve  into  the  chronic  and  persistent  disease. 

Pityriasis  Rosea. — This  malady  has  some  resemblance  to  mild 
scaly  eczema,  but  the  circinate  tendency  shown  in  many  of  its  efflores- 
cences, the  numerous  patches  with  but  slight  disposition  to  confluence, 
the  superficial  character  of  the  process,  its  rapid  appearance,  and  its  limi- 
tation, in  great  measure,  to  the  trunk  and  upper  part  of  the  limbs,  the 
slight  degree  of  itching  or  its  entire  absence,  and  the  definite  course  of  the 
disease,  are  characters  at  variance  with  the  features  and  behavior  of 
eczema.  It  bears  greater  resemblance  to  dermatitis  seborrhoica,  under 
which  it  will  again  be  referred  to. 

Pruritus. — This  disease  is  characterized  by  simple  itching  and  noth- 
ing else,  and,  therefore,  eczema,  with  its  infiltration,  vesicles,  papules, 
scaliness,  etc.,  can  scarcely  ever  be  confounded  with  it.  There  is  only 
one  symptom  common  to  both,  and  that  is  the  itching,  and  this,  as  re- 
marked, is  the  sole  symptom  in  average  cases  of  pruritus.  In  the 
latter  disease,  however,  if  intense  and  persistent  hi  character,  the  con- 
stant rubbing  and  scratching  provoked  may  give  rise  to  follicular  papules 
and  some  erythematous  areas,  but  these  are  always  in  places  readily 
reached  by  the  hands.  Moreover,  the  history  of  pruritus,  with  its 
absence  of  lesional  symptoms,  except  those  as  a  result  of  scratching,  etc., 
will  serve  to  prevent  error.  Pruritus  ani,  pruritus  scroti,  and  pruritus 
vulvae  may,  however,  from  the  incessant  scratching  and  rubbing,  lead  to 
true  eczema. 

Ringworm. — The  ordinary  round  patch  with  the  clearing  center 
of  ringworm  of  the  non-hairy  surface  is  not  met  with  in  eczema.  Nor  is 
the  method  of  its  spread,  beginning  usually  as  a  small  scaly  spot,  often 
soon  afterward  with  a  somewhat  elevated  and  scaly  or  papular  or  vesico- 
papular  border,  and  clearing  up  centrally,  leaving  slight  scaliness  or 
branny  furfuraceous  desquamation  or  a  smooth  surface,  ever  seen  in 
eczema;  this  latter  never  behaves  that  way.  Ringworm  of  the  scalp  may 
suggest  a  mild  scaly  eczema,  but  in  the  former  the  evident  hair  involve- 
ment, as  shown  by  the  broken-off  hairs  and  hair  stumps,  and  partial 
hair  loss  on  the  patch,  and  the  insignificant  scaliness  are  never  found  in 
the  latter  malady.  In  the  more  inflammatory  pustular  or  papulopus- 
tular  ringworm  of  this  region  the  appearances  simulate  eczema,  but  the 
hair  symptoms,  as  described,  are  present  and  serve  to  differentiate. 
Even  in  obscure  disseminated  scaly  spots  of  scalp  ringworm  in  which  the 
alopecia  and  hair  invasion  are  not  so  obvious,  still  broken  hairs  and  short 
small  stumps  just  peeping  out  from  the  follicles  (black-dot  ringworm) 
suffice  to  distinguish  it  from  eczema. 

Ringworm  of  the  genitocrural,  and  sometimes  axillary,  region  assumes 
an  eczematous  aspect,  and  has  been  well  called  "eczema  marginatum," 


ECZEMA 


295 


but  the  sharply  defined  spreading,  often  festooned,  border,  with  usually 
one  or  several  outlying  typical  ring-like  patches,  as  well  as  the  history  of 
the  eczematous-looking  area,  beginning  in  similar  ring-like  manner,  are 
entirely  different  from  ordinary  idiopathic  eczema.  Moreover,  in  a  large 
majority  of  ringworm  cases  a  history  of  contagion  is  elicited.  Nor  does 
ringworm  itch,  as  a  rule,  nearly  so  much  as  eczema,  although  the  last- 
named  type  frequently  does.  Occasionally  an  eczematoid  eruption  due 
to  the  ringworm  fungus  is,  however,  observed  about  the  hands  and 
toes.  In  doubtful  cases  microscopic  examination  of  the  scrapings  will 
determine.  The  differences  from  ringworm  of  the  bearded  region  will 
be  considered  under  the  next  heading. 

Sycosis. — There  is  a  similarity  in  the  eruptions  of  eczema  and  sycosis 
vulgaris,  but  eczema  is  not  often  follicular,  and  the  lesions  are  often 
crowded  together,  forming  a  solid  sheet;  it  rarely  is  limited  to  the  hairy 
parts  of  the  face,  but  oversteps  these  regions,  and  is  also  often  seen  else- 
where upon  the  surface  at  the  same  time;  the  itching  is  troublesome. 
In  sycosis,  on  the  other  hand,  the  lesions  are  always  follicular  and  dis- 
crete, with  each  lesion  pierced  by  a  hair,  and  even  when  crowded,  show 
their  follicular  character;  the  eruption  is  strictly  limited  to  the  hairy 
parts,  and  the  subjective  symptoms  are  rarely  complained  of.  In  eczema, 
moreover,  there  is  at  times  apt  to  be  the  characteristic  gummy  discharge, 
whereas  this  is  not  observed  in  sycosis. 

In  ringworm  sycosis  (tinea  sycosis)  of  the  superficial  type  the  ring 
patches  are  characteristic,  and  serve  to  differentiate  from  eczema. 
In  the  deeply  seated  or  nodular  ringworm  sycosis  there  is  usually  a 
history  of  the  disease  beginning  as  a  ring-like  spot,  the  hairs  are  in- 
volved, are  broken  or  are  loosened  and  fall  out,  and  there  is  marked 
cutaneous  and  subcutaneous  lumpmess  or  nodules — symptoms  which 
are  entirely  lacking  in  eczema. 

Syphilis. — Syphilitic  eruptions  can  rarely  be  confounded  with 
eczema.  The  secondary  eruptions  of  syphilis  are  usually  discrete, 
though  more  or  less  generalized  in  distribution;  there  is  no  tendency 
to  the  formation  of  confluent  areas;  they  are  darker  in  color,  and  more 
sluggishly  inflammatory  in  appearance,  and  the  color  does  not  always 
disappear  upon  pressure,  as  commonly  in  eczema;  and,  in  addition,  there 
are  other  symptoms  of  syphilis,  and  often  a  history  or  evidence  of  the 
initial  lesion;  moreover,  eczema  itches,  and  the  syphilodermata  do  not, 
excepting  sometimes  in  the  miliary  papular  and  papulopustular  eruption, 
and  then  only,  as  a  rule,  in  negroes.  In  this  latter  class,  however,  itch- 
ing, usually  slight  in  character,  is  often  complained  of  in  the  various 
syphilodermata,  especially  the  small  lesional  varieties  named.  The 
limited  papulotubercular  and  tuberculopustular  area  or  areas  of  late 
syphilis  occasionally  present  a  rough  resemblance,  especially  upon  the 
scalp,  but  the  distinct  infiltrate,  the  copper  or  cut-ham  color,  the  sluggish 
character,  the  segmental  and  circinate  arrangement,  and  usually  evi- 
dences of  destructive  action,  as  shown  by  ulceration  and  scarring,  atrophy, 
and  pigmentation,  and  the  absence  of  itching  are  quite  characteristic  of 
syphilis  and  wanting  in  eczema;  moreover,  the  history  and  the  clinical 
behavior  of  the  two  affections  are  different. 


296  INFLAMMA  TIONS 

Squamous  eczema  of  the  palms  and  squamous  syphiloderm  of  this 
region  at  times  resemble  each  other  closely,  but  the  former  is  more 
apt  to  be  diffused  and  often  shows  equal  involvement  with  the  fingers, 
and  in  the  latter  regions  occasional  vesiculation,  usually  deep  seated; 
palmar  syphiloderm  is  generally  patchy,  rather  sharply  defined,  generally 
wavy  or  segmental  in  outline,  and  often  with  a  distinct  circumscribed 
infiltrate.  Fissuring  is  not,  as  a  rule,  a  marked  feature  of  syphilis,  while 
it  is  frequently  a  pronounced  feature  in  eczema;  the  syphiloderm  is  always 
dry;  eczema  is  noted  at  times  to  be  moist,  although  this,  in  the  palmar 
region,  is  often  entirely  wanting  throughout;  in  syphilis  the  eruption  is 
sometimes  limited  to  the  one  hand:  in  eczema  it  is  generally  in  both; 
palmar  syphiloderm  is  sometimes  associated  with  a  similar  condition  on 
the  soles:  eczema  rarely.  Intense  itching  would  indicate  eczema,  but 
comparative  lack  of  it  has  but  little  import,  inasmuch  as  in  squamous 
eczema  of  this  region  it  is  occasionally  trifling — not  complained  of, 
and  even  denied;  entire  absence  of  itching,  however,  usually  means 
syphilis.  Often  a  history  of  the  latter  disease  is  obtainable.  It  must 
be  admitted  that  in  exceptionable  instances  the  diagnosis  as  between  these 
two  conditions  is  difficult,  and  the  course  of  the  disease  under  treatment  is 
to  be  noted. 

Urticaria. — The  ordinary  wheals  of  urticaria  will  almost  invariably 
serve  to  distinguish  it  from  eczema,  in  which  such  lesions  are  not  observed. 
Papular  urticaria  (lichen  urticatus),  in  which,  especially  in  young  chil- 
dren, the  lesions  are  small  and  often  excoriated,  resembles  papular  eczema 
very  closely,  but  in  the  former  they  are  usually  scattered  and  discrete, 
whereas  those  of  eczema  are  commonly  on  one  or  two  regions,  and  often 
show  aggregation  or  solid  patches.  The  papules  of  urticaria  frequently 
are  noted  to  be  left  from  pre-existing  more  or  less  typical  wheals,  and  not 
infrequently  characteristic  wheals,  or  the  history  of  such,  appearing  from 
time  to  time  will  aid  in  the  differentiation. 

There  are  some  other  diseases  with  which  eczema  may,  if  hurriedly 
examined,  be  confused,  but  they  are  so  exceedingly  rare,  even  in  the  ex- 
perience of  dermatologists,  that  special  differentiation  is  scarcely  called 
for.  These  are  prurigo,  pityriasis  rubra  pilaris,  pemphigus  foliaceus,  der- 
matitis repens,  and  Paget's  disease,  but  they  differ  materially  in  appear- 
ance, behavior,  and  course,  as  the  description  of  those  several  diseases 
will  show,  and  under  several  of  which  reference  will  be  made  to  the  more 
important  differential  points. 

Prognosis. — While  eczema  must,  in  the  larger  number  of  cases, 
be  considered  obstinate,  yet  instances  are  relatively  few  in  which  relief 
and  cure  cannot  be  effected,  if  proper  opportunity  is  given  to  reach  that 
end ;  but  this  does  not  necessarily  always  mean  permanency  and  freedom 
from  future  attacks,  unless  the  etiologic  factors  can  be  permanently  re- 
moved or  kept  in  abeyance,  for  if  these  come  again  into  play,  a  recurrence 
is  possible,  or,  in  many  cases,  even  probable,  the  same  as  is  observed  in 
almost  all  other  diseases  under  the  same  circumstances.  Eczema  never 
produces  tissue  destruction  and  never  leaves  scars  or  any  other  trace  ex- 
cept on  the  legs,  where,  if  of  long  duration,  and  especially  in  older  people 


ECZEMA 


297 


and  those  with  varicose  veins,  some  pigmentation  may  remain.  Nor 
has  eczema  any  direct  action  upon  the  general  health,  but  in  severe,  long- 
continued,  intensely  itchy  cases,  from  the  consequent  worry  and  loss  of 
sleep,  the  patient  may  become  debilitated  and  neurasthenic.  The  prog- 
nosis in  the  individual  case  depends  upon  several  factors — the  locality 
and  extent  of  the  disease,  its  duration  and  previous  behavior,  the  remova- 
bility of  the  predisposing  and  exciting  causes,  the  general  health,  and  the 
attention  the  patient  can  or  will  give  to  carrying  out  the  treatment.  It 
may  be  said  that  acute  or  sudden  attacks  yield,  as  a  rule,  more  readily  than 
those  that  are  developed  slowly  and  insidiously.  The  moist  types  are 
generally  also  more  responsive  than  the  dry  forms.  Cases  in  which  there 
is  a  marked  tendency  to  fissuring  are  usually  obstinate. 

Wherever  the  disease  is  situated,  whatever  its  type,  extent,  and  dura- 
tion may  be,  and  whatever  the  age  of  the  patient,  its  cure  is  never  attended 
with  evil  consequences,  nor  can  its  cure  be,  for  the  comfort  and  well-be- 
ing of  the  patient,  too  rapid.  The  few  isolated  instances  among  the  hun- 
dreds of  thousands  of  eczema  cases  in  which  an  untoward  result  has  been 
reported  (Brocq,  Gaucher,  Brooke,  Duhring,  Hallopeau  and  Leredde)1 
as  possibly  due  to  rapid  disappearance  or  suppression  of  the  cutaneous 
disease  can  be  more  reasonably,  I  believe,  placed  to  the  score  of  pure  coin- 
cidence. Indeed,  instead  of  such  suppression  being  the  cause,  it  is  itself 
probably  the  result,  of  the  intercurrent  constitutional  disease,  as  it  is  a 
matter  of  not  uncommon  observation  that  inflammatory  skin  affec- 
tions tend  to  subside  temporarily  upon  the  advent  and  during  the 
course  of  a  severe,  especially  febrile  disease.  In  fact,  one  can  safely  say 
that  the  secret  of  the  attainment  of  a  rapid  suppression  of  an  eczema 
has  yet  to  be  learned,  for,  unfortunately,  the  cure  is  in  the  vast  majority 
of  cases  accomplished  only  after  at  least  several  weeks  or  months  of  per- 
sistent effort. 

Eczema  of  the  scalp  often  responds  rapidly  if  the  infiltration  is  not 
very  pronounced.  As  a  rule,  the  hair  suffers  but  little;  in  infants,  from 
the  constant  rubbing  of  the  back  of  the  head  against  the  pillow,  the  hair 
is  sometimes  rubbed  off  to  a  variable  extent,  but  not  permanently.  On 
the  face,  the  disease  is  frequently  obstinate,  and  especially  in  those  whose 
vocation  subjects  them  to  exposure  to  cold  winds  and  dampness,  or  to 
intense  heat  or  to  irritating  substances.  Eczema  of  the  nares  and  of  the 
lips  is  somewhat  variable  as  to  the  time  and  effort  required,  some  cases 
yielding  readily.  Eczema  of  the  hands  is  often  obstinate,  occurring  as  it 
does  most  frequently  in  those  of  the  laboring  classes,  whose  work  in  itself 
may  be  the  exciting  cause,  and  which  prevents  a  response  to  therapeutic 
measures;  in  such  cases,  indeed,  unless  the  occupation  can  be  temporarily 
suspended,  a  cure  is  usually  impossible;  and  in  many  of  these  instances 
resumption  of  the  same  work  will  often  induce  another  attack.  Eczema 
of  the  nails  is,  as  a  rule,  obstinate.  Eczema  of  the  crurogenital  and  anal 
regions  is  also  frequently  rebellious,  the  friction,  heat,  and  moisture  of  the 

1  Brocq,  Jour,  de  medicine  de  Paris,  1889,  pp.  680  and  691,  and  Brit.  Jour.  Derm., 
1889,  p.  105;  Gaucher,  Congres  Internal,  de  Derm,  et  de  Syph.,  1889,  Compt.-Rend., 
p.  538  (refers  especially  to  children);  Brooke,  Medical  Chronicle  (Manchester),  1889-90, 
vol.  xi,  p.  206;  Duhring,  Cutaneous  Medicine,  part  ii,  p.  341;  Hallopeau  et  Leredde, 
Traite  pratique  de  Dermatologie,  Paris,  1900,  p.  357. 


298  INFLAMMATIONS 

parts  serving  to  keep  up  the  disease  or  rendering  the  applications  less 
efficacious;  the  same  may  be  said,  but  less  strongly,  of  the  disease  in  other 
flexures.  On  the  legs  the  malady,  though  severe,  commonly  yields  more 
or  less  readily,  but  occurring  in  those  of  advancing  years,  whose  necessi- 
ties require  them  to  be  upon  their  feet  many  hours  of  the  day,  it  is  some- 
times slow  to  respond,  and  occasionally  treatment  fails  absolutely  until 
this  predisposing  cause  is  lessened  or  temporarily  suspended.  In  eczema 
of  the  trunk  the  disease  is  rarely  obstinate;  about  the  nipple  and  the 
umbilicus,  however,  it  is  often  persistent.  In  acute,  more  or  less  general- 
ized eczema  it  responds,  as  a  rule,  somewhat  rapidly,  but  after  a  certain 
point  is  reached  the  progress  is  much  slower,  and  in  occasional  cases  the 
disease  persists  upon  one  or  two  regions,  most  commonly  the  legs,  for 
some  time  after  it  has  been  removed  from  other  parts. 

Infantile  eczema,  as  a  rule,  is,  more  especially  if  of  the  face  and  scalp, 
its  most  common  situations,  quite  amenable  to  treatment,  though  often 
slowrly  so;  if  in  the  first  year  or  two  of  life,  in  some  cases  slight  recurrences 
may  be  expected,  but  if  the  patient  is  aged  four  to  five,  the  time  when  such 
eczemas  tend  to  get  well  spontaneously,  not  only  will  the  disease  often 
respond  surprisingly  well,  and  to  even  treatment  of  an  indifferent  kind, 
if  not  irritating,  but  the  cure  usually  remains  permanent.  On  other 
parts  the  results  are  finally  satisfactory  also,  but  are  not  so  quickly 
obtained. 

Treatment.— The  earlier  French  teaching  that  eczema  was  due 
to  a  diathesis,  and  that  treatment  was  to  be  chiefly  constitutional,  and 
the  antithesis  in  the  leading  Vienna  belief  of  about  the  same  and  later 
period  that  the  disease  was  essentially  external  in  character,  and  required, 
as  a  rule,  external  treatment  alone  for  its  removal,  have  gradually  been 
approaching  a  middle  ground,  which  English  and  American  physicians 
have,  upon  the  whole,  for  a  long  time  maintained — that  most  cases,  for 
success  or  any  permanency,  demand  both  constitutional  and  local  reme- 
dies. This,  I  believe,  experience  proves  to  be  the  rational  view.  It  is 
true  many  cases,  some  of  which — as,  for  example,  trade  eczemas — seem  to 
be  entirely  local  in  their  nature;  and  in  such  cases  external  treatment 
alone  will  have  satisfactory  results.  But  even  in  some  of  these  patients 
underlying  or  concomitant  systemic  disorders  often  impede  the  progress 
toward  recovery,  and  if  present  should  be 'given  attention. 

Constitutional  Treatment. — This  does  not  necessarily  always  mean 
medicinal,  for  often  attention  to  diet  and  other  hygienic  considerations 
are  more  potent  than  drugs.  While  it  is  not  possible  to  say  that  certain 
foods  directly  induce  eczematous  conditions,  still  there  are  many,  through 
their  difficult  digestibility  or  through  their  influence  upon  the  digestive 
process,  and  possibly  their  absorption  before  thoroughly  in  condition  for 
such,  wThich  are  often  factors  of  some  moment.  For  this  reason  the  diet 
in  eczema  cases  should  always  be  plain  but  nutritious,  the  meals  taken  at 
regular  times,  and  in  sufficient,  but  not  superfluous  quantity.  Such 
foods  as  pork,  in  any  form,  salted  meats,  pastries  of  all  kinds,  veal,  lob- 
sters, crabs,  "gamy"  fowls,  fried  dishes,  gravies,  sauces,  cheese,  pickles, 
condiments,  fruits,  and  like  articles  are  to  be  avoided.  Fish  in  some  of  the 
cases  is  a  questionable  food,  probably  due  to  the  fact  that  much  of  it  on 


ECZEMA 


299 


the  market  at  the  present  day  is  from  "cold  storage,"  and  may  have  under- 
gone change.  Oysters  in  the  cold  season  are  permissible,  for  they  are 
then  usually  well  kept,  but  in  warm,  sultry  weather  they  undergo  rapid 
deterioration  and  seem  to  develop  intestinal  toxins,  and  often  aggravate 
the  disease.  Excessive  tea-  or  coffee-drinking  is  to  be  interdicted;  like- 
wise indulgence  in  beer,  wine,  and  other  alcoholic  stimulants;  the  malted 
liquors  especially  seem  to  exert  an  unfavorable  effect.  Alcohol  tends  to 
produce  dilatation  of  the  cutaneous  vessels,  besides,  its  influence  in  invok- 
ing or  emphasizing  defective  kidney  elimination,  and  is,  therefore,  even 
in  moderate  quantities,  especially  damaging.  To  the  very  old  and  feeble, 
accustomed  to  whisky  or  brandy,  and  who  apparently  need  its  support, 
its  continued  use  in  moderate  quantity  should  ordinarily  be  allowed. 
The  excessive  use  of  tobacco  should  also  be  prohibited. 

An  ample  dietary  is  to  be  found  with  the  meats,  beef,  mutton,  lamb, 
poultry,  and  with  the  ordinary  vegetables;  potatoes  should  be  taken  in 
moderation.  In  gouty  and  rheumatic  cases  an  excessive  meat  diet  should 
be  avoided,  but  there  are  some  instances  of  these  underlying  states  that 
are  due  rather  to  the  faulty  starch  digestion  than  to  the  meats,  usually 
in  those  in  whom  there  is  distinct  digestive  weakness,  and  such  patients 
will  often  do  better  with  a  fairly  full  meat  allowance,  together  with  the 
less  starchy  vegetables.  In  troublesome  cases,  if  of  any  extent,  a  rigor- 
ous milk  diet  with  an  allowance  of  meat  or  eggs  once  daily  will  sometimes 
start  the  change  toward  recovery.  In  the  matter  of  food,  individual 
idiosyncrasies  should  be  considered.  In  fact,  in  obstinate  and  persistent 
cases  a  purely  meat  diet  had  proved  of  curative  aid  in  some  instances 
(Squire,  McCall  Anderson).  The  same  experience  has  also  been  noted 
with  a  purely  vegetable  diet  (Neusser,  Jarisch) ;  the  general  condition  of 
the  patient  and  his  constitutional  traits  influencing  the  selection.  An- 
other factor,  not  medicinal,  and  often  of  service,  is  the  free  drinking  of 
water,  not  during  the  meals,  but  between  times;  a  full  glass  of  water  a 
half  hour  to  an  hour  before  each  meal,  and  at  other  times  is  often  of  serv- 
ice in  promoting  proper  elimination  through  the  kidneys.  In  some 
patients  the  water  before  meals  can  be  taken  with  greater  advantage 
quite  hot.  It  is  the  free  water-drinking,  I  believe,  along  with  the  regula- 
tion of  the  diet  and  the  ordered  exercise,  and  consequent  regular  bowel 
movement,  which  is  the  strong  element  at  the  different  mineral  spring 
resorts,  the  medicinal  ingredients  of  the  water  scarcely  being  in  sufficient 
quantity  to  be  of  direct  service.  Systematic  exercise,  preferably  in  the 
open  air,  moderate  indulgence  in  calisthenics,  living  in  well  sun-lighted 
rooms,  and  being  as  much  as  possible  out-of-doors  under  the  direct  in- 
fluence of  the  sun's  rays,  are  matters  of  great  value  in  cases  of  any  extent. 
The  value  of  light,  and  especially  sunlight,  as  a  therapeutic  agent,  is  not, 
I  believe,  as  yet  given  the  appreciation  it  deserves. 

The  plan  of  constitutional  medicinal  treatment,  when  such  is  indi- 
cated, as  it  usually  is,  is  to  be  based  upon  the  indications  in  the  indi- 
vidual case.  A  careful  examination  into  the  patient's  general  health 
will  usually  give  the  cue  to  the  line  of  treatment  to  be  adopted.  There 
are  no  specifics  for  this  disease;  arsenic,  which  was  formerly  in  great 
vogue,  is  now  known  to  be  only  occasionally  of  service,  although  it  is 


300 


INFLAMMA  TIONS 


still  greatly  used,  often  to  the  patient's  disadvantage,  by  the  general 
profession.  It  should,  as  a  rule,  be  the  last  remedy  resorted  to,  rather 
than  the  first,  as  other  plans  are  much  more  generally  successful.  This 
remedy  will  be  referred  to  again.  The  aim  in  all  cases  is  to  see  that  the 
important  emunctories  of  the  body — the  intestinal  tract  and  the  kidneys 
— are  performing  their  work ;  sometimes  this  is  accomplished  by  attention 
to  hygienic  means  alone,  as  already  indicated,  but  often  it  needs  medicinal 
re-enforcement.  A  proper  action,  and  preferably  free  action,  of  the  bowels 
is  a  most  essential  desideratum  in  the  management  of  eczema. 

In  some  cases  the  constitutional  treatment,  or,  properly  speaking, 
management,  need  not  go  beyond  the  measures  just  indicated;  but 
in  many  instances,  as  noted  in  discussing  etiology,  there  is  disturb- 
ance of  the  digestive  apparatus,  of  which  constipation  is  but  a  feature. 
In  many  of  these  patients  the  daily  or  occasional  administration  of  a 
laxative,  along  with  an  ordinary  tonic  digestive  mixture,  associated 
with  mild  soothing  or  slightly  stimulating  external  applications,  will 
soon  bring  about  recovery.  As  a  rule,  the  various  salines,  such  as 
Epsom  salts,  Rochelle  salts,  sodium  phosphate,  and  the  saline  aperi- 
ent mineral  waters,  are  of  most  service  in  eczema  cases.  A  frequently 
used  and  valuable  saline  laxative  tonic  is  that  known  as  "mistura  ferri 
acida,"  the  formula  for  which  is  as  follows: 

fy     Magnesii  sulphat.,  5j~iss  (32.-4S.); 

Ferri  sulphat.,  gr.  iv  (0.265); 

Ac.  sulph.  dilut.,  f  3j  (4.); 

Aquae  menth.  pip.,  q.  s.  ad  fgiv  (128.). 

SIG. — A  tablespoonful  in  a  full  tumblerful  of  water  about  twenty  minutes  before 
breakfast. 

If  not  sufficiently  active,  the  dose  may  be  increased  somewhat,  or  a 
smaller  amount  can  be  taken  before  each  meal.  In  gouty  or  rheu- 
matic cases  the  acid  should  be  omitted.  Another  saline  mixture  of 
value,  and  which  can  be  used  as  a  substitute  for  Carlsbad  salts,  and 
which  is  in  reality  more  efficient  for  these  cases,  is:  1$.  Granulated  sodium 
sulphate,  3x  (40.);  sodium  bicarbonate,  3iv  (16.);  sodium  chlorid,  oij 
(8.) ;  the  dose  is  from  one  to  two  teaspoonfuls  in  a  tumblerful  of  water 
twenty  to  thirty  minutes  before  breakfast,  or  in  smaller  dosage  before 
each  meal.  It  is  to  be  kept  in  a  closely  stoppered,  wide-mouthed  bottle, 
as  it  is  hygroscopic.  Patients  who  do  not  seem  to  bear  salines  well  can 
take  the  following  bitter  laxative  tonic,  and  which  can  be  given  in  many 
cases  to  advantage:  1$.  Sodii  salicylat.,  oj-ij  (4--8.);  ext.  cascarae 
sagradae  fl.,  f5j-iv  (4.-i6.);  tinct.  nucis  vomicae,  foij-iv  (8.-i6.);  and 
tinct.  cardamom  comp.,  or  tinct.  gentian  comp.,  q.  s.  ad  f5iij  (96.) ;  of  this, 
a  teaspoonful  in  water  after  each  meal.  The  quantity  of  cascara  should  be 
increased  or  diminished  according  to  the  effects;  ordinarily,  two  to  three 
drams  (8.-I2.)  in  such  a  mixture  will  be  required.  In  some  cases,  espe- 
cially if  there  is  torpid  liver  action,  an  occasional  laxative  dose  of  calomel, 
usually  i  to  3  grains  two  or  three  times  weekly,  will  not  only  be  a  satisfac- 
tory laxative,  which  can  be  taken  for  a  time,  but  will  sometimes  exert  a 
favorable  influence  upon  the  disease.  Or,  instead  of  taking  it  in  this 
dosage,  the  small  triturate  of  yV  of  a  grain  (0.0065)  °f  calomel  and  i  or  2 


ECZEMA 


301 


grains  (0.065-0.13)  of  sodium  bicarbonate  can  be  given  at  half  or  hour 
intervals  until  laxative  effect  is  brought  on — not  more  than  10  to  15 
tablets,  and  repeated  every  few  days.  Among  other  satisfactory  laxa- 
tives to  which  recourse  may  be  had  are  the  aloin-strychnin-belladonna 
pills,  the  compound  licorice  powder,  and  the  plain  fluid  extract  of  cascara 
sagrada. 

In  some  of  the  eczema  cases  in  which  stomachic  acidity  is  a  factor 
sodium  bicarbonate,  or  if  there  is  fermentative  tendency,  sodium  ben- 
zoate,  5  to  10  grains  (0.33-0.66)  three  times  daily,  alone  or  often  associated 
with  advantage  with  a  bitter,  will  prove  of  benefit.  In  other  cases 
hydrochloric  acid  often  acts  satisfactorily;  as  a  rule,  however,  acids  are  not 
so  desirable  in  eczema  as  alkalies.  In  many  instances  of  digestive  debility 
the  various  digestive  aids,  such  as  pepsin  and  pancreatin,  can  be  given 
along  with  a  bitter  stomachic.  In  some  of  these  cases,  usually  those  of 
stomachic  and  intestinal  indigestion  or  catarrh,  in  which  diarrheic  attacks 
come  on  from  time  to  time,  laxatives  must  be  used  with  care;  in  such 
patients  or  at  such  times  bismuth,  charcoal,  and  salol  can  be  administered. 
In  short,  in  these  cases  the  aim  is  to  remove  any  existing  dyspeptic  con- 
ditions, to  improve  the  digestive  tone,  and  to  meet  any  special  indications 
as  they  may  arise.  In  persistent  stomachic  catarrh  occasional  lavage  of 
this  organ  is  to  be  tried. 

In  another  class  of  patients — the  neurasthenic  class — invigorating 
measures  of  all  kinds  are  to  be  advised;  in  some,  absolute  or  relative 
rest;  in  others,  daily  calisthenics  and  out-door  exercise;  general  massage 
in  suitable  cases;  and  the  use  of  such  drug  tonics  as  strychnin,  quinin, 
the  hypophosphites,  cod-liver  oil,  and  arsenic.  It  is  in  this  class,  and 
especially  when  the  eruption  is  extensive,  that  electricity,  in  the  method 
of  general  galvanization,  seems  to  be  of  service;  running  a  strong  current 
down  the  spine  is  also  of  value.  It  is  probably  more  particularly  in 
neurotic  cases  that  counterirritation  (Crocker)1  by  means  of  mustard 
plasters,  heat,  friction,  or  wire-brush  electrode  (Hyde)2  over  the  corre- 
sponding vasomotor  centers  occasionally  proves  of  value.  It  is  not  ad- 
visable, however,  in  my  judgment,  to  use  such  counterirritants  in  instances 
in  which  there  is  still  tendency  to  outcropping  of  new  areas.  Duhring  com- 
mends antipyrin  and,  bromids  in  moderate  doses  for  neurasthenic  cases. 

In  other  cases — the  gouty  and  rheumatic — the  salicylates,  salol, 
salophen,  salicin,  sodium  bicarbonate,  potassium  bicarbonate,  potas- 
sium acetate,  the  salts  of  lithium,  and  exceptionally  colchicum,  are  the 
most  important  remedies,  along  with  attention  to  diet  in  the  lines  already 
indicated.  In  another  class  of  cases  the  disease  seems  to  be  kept  up  by  a 
general  debilitated  state  of  the  system,  and  in  these  there  is  nothing  so 
valuable,  if  it  can  be  taken  and  digested,  as  cod-liver  oil.  The  dose  should 
not  be  large — from  f  to  2  fluidrams  (2-8.)  will  be  sufficient;  in  fact,  for 
its  good  effects  the  dose  of  a  dram  (4.)  need  rarely  be  exceeded,  and  when 
so  limited,  there  is  less  chance  of  disturbing  digestion,  and  thus  necessi- 
tate the  discarding  of  a  valuable  remedy.  With  this  may  be  administered 
fairly  large  doses  of  strychnin,  and  in  some  cases  small  doses  of  iron. 

1  Crocker,  Brit.  Med.  Jour.,  July  9,  1887,  p.  66. 

2  Hyde,  "Diseases  of  the  Skin,"  Twentieth  Century  Practice,  vol.  v,  p.  196. 


302  INFLAMMA  TIONS 

There  are  other  classes  of  patients,  etiologically  considered,  but 
the  several  named  comprise  most  of  the  cases.  For  instance,  mala- 
ria, diabetes,  and  albuminuria  may  at  times  be  considered  active  un- 
derlying conditions,  and  then  proper  treatment  of  these  will  aid  materi- 
ally in  rendering  the  external  treatment  more  effective.  In  some  in- 
stances, however,  it  is  difficult  to  assign  a  cause  for  the  disease,  either 
constitutional  or  external.  Under  such  circumstances  the  treatment  is 
entirely  empirical,  being  chiefly  conducted  on  the  assumption  that  an 
obscure  underlying  gouty  cause  is  operative,  or  some  slight  or  un- 
recognizable assimilative  or  digestive  irregularity.  If  treatment  upon 
such  lines  seems  futile,  there  are  certain  special  remedies,  variously 
indorsed,  that  may  be  tried  experimentally. 

Arsenic  has  long  been  extolled  as  having  a  specific  influence  in  ec- 
zema, but  it  may  be  safely  stated  that  it  is  prescribed  by  specialists  for 
alleged  specific  effect  in  only  a  small  percentage  of  cases.  It  is  often 
given  in  small  doses  as  a  tonic  along  with  other  drugs  of  the  same  class, 
and  is  especially  valuable  in  patients  with  underlying  anemia,  chlorosis, 
etc.  (Hardaway,  Morrow,  Jarisch,  and  many  others).  It  may  be  tried, 
however,  in  obscure  cases  for  its  specific  effect.  The  drug  is  a  cutaneous 
stimulant,  and  should  not,  therefore,  be  employed  in  acutely  developing 
cases,  nor,  as  a  rule,  in  those  of  an  acute  type,  as  aggravation  will  almost 
certainly  follow.  Its  special  field  is  thought  to  include  those  of  a  sluggish, 
papular,  or  squamous  type,  and  La  some  such  instances  I  have  occasionally 
seen  it  act  most  happily,  but  even  in  especially  indicated  cases  it  often 
fails  to  make  an  impression,  and  sometimes  is  detrimental.  It  should  be 
continued  for  some  weeks  unless  the  disease  seems  aggravated  or  the 
drug  causes  positive  systemic  disturbance,  usually  digestive  or  neu- 
rotic in  character.  Among  other  remedies  variously  extolled  may  be 
mentioned  viola  tricolor  (Piffard,1  Ferguson),  oil  of  copaiba,  oil  of 
turpentine  (Crocker),  tar  (McCall  Anderson,  Duhring),  jaborandi  or 
pilocarpin  (Simon,  Jamieson),  ergotin  (Lewin,  Jarisch),  ichthyol  (Unna), 
and  wine  of  antimony  or  tartrate  of  antimony  (Morris,  Jamieson2). 

Eczema  in  infants  and  young  children  is  most  frequently  attribu- 
table to  improper  feeding,  to  digestive  irregularities,  and  to  constitu- 
tional debility.  Special  attention  must,  of  course,  be  given  to  the 
feeding,  and  it  is  to  be  remembered  that  in  artificially  fed  infants  milk, 
sterilized  or  pancreatinized,  is  to  constitute  the  chief  and,  as  a  rule, 
the  only  food.  Not  much  is  to  be  hoped  for  permanently  in  these 
cases  of  eczema  in  infants  and  children  unless  the  dietary  is  rigorously 
supervised.  Lime-water  added  to  the  milk,  a  tablespoonful  (16.) 
to  the  4  ounces  (128.),  is  sometimes  a  help.  Constipation  is  to  be  cor- 
rected by  the  administration  of  fluidextract  of  cascara  sagrada,  gray 
powder,  or  castor  oil.  Of  the  first,  the  dose  is  from  2  to  10  drops  (0.133- 
0.65),  given  in  a  little  syrup  of  ginger  or  orange  or  other  flavoring  excipi- 
ent;  the  dose  of  gray  powder  is  from  i  to  2  grains  (0.065-0.13)  at  bed- 

1  Piffard,  "On  Viola  Tricolor  and  Its  Use  in  Eczema,"  Med.  Record,  April  29,  1882; 
Ferguson,  "Viola  Tricolor  in  Chronic  Eczema,"  Canadian  Jour.  Med.  Sci.,  April,  1882. 

2  Malcolm  Morris,  Brit.  Med.  Jour.,  Sept.  22,  1883,  p.  572;  Jamieson,  Brit.  Jour. 
Derm.,  1891,  p.  271. 


ECZEMA 


303 


time  every  second  or  third  night;  castor  oil  may  be  given  with  an  equal 
part  of  the  spiced  syrup  of  rhubarb,  in  the  dose  of  from  one-half  to  a 
teaspoonful  at  bedtime,  or  three  times  daily,  depending  upon  the  age  of 
the  child  and  the  effect  produced.  Enemata  and  glycerin  suppositories 
may  also  be  resorted  to  from  time  to  time.  In  these  little  patients  a  small 
dose  of  sodium  bicarbonate  three  times  daily  will  sometimes  influence 
the  disease  favorably.  In  fact,  in  these  cases  the  digestion  must  be 
looked  after  carefully.  In  many  of  these  infants  the  nutrition  is  below 
the  standard,  or  the  patients  are  of  the  so-called  strumous  diathesis. 
Under  such  circumstances  cod-liver  oil  is  a  most  admirable  remedy,  given 
in  emulsion  with  calcium  lactophosphate,  or  in  mixture  with  an  equal 
part  of  lime-water;  of  either  of  these  the  dose  is  from  one-half  to  a 
teaspoonful  three  times  daily.  A  mixture  which  I  have  often  found  use- 
ful in  such  cases  and  in  which  constipation  is  present  is  one  composed  of 
cod-liver  oil  and  castor  oil  in  variable  proportion,  according  to  the  bowel 
torpidity,  and  with  several  drams  of  spiced  syrup  of  rhubarb  to  the  3 
ounces  (96.),  to  give  it  flavor.  In  infantile  eczema  cases  the  possibility 
of  the  disease  being  dependent  upon  or  aggravated  by  reflex  irritation  is 
to  be  borne  hi  mind;  the  question  of  an  adherent  prepuce,  an  emerging 
tooth,  or  intestinal  parasites  should  receive  attention. 

External  Treatment. — The  external  treatment  of  eczema  is  of  essen- 
tial importance,  and  must  be  resorted  to  in  every  instance.  In  certain 
cases,  as  already  remarked,  external  applications  alone  suffice  to  bring 
about  a  cure.  There  are  certain  general  principles  in  the  local  manage- 
ment of  this  malady  that  should  be  kept  well  in  mind.  The  affected 
surface  is  to  be  freed  from  the  products  of  the  disease — the  crusting  and 
the  scaliness.  This  is  best  accomplished  by  means  of  oily  or  unctuous 
applications,  supplemented,  in  suitable  cases,  from  time  to  time,  with 
washing  with  soap  and  warm  water.  In  acute  cases,  however,  and  also, 
as  a  rule,  in  those  of  an  acute  type,  soap  and  water  are  rarely  admissible; 
in  such  instances  cleansing  can  usually  be  effected  by  gently  wiping 
with  cold  cream  or  petrolatum.  Many  cases  in  which  there  is  but  a 
slight  degree  of  scaliness  or  crusting  the  remedial  treatment  alone,  es- 
pecially if  consisting  in  the  application  of  ointments  or  oils,  will  serve  in 
itself  to  remove  such  products.  In  those  of  more  marked  scaliness  or 
crusting,  plain  carbolized  oil  (gr.  v-f 5 —0.33-32.)  or  liquid  petrolatum 
may  be  used  freely,  applying  it  every  hour,  or  flannel  cloths  soaked 
in  oil  can  be  applied  and  allowed  to  remain  in  contact  with  the  affected 
surface;  after  several  hours  or  half  a  day  the  parts  are  then  washed  with 
warm  water  and  a  mild  toilet  soap.  Or  the  remedial  application  may  even 
in  such  instances  in  the  very  beginning  be  supplemented  with  the  daily 
washing  with  soap  and  water,  and  as  soon  as  the  surface  is  freed,  the  latter 
can  be  omitted  or  used  at  intervals.  If  the  crusting  is  abundant  and  ad- 
herent, a  plain  poultice  or  starch  poultice,  and  preferably  made  with  2 
per  cent,  boric  acid  solution,  may  be  used  instead  of  oily  applications 
for  the  purpose  of  softening,  and  be  followed  by  the  soap-and-water 
washing. 

After  removal  of  the  scaliness  or  crusting,  soap  and  water  are,  as 
a  rule,  to  be  used  as  infrequently  as  possible  in  average  cases  of  the  acute 


304  INFLAMMA  TIONS 

and  subacute  types  of  the  disease,  as  both  are  irritating  in  their  effect; 
in  instances  of  marked  irritability,  or  aggravation  from  such,  the  parts 
can  be  cleansed  from  time  to  time  with  cold  cream,  vaselin,  or  almond  oil. 
In  certain  cases,  however,  more  especially  those  of  chronic  sluggish 
character,  the  use  of  soap  and  water  has  a  therapeutic  value. 

The  selection  of  the  plan  of  medication  and  the  strength  and  char- 
acter of  the  applications  depend  chiefly  upon  the  type  of  inflammatory 
action.  Even  in  long-continued  cases  of  the  disease  the  type  of  inflam- 
mation is  at  times  persistently  acute,  although  more  frequently  subacute. 
On  the  other  hand,  some  are  from  the  outset  sluggish  or  chronic  in  charac- 
ter. For  a  proper  conception  of  the  management  of  eczema,  therefore, 
the  degree  of  inflammatory  activity  must  be  considered;  it  matters  not 
upon  what  part  of  the  body  the  disease  may  be  located.  In  great  measure, 
too,  upon  the  character  and  type  depends  the  choice  of  whether  lotions, 
dusting-powders,  ointments,  oils,  or  fixed  dressings  shall  be  employed. 
This  will  be  indicated  as  the  various  inflammatory  grades  are  considered, 
but  there  is  no  absolute  rule.  It  can,  however,  upon  the  whole,  be  said 
that  lotions  with  sediments  are  most  useful  in  the  acute  and  subacute 
moist  types;  that  clear  lotions  may  be  used  in  such  instances,  as  also 
in  dry  types,  often  with  benefit,  if  \  to  2  drams  (2.-8.)  of  glycerin  are 
added  to  the  pint  (500.),  but,  as  a  rule,  more  satisfactorily  when  conjointly 
with  ointments;  clear  lotions  can  also  be  used  in  erythematous  types,  some- 
times alone,  but  usually  preferably  with  a  supplementary  dusting-powder. 
In  thickened,  subacute  and  sluggish  cases  ointments  and  fixed  dressings 
(gelatin,  etc.)  are  generally  most  useful,  and  especially  in  the  dry  forms. 
Oils  are  also  of  value  in  the  latter,  but  their  use  is  limited. 

A  substitution  of  one  plan  or  form  of  application  for  another  is 
often  necessary,  either  for  the  reason  that  no  improvement  had  followed 
or  in  consequence  of  change  of  type — from  moist  to  dry — as  the  result 
of  the  treatment  first  employed.  Nor  is  it  always  possible  to  say  that  a 
given  remedy  will  be  of  service,  some  skins  exhibiting  marked  idiosyn- 
crasy; all  changes  should  be  instituted  cautiously,  and,  as  a  rule,  the  ap- 
plication tried  on  a  limited  area  first.  It  should,  moreover,  be  a  dermato- 
logic  axiom,  and  most  applicable  in  eczema,  that  so  long  as  a  selected 
remedy  or  plan  is  benefiting  it  should  be  continued. 

The  methods  of  applying  the  remedies  are  of  importance.  The 
clear  washes  can  be  simply  applied  with  a  soft  linen  rag  or  a  pledget 
of  absorbent  cotton  or  with  an  atomizer;  those  containing  sediments 
dabbed  on  for  several  minutes  and  allowed  to  dry  on,  or  pieces  of  linen 
cloths  can  be  kept  constantly  applied  and  freely  wet  with  it  from  time 
to  time.  Lotions  are  not  to  be  rubbed  on.  Oily,  emulsion-like  applica- 
tions can  be  applied  in  the  same  manner  as  the  sediment  lotions.  In 
sluggish  cases  plain  oily  applications  can  be  rubbed  in,  and  usually  with 
considerable  vigor.  Ointments  are  applied  in  all  types  of  a  moist  char- 
acter, and  also  in  the  acute  dry  type,  either  by  anointing  or  spread  upon 
lint.  The  latter  is  more  efficient,  but  not  always  practicable.  In  dry, 
sluggish,  subacute  and  chronic  types  they  can  be  rubbed  in,  using  a  vari- 
able amount  of  friction,  and  if  increased  action  is  desired,  can  then  be 
applied  as  a  spread  plaster.  If  at  any  time  the  sediment  of  lotions  or  the 


ECZEMA  305 

pastes  should  mass  upon  the  surface  and  adhere  firmly,  softening  with  an 
oil  or  cold  cream  or  vaselin  will  usually  suffice  for  removal. 

One  of  the  most  troublesome  phases  of  the  management  of  eczema 
cases  is  the  control  of  the  itching,  and  often  attention  must  be  given, 
for  a  time  at  least,  to  this  point  exclusively.  Ordinarily  the  plans  of 
treatment  to  be  considered  will  hold  this  symptom  within  bounds,  but 
occasionally  the  selected  plan  must  give  way  to  another,  or  recourse  must 
be  had  to  the  special  remedies  useful  in  this  condition.  The  addition  of 
carbolic  acid,  thymol,  or  hydrocyanic  acid  to  the  selected  application  will 
usually  suffice;  in  exceptional  instances,  if  relief  is  not  afforded,  applica- 
tions of  hot  water  as  hot  as  can  be  borne,  and  more  certainly  if  it  contains 
\  to  i  grain  (0.033-0.065)  of  sodium  bicarbonate  to  the  ounce  (32.),  will 
bridge  over  the  pruritic  attack.  To  the  pint  of  lotion  carbolic  acid  can  be 
used  in  the  quantity  of  \  to  2  drams  (a.-S.) ;  thymol,  8  to  16  grains  (0.5-1.) ; 
dilute  hydrocyanic  acid,  i  to  4  drams  (4.-! 6.);  and  to  the  ounce  of  oint- 
ment carbolic  acid,  2  to  30  grains  (0.133-2.);  thymol,  i  to  10  grains 
(0.065-0.65);  dilute  hydrocyanic  acid,  5  to  20  minims  (0.35-1.35). 
Menthol  can  also  be  used  in  ointment,  i  to  10  grains  (0.065-0.65)  to  the 
ounce  (32.),  Of  these,  carbolic  acid  is  the  most  valuable.  Thymol, 
in  lotion,  needs  some  alcohol  and  glycerin  for  its  solution. 

Unless  one  is  especially  skilled  in  the  management  of  diseases  of 
the  skin  it  is  a  good  plan  to  begin  the  treatment  of  all  cases,  even  though 
somewhat  sluggishly  inflammatory,  with  the  remedial  applications  to 
be  mentioned  as  appropriate  for  the  acute  type;  much  can  frequently  be 
accomplished,  and  at  least  the  patient's  confidence  is  gained,  and  then 
one  can,  if  it  seems  necessary,  go  ahead  more  boldly. 

In  acute  or  actively  inflammatory  cases  of  any  variety,  and  in  almost 
all  cases  in  which  there  is  scarcely  perceptible  infiltration  and  no  epidermic 
thickening,  mild  applications  alone  are  well  borne.  In  such  the  conjoint 
use  of  a  boric  acid  lotion,  15  grains  (i.)  to  the  ounce  (32.),  and  a  mild 
ointment,  such  as  the  zinc  oxid,  cold  cream,  or  petrolatum,  will  often 
give  relief;  the  zinc  ointment  is  probably  the  most  satisfactory.  The 
same  may  be  said  of  the  treatment  (White)  with  lotio  nigra,  pure  or  pref- 
erably with  an  equal  part  of  lime-water,  in  conjunction  with  such  an 
ointment;  if  over  a  large  surface,  the  dilution  with  lime-water  should  be 
greater,  to  avoid  the  possibility  of  mercurial  absorption.  The  lotion  is 
first  thoroughly  dabbed  on  for  several  minutes  or  longer,  and  allowed  to 
dry  or  partly  dry;  then  a  small  quantity  of  the  selected  ointment  is 
gently  smeared  over;  or  the  ointment  may  be  applied  spread  upon  lint 
or  linen.  If  the  disease  is  extensive  and  there  is  danger  of  chilling,  the 
surface  can  be  merely  moistened  with  the  selected  lotion,  and  then  the 
salve  applied  immediately;  or  preferably  a  small  part  may  be  thoroughly 
gone  over  at  a  time,  and  as  soon  as  anointed  another  part  treated.  When 
the  application  is  repeated,  which  should  be  done  every  several  hours, 
or,  at  the  least,  two  or  three  times  daily,  the  parts  are  first  gently  wiped 
off  with  a  piece  of  soft  linen  or  absorbent  cotton;  in  many  of  the  cases 
in  which  the  ointment  was  merely  smeared  on  it  has  entirely  disappeared 
by  the  time  another  application  is  to  be  made.  I  cannot  speak  too  highly 
of  these  two  plans,  nor  urge  too  strongly  their  value  and  safety  in  the  be- 

20 


306  INFLAMMA  TIONS 

ginning  management  of  most  cases ;  it  is  only  in  extremely  rare  instances 
that  either  proves  irritating.  The  boric  acid  lotion  is  especially  valuable, 
probably  by  its  mild  antiseptic  property,1  and  is,  in  my  practice,  almost 
indispensable.  The  use  of  a  compound  lotion  alone  is  often  beneficial 
in  the  erythematous  and  papular  varieties: 

ty    Acid,  borici,  5ij  (8.); 

Acid,  carbolici,  3ss  (2.); 

Glycerini,  njjx-xxx  (0.65-2.); 

Aquae,  q.  s.  ad  Oss  (250.). 

This  can  be  used  with  or  without  an  ointment.  Its  effect  is  some- 
times enhanced  by  applying,  immediately  after  it  dries,  a  simple  or  com- 
pound dusting-powder,  such  as  named  below.  An  oily  lotion  or  lini- 
ment, soothing  in  these  acute  cases,  is  one  composed  of  equal  parts  of 
lime- water  and  sweet  almond  oil,  with  \  to  2  grains  (0.033-0.13)  of 
carbolic  acid  or  resorcin  to  the  ounce  (32.).  Or  in  these  same  types  and 
also  in  the  vesicular  form  of  the  disease  the  following  calamin-and-zinc- 
oxid  lotion  may  be  used: 

1^.     Calaminae, 

Zinci  oxidi  aa  3ij-iv  (8.-i6.); 

Liquor,  calcis,  f5ij  (64.); 

Aquas,  q.  s.  ad  Oss  (250.). 

This  is  to  be  dabbed  on  freely  several  times  daily;  it  will  act  more  satis- 
factorily if  linen  cloths  kept  wet  with  it  are  constantly  applied.  If  the 
itching  is  troublesome,  to  the  last  lotion  may  also  be  added  from  15  grains 
to  i  dram  (i.~4.)  of  carbolic  acid,  or  from  2  to  8  grains  (0.13-0.53)  of 
thymol,  or  from  8  grains  to  \  dram  (0.52-2.)  of  resorcin,  to  8  ounces  (250.). 
These  several  last-named  drugs  may  be  used  alone  as  lotions,  in  the 
strengths  indicated,  especially  in  the  erythematous  and  papular  varieties. 
Another  mild  soothing  lotion  of  benefit  in  cases  of  acute  type  consists  of: 

1$.     Zinci  oxidi,  3ij-iv  (8.-i6.); 

Acid,  carbolici,  gr.  xx  (1.3); 

Mucilag.  acaciae,  fSij  (7.5); 

Emuls.  amygdalae,  f3ij  (60.); 

Aquas,  q.  s.  ad  fSviij  (250.). 

Liquor  carbonis  detergens,2  from  i  to  2  drams  (4--8.)  to  the  pint  (500.) 
of  water,  or  in  the  same  proportion  added  to  the  several  lotions  named, 

1  See  suggestive  paper  by  Klotz,  "The  Principles  of  Antisepsis  in  the  Treatment  of 
Eczema,"  Jour.  Cutan.  Dis.,  1894,  p.  99.     Only  the  milder  antiseptics  are  permissible 
in  eczema,  the  _  employment  of  the  stronger  surgical  antiseptics,  such  as  corrosive 
sublimate  solutions,  formalin,  strong  carbolic-acid  solutions,  etc.,  are  usually  aggra- 
vating. 

2  Liquor  carbonis  detergens  is  a  proprietary  coal-tar  preparation  made  by  Wright  & 
Co.,  London;  it  is  essentially  a  solution  of  coal-tar  in  soap-bark  tincture.     Equally 
as  good,  however,  and  even  superior,  is  one  which  I  can  strongly  commend,  used  for 
many  years  at  the  Skin  Dispensaries  of  the  University  of  Pennsylvania,  Jefferson 
Medical  College  Hospital,  Philadelphia  Dispensary  for  Skin  Diseases,  and  Howard 
Hospital,  made  as  follows:  Coal-tar,  4  parts;  strong  soap-bark  tincture,  9  parts;  digest 
for  eight^  days,  frequently  shaking  and  stirring,  and  finally  filtering.     The  soap-bark 
tincture  is  made  with  i  pound  soap-bark  to  i  gallon  95  per  cent,  alcohol,  digesting  for  a 
week  or  so.     More  recently  Professor  Duhring,  Amer.  Jour.  Med.  Sci.,  May,  1894,  has 
modified  this  formula,  using  i  part  coal-tar  to  6  parts  soap-bark  tincture,  and  suggested 


ECZEMA  307 

is  useful  in  these  cases.  Ichthyol  as  a  lotion,  from  i  to  4  drams  (4.-!  6.) 
to  the  pint  (500.),  also  proves  of  service.  Lead-water  (liquor  plumbi 
subacetat.  dilut.)  with  several  or  more  parts  water  is  likewise  a  soothing 
application,  sometimes  beneficial  in  the  acute  types. 

With  the  lotions  free  from  sediments  their  use  with  supplementary 
applications  of  a  dusting-powder  after  the  lotion  has  dried  on,  or  before 
completely  dry,  is  often  an  admirable  method,  especially  in  the  erythem- 
atous  and  papular  types. 

Powders  are,  indeed,  frequently  used  alone  hi  the  first  few  days,  in 
extensive  erythematous  acute  cases  of  this  class,  and  sometimes  give 
a  good  deal  of  relief,  and  are  more  especially  serviceable  when  the  affec- 
tion occurs  in  regions  where  two  surfaces  come  in  contact.  They  are  also 
occasionally  used  in  the  secondary  stages  of  the  more  acute  vesicular 
disease,  for  their  desiccating  influence,  especially  in  cases  in  which  oint- 
ment applications  and  lotions  are  found  to  be  irritating.  The  powders 
most  commonly  employed  are  zinc  oxid,  talc,  boric  acid,  lycopodium, 
starch,  magnesium  carbonate,  rice-flour,  zinc  oleate,  zinc  stearate,  and 
bismuth  subnitrate.  The  following  is  a  serviceable  and  clean  combina- 
tion: !$.  Pulv.  ac.  borici,  gr.  xxx  (2.);  talci,  zinci  oxidi,  aa  5ss  (16.). 
As  a  rule,  however,  it  will  be  found  that  the  conjoint  use  of  a  lotion  and 
powder  is  preferable  to  the  latter  alone. 

In  some  cases  of  the  acute  inflammatory  type  ointments  are  found 
more  comforting,  although  in  the  early  stages,  as  a  rule,  not  so  fre- 
quently so  as  lotions.  They  are  more  especially  useful  in  the  dry  vari- 
eties, and  when  there  is  a  tendency  to  desquamation  and  cracking. 
Even  in  most  of  these  instances  the  preliminary  application  of  a  lotion, 
more  particularly  the  boric  acid  lotion,  seems  to  be  an  advantage. 
Zinc  oxid  ointment,  already  referred  to,  can  be  used  alone,  and  is  ex- 
tremely valuable,  often  affording  relief;  if  the  parts  feel  tense  and  hot, 
an  ointment  made  of  this  and  an  equal  part  of  cold  cream  can  take  its 
place;  instead  of  the  zinc  oxid  constituent,  bismuth  subnitrate  can  be  at 
times  substituted  to  advantage.  Cold  cream  itself  is,  indeed,  a  valuable 
salve  in  these  cases,  and.  especially  when  used  conjointly  with  a  lotion. 
In  fact,  cooling  salves— those  containing  water— are  usually  most  sooth- 
ing. For  this  reason  an  ointment  (Unna)  composed  of  lanolin  i  part, 
lard,  2  parts,  and  rose-water  3  parts,  can  often  be  used  as  a  soothing 
refrigerant  application;  or  in  place  of  the  rose-water  lead- water  or  lime- 
water  can  be  substituted  (Duhring)  with  advantage,  especially  in 
markedly  acute  types,  the  latter  ingredients  adding  to  its  soothing  prop- 
erties. Diachylon  ointment,  if  well  and  freshly  prepared,  is  also  sooth- 
ing and  mildly  astringent,  but  it  is  difficult  to  get  a  good  preparation; 
in  the  latter  event,  or  if  not  fresh,  irritation  often  follows  its  application. 
Plain  petrolatum  suits  some  cases,  but  disagrees  with  others,  and,  as  a 
rule,  is  not  to  be  used  alone  in  the  acute  type,  but  as  a  base  or  part  constit- 

the  name  compound  tincture  of  coal-tar  (tinct.  picis  mineralis  comp.);  it  is,  however, 
weaker  than  the  other  formula  named.  Many  other  formulas  are  to  be  found  in  litera- 
ture, some  good,  some  indifferent,  and  some  bad.  The  recent  papers  by  Brocq  \  L-e 
Goudron  de  Houille  Brut  en  Dermatologie,"  Annalex,  IQOQ,  p.  i,  with  brief  review  and 
some  references)  and  by  Dind  ("L'emploi  du  Goudron  de  Houille  (coal-tar)  dans  1 
applications  cutanees,"  ibid.,  p.  170)  give  various  formulas  and  combinations. 


308  INFLAMMA  TIONS 

uent  of  a  base  for  incorporation  of  powdery  ingredients  it  is  often  per- 

missible and  satisfactory.  The  following  I  have  often  used  in  these  cases 
with  benefit: 

1$.     Calaminae, 

Zinci  oxidi,  aa  gr.  xl  (2.65); 

Amyli,  5j  (_4-); 

Ac.  salicylici,  gr.  iij-x  (0.2-0.65); 

Petrolati,  q.  s.  ad  3j  (32.)- 


One  composed  of  calamin,  3j  (4-)>  and  ungt.  zinci  oxidi,  3vij  (28.), 
is  also  often  valuable.  In  pustular  eczema  of  the  acute  type  lotions 
and  ointments  conjointly  used  afford  the  most  satisfactory  results,  and 
a  minute  quantity  of  white  precipitate,  i  to  3  grains  (0.065-0.2)  to  the 
ounce  (32.)  of  ointment,  will  add  to  the  favorable  effects  in  some  in- 
stances. Boric  acid  ointment  is  also  useful  in  such  cases. 

Very  often,  when  salves,  such  as  described,  will  not  agree,  the  so- 
called  pastes  (Lassar,  Unna,  Griindler)1  can  be  employed.  In  fact, 
these  latter  are  often  the  more  acceptable,  and  act  satisfactorily.  They 
possess  a  certain  porosity,  and  while  they  are  protective,  they  do  not 
entirely  block  up  exudation.  The  salve  mentioned  above,  containing 
zinc  oxid,  calamin,  and  starch,  is  somewhat  of  this  nature.  The  type 
of  this  class,  is,  however,  the  following  (Lassar's  paste)  : 

fy     Zinci  oxidi, 

Amyli,  aa  3ij  (8.); 

Petrolati,  3iv  (16.). 

In  this  is  commonly  incorporated  3  to  10  grains  (0.2-0.65)  °f  salicylic 
acid.  The  latter  amount  is  usually  added,  and  when  so  constituted 
the  paste  is  generally  known  as  the  "salicylic  acid  paste,"  "salicylated 
paste."  In  fact,  when  "Lassar's  paste"  is  referred  to,  this  salicylated 
paste  is  usually  meant.  It  is  a  most  admirable  preparation,  not  only 
in  the  less  actively  acute  types,  but  in  the  subacute  cases.  Another 
paste  which  is  also  satisfactory  is  one  similar  to  that  given:  fy  Zinci 
oxidi,  amyli,  ac.  borici,  aa  gr.  Ixxx  (5.33);  ac.  salicylici,  gr.  iij-x  (0.2- 
0.65);  petrolati,  3iv  (16.).  To  these,  and  in  fact  to  the  salves  already 
mentioned,  in  extremely  itchy  cases,  can  be  added  to  the  ounce  (32.) 
i  to  3  grains  (0.065-0.2)  of  carbolic  acid;  a  stronger  proportion  —  up  to 
10  grains  (0.65)  —  is  sometimes  permissible,  especially  in  the  less  actively 
acute  cases. 

In  eczema  of  a  subacute  or  moderately  inflammatory  type,  whether 
beginning  as  such  or  evolving  from  the  acutely  inflammatory  cases, 
and  in  which  there  is  distinct  infiltration  or  epidermic  thickening,  it  is 
advisable  to  begin  the  treatment  with  one  of  the  several  applications 
suggested  for  the  acute  type.  Too  much  stress  cannot  be  laid  upon  this 
point,  for  often  the  quickest  and  most  satisfactory  results  are  thus 
attained.  Cautiously,  if  necessary,  as  it  frequently  will  be,  the  various 

Lassar,  "Ueber  Salicylpasten,"  Monatshefte,  1883,  vol.  ii,  p.  97;  Unna,  "Die 
Pastenbehandlung  der  entziindlichen  Hautkrankheiten,  insbesondere  des  Ekzems," 
ibid.,  1884,  vol.  Hi,  p.  38:  Griindler,  "Ueber  Fasten,"  ibid.,  1888,  vol.  vii,  p.  1029;  G.  W. 
Wende,  "Ointments  and  Pastes,"  Amcr.  Med.  Quarterly,  June,  1899  (an  excellent  ex- 
position of  the  subject). 


ECZEMA 


309 


active  ingredients  named  in  some  of  the  lotions  and  ointments— as,  for 
instance,  carbolic  acid,  salicylic  acid,  etc. — can  be  added  in  greater  pro- 
portion. A  lotion  containing  |  to  2  ounces  (i6.-64.)  of  liquor  carbonis 
detergens  to  the  pint  (500.)  of  water  is  extremely  valuable  in  many  cases, 
and  can  be  used  plain  as  such,  or  this  tar  product  can  be  added  to  any 
of  the  several  lotions  already  named.  This  is  one  of  the  most  valuable 
tar  preparations  in  these  cases,  and  least  likely  to  disagree,  but,  as  with 
all  tarry  applications,  it  should  be  used  cautiously  at  first,  as  some  skins 
are  intolerant  to  this  drug.  The  carbolized  boric  acid  lotion  referred  to 
may  also  be  prescribed  with  from  2  to  5  grains  (0.13-0.32)  of  tannic  acid 
to  the  ounce  (32.).  Resorcin  is  also  valuable  in  this  type,  employed  as  a 
lotion  of  from  3  to  10  grains  (0.2-0.66)  to  the  ounce  (32.),  or  as  an  oint- 
ment of  from  10  to  20  grains  (0.65-1.33)  to  the  ounce  (32.).  Ichthyol 
in  from  a  2  to  a  5  per  cent,  lotion  is  sometimes  valuable.  The  following 
is  also  useful : 

1$.    Zincioxidi,  3ij  (8.); 

Liquor,  plumbi  subacetatis  diluti,  fSvj  (24.); 

Glycerini,  foij  (8.); 

Infus.  picis  liquidas,  q.  s.  ad  fjiv  (128.). 

In  limited  areas,  especially  of  a  slightly  moist  type,  painting  on  a  satu- 
rated solution  of  picric  acid  (Maclennan,  Thiery,  Leredde,  Radaeli) 
two  or  three  times  daily  for  three  or  four  days,  and  then  applying  emol- 
lients, waiting  until  the  film  thus  formed  comes  off,  is  sometimes  of  ser- 
vice. In  these  cases,  as  well  as  in  those  of  a  chronic  type,  an  occasional 
painting  (every  five  to  ten  days)  with  a  i  to  10  per  cent,  aqueous  solution 
of  silver  nitrate,  or  with  a  i  to  3  per  cent,  solution  in  sweet  spirits  of  niter, 
proves  valuable,  more  especially  in  the  slightly  moist  cases.1 

In  this  type  the  results  are  usually  better  when  a  lotion,  if  employed, 
is  followed  by  a  salve;  and  an  occasional  stirring  up  of  the  surface  with 
a  strong  lotion,  followed  by  one  of  the  soothing  ointments,  sometimes 
constitutes  a  good  plan.  As  a  general  rule,  however,  soothing  remedies 
are  here,  as  in  the  acute  type,  to  have  first  place.  Some  cases  seem  to 
do  better  on  ointments  alone.  White  precipitate  can  be  added  to  the 
several  already  named,  in  the  proportion  of  5  to  30  grains  (0.33-2.)  to 
the  ounce  (32.).  Calomel,  in  the  same  proportion,  acts  well  in  many 
instances,  and  is  the  one  I  most  frequently  have  first  recourse  to  when 
stronger  applications  are  found  necessary: 

1$.     Hydrargyri  ammoniati  seu  hydrargyri 

chloridi mitis,  gr.  v-xxx  (0.32-2.); 

Acidi  carbolici,  gr.  v-x  (0.33-0.65); 

Ungt.  zinci  oxidi,  5j  (32-)- 

If  this  last  ointment  is  to  be  rubbed  in,  as  in  erythematous  and  squamous 
areas,  the  zinc  oxid  ointment  can  sometimes  be  replaced  with  advantage 
by  petrolatum,  lard,  or  cold  cream.  Another  formula  (Klotz2)  that  is 
useful,  especially  as  a  preparatory  measure,  in  subacute  thickened  eczema 

1  See  interesting  paper  by  Dunn,  "Nitrate  of  Silver  in  Dermatology,"  Pennsylvania 
Med.  Jour.,  Jan.,  1901. 

2  Klotz,  New   York  Med,  Jour.,  Sept.  17,  1887. 


3  I O  IN  FLA  MM  A  TIONS 

of  the  hands  and  extremities,  for  constant  application  in  the  form  of  a 
plaster,  consists  of: 

1$.    Acidi  salicylici,  gr.  x-xx  (0.65-1.33); 

Emplastri  plumbi,  Sjjss  (o.io); 

Emplastri  saponis,  Siiss  (o.io); 

Petrolati,  5"j  (12.).     M. 

The  same  can  be  said  of  a  5  per  cent,  salicylated  soap-plaster  (Pick1). 
An  ointment  of  alumnol  or  of  aristol,  from  \  to  i  dram  (2. -4.)  to  the 
ounce  (32.),  and  an  ointment  of  acetanilid,  from  5  grains  to  i  dram 
(0.33-4.)  to  the  ounce  (32.),  prove  beneficial  in  some  instances.  The 
tarry  ointments  may  be  used  in  these  cases,  but  they  should  be  weak  and 
employed  at  first  cautiously,  as  they  may  disagree.  The  following  are 
mild,  and  can  be  often  prescribed  with  great  advantage;  the  first  one 
is  the  milder  and  safer  for  beginning  a  change  in  the  treatment,  and  one 
that  can  be  recommended: 

fy    Liquor,  carbonis  deterg.,  3j-ij  (4-~8.); 

Ungt.  zinci  oxidi,  q.  s.  ad  5j  (32-)-    M. 

Or 

Ifc.     Ungt.  picis  liquidae,  3HJ  (4-~8.); 

Ungt.  zinci  oxidi,  q.  s.  ad  5j  (32-)-     M. 

If  the  larger  quantity  of  the  liquor  carbonis  detergens  is  prescribed 
in  the  former,  the  zinc  oxid  ointment  should  be  partly  replaced  (about 
3j-ij  (4--8.))  with  powdered  starch,  simple  cerate,  or  lanolin,  otherwise 
the  resulting  ointment  would  be  too  soft.  The  salicylic  acid  paste  makes 
a  good  base  for  it. 

These  cases  may  at  times  be  satisfactorily  treated  with  some  of  the 
fixed  dressings,  especially  the  salve-mulls  and  gelatin  applications,  the 
medication  varying  somewhat,  usually  being  zinc  oxid,  ichthyol,  boric 
acid,  small  quantities  of  tar,  or  resorcin.  The  salve-mulls2  (Unna)  are 
especially  valuable  in  irritable  cases, — the  zinc  oxid  and  the  boric  acid 
salve-mulls, — and  can  be  used  with  safety,  both  in  this  type  and  the  acute 
type  cases.  They  are  kept  constantly  applied,  changing  once  in  the  twelve 
or  twenty-four  hours,  according  to  circumstances.  My  experience  has 
chiefly  been  with  the  two  named,  although  they  are  made  with  various 
other  medicaments  incorporated. 

The  gelatin  applications  (Pick,  Unna,  Morrow,  and  others)3  are  most 
admirable  and  constitute  a  valuable  method  of  treating  many  cases  of 
the  disease,  more  particularly  when  upon  the  lower  extremities.  They 
are  especially  useful  in  cases  of  this  type  of  inflammatory  action,  but  they 

1  Pick,    V erhandlungen  der  Deutschen  dermal.  Gesellschaft,  I.  Congress,  Vienna, 
1889. 

2  The  salve-mulls,  and  also  the  plaster-mulls  to  be  referred  to,  are  made  by  Beiers- 
dorf,  Germany,  and  imported,  through  Lehn  and  Fink,  New  York.     They  are  some- 
what expensive,  but  have  not  yet  been  successfully  imitated  in  this  country. 

3  M.  Pick,  <;Die  therapeutischen  Verwendung  arzneihal tiger  Gelatine  bei  Haut- 
krankheiten,"  Monatshefte,  1883,  vol.  ii,  p.  33;  and  Prager  med.  Wochenschr.,  1883,  No. 
6;  Unna  und  Beiersdorf,  "Leimglycerin  als  Konstituens  in  der  Dermatotherapie — 
Gelatinae  glycerinatas  medicatae,"  Monatshefte,  1883,  vol.  ii,  p.  37;  and  Jour.  Cutan. 
Dis.,  1884,  vol.  ii,  p.  54  (this  paper  contains  tables  of  formulas  for  various  drugs  with 
gelatin,  glycerin,  and  water,  both  for  soft  and  hard  preparations) ;  Morrow,  "An  Im- 
proved Method  in  the  Treatment  of  Certain  Forms  of  Skin  Affections,"  Med.  Record, 
March  i,  1884;  Eddowes,  Medical  Times  and  Hospital  Gazette,  Sept.,  1899. 


ECZEMA  3!! 

can  also  be  used  in  some  of  those  of  the  more  acute  variety,  and  are  like- 
wise of  distinct  service  in  the  sluggish  cases.  There  are  various  formulas 
given,  but  the  most  generally  useful  are  the  following — hard  preparation: 
Gelatin,  4  parts;  glycerin,  i  part;  water,  8  parts  (Morrow);  soft  prepara- 
tion— and  that  which  I  have  used  most  frequently:  gelatin,  2  parts; 
zinc  oxid,  i  part;  glycerin,  3  parts;  water,  4  to  6  parts,  and  to  this  prep- 
aration is  added  2  per  cent,  of  ichthyol,  i  per  cent,  of  carbolic  acid,  or 
salicylic  acid.  That  containing  zinc  oxid  and  ichthyol  is  most  service- 
able; the  same  ingredients  can  also  be  added  to  the  first  formula.  When 
needed  for  use,  it  is  melted  over  a  water-bath  (a  double  farina  or  oat- 
meal boiler  answers  the  purpose),  and  applied  with  a  broad  brush  of 
from  i  to  3  inches  wide.  If  desired,  if  the  harder  preparation  is  used, 
it  can  be  allowed  to  dry  on,  and  then  simply  dusted  over  with  an  indiffer- 
ent powder.  I  prefer  using  the  softer  gelatin  preparation,  and  then 
before  the  gelatin  is  dry  to  apply  a  thin  gauze  bandage;  this  adds  to  the 
completeness  and  effectiveness  of  the  dressing.  This  can  ordinarily  be 
left  on  three  to  five  days;  when  its  removal  is  desired,  it  is  softened  thor- 
oughly with  warm  or  hot  water,  after  which  it  readily  comes  off;  a  fresh 
dressing  then  is  applied. 

Linimentum  exsiccans  (Pick1),  of  which  tragacanth  is  the  basis,  is 
another  dressing  which  dries  on,  but  it  is  not  comparable  to  the  gelatin 
application,  although  it  can  often  be  more  conveniently  used  on  some 
situations  than  the  latter.  The  folio  wing  is  the  formula:  fy  Tragacanth 
5  parts;  glycerin,  2  parts;  boiling  water,  to  make  100  parts;  to  this  is 
usually  added,  to  preserve  it,  2  per  cent,  of  boric  acid.  It  can  be  variously 
medicated,  that  with  5  to  10  per  cent,  of  zinc  oxid,  and  0.5  to  i  per  cent, 
of  carbolic  acid,  is  most  commonly  used.  This  dries  slowly,  and  I  believe 
is  not  so  good  as  one  with  acacia  as  the  base:  1$.  Zinci  oxid.,  2  parts; 
glycerin,  i  part;  and  mucilage  of  acacia,  5  to  8  parts;  the  various  drugs 
can  also  be  added  to  this.  Somewhat  similar  to  that  of  Pick's,  but  su- 
perior, is  one  made  with  bassorin  (Elliot2) :  Bassorin,  48  parts;  dextrin,  25 
parts;  glycerin,  10  parts;  and  water  to  make  100  parts;  it  should  be  pre- 
pared cold.  Zinc  oxid,  ichthyol,  and  other  medicaments  can  be  incor- 
porated. These  several  drying  paints  are,  as  a  rule,  not  practicable  in 
hot  weather,  as  the  increased  perspiration  makes  them  sticky.  After 
the  application  dries  on  a  powder  can  be  dusted  over. 

In  the  management  of  eczema  of  chronic  (sluggish)  inflammatory 
type  in  which  there  are  moderate  or  pronounced  infiltration  and  epidermic 
thickening,  the  various  applications  already  indicated  in  the  treatment 
of  the  acute  and  subacute  types,  especially  of  the  latter,  can  be  tried  first. 
In  many  of  these  cases,  however,  these  will  only  bring  about  slight 
betterment,  and  stronger  methods  must  be  resorted  to.  An  occasional 
or  frequent,  according  to  circumstances,  vigorous  shampooing  with 
sapo  viridis,  conjointly  with  the  above  lines  of  treatment,  will  often  bring 
about  a  favorable  result.  After  the  soap-washing  the  parts  should,  of 

1  F.  J.  Pick,  "Ueber  die  Anwendung  eintrocknender  Linimente  (Linimenta  exsic- 
cantia)  bei  der  Behandlung  von  der  Hautkrankheiten,"  Archiv,  1891,  p.  633. 

2  Elliot,  "Bassorin  Paste:   A  New  Base  for  Dermatological  Preparations,^  Jour. 
Cutan.  Dis.,  1891,  p.  48;  "Bassorin  Paste  in  the  Treatment  of  Skin  Diseases,    ibid., 
1892,  p.  184. 


312  INFLAMMATIONS 

course,  always  be  rinsed  off  with  clean  water  and  tapped  dry  before  the 
remedial  applications  are  made.  Stronger  remedies  are,  however,  often 
called  for;  they  are  essentially  the  same  as  indicated  in  the  above  types, 
but  in  increased  strength.  The  various  lotions,  especially  of  resorcin, 
can  be  employed,  with  several  times  as  much  of  this  ingredient  contained 
therein — 5  to  20  grains  (0.33-1.33)  to  the  ounce  (32.);  and  it  can  be  fol- 
lowed by  a  strong  salve.  The  calomel  and  white  precipitate  ointments, 
already  suggested,  are  often  of  service,  containing  40  to  80  grains  (2.65- 
5.33)  of  the  mercurial  to  the  ounce  (32.);  such  ointments  should  be  well 
rubbed  in,  but  are  not  applicable  to  large  surfaces  for  fear  of  absorption; 
for  the  latter  reason  their  application  as  a  spread  ointment,  except  to  a 
small  area,  is  not  advisable. 

Tarry  preparations  are  most  frequently  of  use  in  these  cases,  dis- 
agreeing occasionally;  they  are  most  satisfactory  in  the  dry  sluggish 
types.  The  mildest  of  all  is  the  liquor  carbonis  detergens,  already 
referred  to;  as  a  lotion  it  can  usually  be  employed  strong,  even  up  to 
the  pure  solution,  followed  by  a  salve  containing  it,  as  before  given, 
or  with  the  calomel  or  white  precipitate  ointment.  As  a  rule,  however, 
the  stronger  vegetable  tars  are  usually  necessary,  such  as  the  oil  of 
cade  or  the  official  tar  ointment.  The  former  can  be  used  with  i  or 
3  parts  of  almond  or  olive  oil,  or  in  ointment  with  simple  cerate,  2  to 
3  drams  (8.-I2.)  to  the  ounce  (32.).  Sometimes  a  satisfactory  method 
is  to  prescribe  it  with  alcohol,  i  to  2  parts,  paint  over  the  surface,  al- 
low to  dry,  and  then  put  on  a  spread  salve  application  of  one  of  the 
mild  salves — the  salicylated  paste  is  an  eligible  one.  The  official  tar 
ointment  should  at  first  be  used  with  i  to  2  parts  lard,  and  increased  in 
strength  if  necessary.  In  favorable  cases  the  infiltration  rapidly  dis- 
appears under  the  use  of  these  several  tar  preparation.  In  limited  dry 
areas,  if  not  too  much  thickened,  the  tar,  as  the  oil  of  cade,  can  be  in- 
corporated with  collodion,  i  dram  (4.)  to  the  ounce  (32.),  and  painted  on 
two  or  three  times  daily  for  several  days,  and  then  under  a  mild  salve 
dressing  allow  the  film  to  come  up;  the  painting  can  then  be  renewed. 
If  the  odor  of  tar  is  a  serious  objection,  a  strong  ointment  of  resorcin 
or  /3-naphthol,  or  salicylic  acid,  30  to  60  or  more  grains  to  the  ounce, 
can  be  employed  at  times  with  great  advantage,  but,  like  all  other 
remedies,  they  at  times  disagree.  Painting  on  iodin  tincture,  at  first 
weakened  with  i  part  alcohol,  once  every  few  days,  is,  conjointly  with 
salves,  sometimes  of  service.  The  gelatin  dressing  treatment  should 
not  be  forgotten  in  these  cases,  as  it  is  often  a  valuable  method;  it  can 
sometimes  advantageously  be  preceded  by  a  shampooing  with  sapo 
viridis  and  hot  water,  and  sometimes  by  a  preliminary  painting  with 
pure  or  weakened  liquor  carbonis  detergens. 

Occasionally  an  ointment  of  sulphur,  20  to  60  grains  (1.35-4.)  to 
the  ounce  (32.),  preferably  of  the  salicylated  paste,  acts  beneficially. 
A  compound  ointment  sometimes  useful  in  these  thickened  sluggish 
cases  is  the  following:  1$.  Sulphur,  praecip.,  3ss-ij  (2.-8.);  ungt.  picis 
liquidae,  5ij-iv  (8.-i6.);  petrolati,  q.  s.  ad  oj  (32.).  Sulphur  must, 
however,  be  used  with  caution,  as  it  frequently  disagrees. 

Sulphur,  in  the  more  sluggish,  obstinate  cases,  is  sometimes  used 


ECZEMA 


313 


in  the  form  of  sulphur  baths,  and  these,  one  every  two  or  three  days,  can, 
in  some  instances,  be  tried,  at  least  as  an  adjuvant  measure.  The 
bath  is  made  by  adding  i  to  4  ounces  (32.-! 28.)  of  potassium  sulphid  to 
the  ordinary  bath-tub  about  half  full  (about  30  gallons),  the  water  being 
sufficiently  warm  for  the  patient  to  remain  in  five  to  fifteen  minutes 
without  being  chilled.  Tar  baths  are  also  occasionally  resorted  to,  the 
affected  parts  being  first  scantily  or  freely  painted  or  rubbed  with 
pix  liquida  or  oil  of  cade,  and  the  patient  then  getting  in  a  warm  plain 
bath.  Neither  of  these  methods  has  found  use  in  my  practice  in  late 
years,  as  favorable  effects  were  so  infrequent  and  irritation  or  aggrava- 
tion not  unusual.  In  some  cases,  however,  a  course  of  baths  at  the  sul- 
phur spring  resorts,  with  the  advantages  of  change  of  scene,  release  from 
care,  supervised  diet,  and  out-door  life,  is  serviceable. 

Other  remedies  to  which  recourse  must  sometimes  be  had,  when 
other  plans  have  failed,  are  ointments  of  chrysarobin  and  pyrogallol, 
20  to  50  grains  (1.33-3.33)  to  the  ounce  (32.),  but  these  also  must  be 
cautiously  employed.  In  obstinate  cases  it  is  sometimes  advisable  to 
excite  inflammatory  action,  and  then  follow  with  soothing  applications. 
When  there  is  pronounced  infiltration  of  limited  extent,  which  is  slow 
in  undergoing  absorption,  the  cautious  application,  every  few  days,  of 
the  negative  electrode  of  the  galvanic  battery,  using  5  to  20  milliam- 
peres,  will  occasionally  give  the  impetus  toward  recovery.  The  static 
spark  is  also  at  times  of  service  in  such  cases.  In  some  instances  the 
application  of  a  high  frequency  current  by  means  of  the  vacuum  elec- 
trodes, for  several  minutes  or  longer,  and  repeated  every  few  days,  has 
been  beneficial  and  occasionally  curative.  The  same  may  be  said  of  the 
action  of  the  Rontgen  rays ;  with  cautious  exposure  of  three  to  ten  minutes, 
with  a  soft  to  medium  tube,  at  varying  distances  of  from  3  to  10  inches, 
repeated  at  intervals  of  several  days. 

In  the  treatment  of  the  thickly  indurated  or  sclerosed  and  verrucous 
patches  strong  applications  are,  as  a  rule,  necessary  to  bring  about 
their  removal,  or  such  modification  that  cure  is  then  possible  by  the 
various  plans  already  named.  For  reducing  these  patches  there  are 
several  preparations  which  are  of  service — chiefly  sapo  viridis,  caustic 
potash,  and  salicylic  acid.  If  at  all  extensive,  a  compound  of  equal 
parts  of  sapo  viridis,  tar,  and  alcohol  can  be  used,  rubbing  it  in  twice 
daily,  and  allowed  to  dry  on.  This  can  be  continued  for  several  days  or 
longer  if  no  reactive  irritation  sets  in,  and  then  the  parts  soaked  in  hot 
water,  with  i  or  2  drams  (4--8.)  of  borax  to  the  quart  (1000.),  and 
subsequently  thoroughly  washed  with  sapo  viridis,  rinsed,  and  dried. 
The  treatment  can  be  resumed  and  continued  in  the  same  way  until 
the  Infiltration  is  thinned  down  and  the  induration  removed,  or  until 
irritation  is  produced,  when  milder  applications  can  be  made.  A 
cleaner  method,  and  more  rapid,  but  requiring  greater  caution,  is  the 
use  of  a  solution  of  caustic  potash,  \  to  2  drams  (a.-8.)  to  the  ounce 
(32.)  of  water.  This  is  applied  carefully,  permitted  to  act  a  few  minutes, 
washed  off,  or  its  further  action  prevented  by  application  of  vinegar  or 
dilute  acetic  acid,  and  a  mild  spread  salve  put  on;  this  is  to  be  repeated, 
if  necessary,  from  time  to  time.  A  method  safer  in  the  hands  of  those 


3 14  INFLAMMATIONS 

less  experienced  is  the  application  of  a  20  to  25  per  cent,  salicylic  acid 
rubber  plaster,  kept  constantly  applied  from  one  to  several  days,  renew- 
ing when  it  loosens.  The  upper  surface  of  the  hardened  tissue  will  be 
found  softened,  and  after  soaking  in  hot  water,  can  be  rubbed  or  scraped 
off,  to  be  followed  by  renewal  of  the  treatment  until  the  desired  end  is 
accomplished.  A  4  to  10  per  cent,  paint  of  salicylic  acid  in  collodion, 
painted  on  twice  daily  for  several  days,  and  then  permitted  to  loosen,  and 
the  part  soaked  and  rubbed  or  scraped  as  above,  and  repeated,  will 
finally  accomplish  the  same  purpose,  but  usually  more  slowly.  The 
imported  salicylic  acid  plaster-mull  (Unna)  is  also  valuable  for  this  pur- 
pose. Papoid  and  boric  acid,  in  equal  parts,  with  enough  glycerin  and 
water  to  make  a  paste,  and  spread  on  overnight,  will  sometimes  have  a 
softening  influence  on  hardened  patches.  As  in  other  types,  treatment  by 
Rontgen  rays  can  be  cautiously  tried  in  particularly  obstinate  cases. 

A  preparation  sometimes  useful  in  these  cases,  as  well  as  in  some 
instances  of  the  chronic  sluggish  type,  is  that  known  as  "liquor  picis 
alkalinus"  (Bulkley).  It  is  to  be  used  cautiously,  either  as  a  strong 
solution  with  5  or  more  parts  of  water,  or  as  an  ointment,  i  to  2  drams 
(4--8.)  to  the  ounce  (32.).  As  a  weaker  lotion,  \  to  2  drams  (2.-8.) 
to  the  pint  (500.),  it  can  also  be  employed  in  the  subacute  varieties, 
often  controlling  the  itching  satisfactorily.1  In  extremely  rebellious, 
thickened  sclerous  patches  the  stimulating  and  superficially  cauterizing 
action  of  carbon-dioxid  snow  (q.  ».)  can  be  carefully  tried. 

REGIONAL  AND  INFANTILE  ECZEMA 

Regional  and  infantile  eczemas  are  here  considered  mainly  from 
the  standpoint  of  treatment.  They  differ  in  no  material  respects  from 
the  disease,  and  its  types  as  already  described;  if  there  is  any  modifi- 
cation, it  will  be  referred  to.  Infantile  eczema  is  usually  of  the  acute 
and  subacute  grades,  for  which  the  treatment  is  the  same  as  that  for 
eczema  of  adults  of  the  same  types;  mild  remedies  are,  as  a  rule,  how- 
ever, to  be  employed,  and  if  the  more  stimulating  applications  are  seem- 
ingly required  to  reach  a  result,  they  must  be  used  with  greater  caution. 
Overfeeding  is  occasionally  a  factor,  though  not  so  frequently  as  improper 
and  deficient  supply.  Bohn2  places  a  great  deal  of  stress,  and  rightly,  I 
believe,  upon  obesity  (Fettsucht)  as  a  factor  in  infantile  eczema  in  the 
first  and  second  years,  due  to  the  character  and  the  often  unnecessary 
quantity  of  the  nourishment  given.  The  influence  of  digestion  as  an 
important  etiologic  factor  in  infants,3  as  well  as  in  adults,  must  be  borne 
in  mind,  and  proper  feeding  is,  therefore,  imperative. 

1  Liquor  picis  alkalinus  is  made  of  i  part  caustic  potash,  2  parts  pix  liquids,  and 
5  parts  water;  the  potash  is  dissolved  in  the  water  and  gradually  added  to  the  tar  with 
rubbing  in  a  mortar. 

2  Bohn,  "Eczema,"  p.  133,  in  Gerhardt's  Handbuch  der  Kinderkrankheiten  (Nach- 
trag),  Tubingen.  1883. 

*  Schwartz,  "Dermatoses  liees  aux  troubles  gastro-intestinaux  chez  les  enfants," 
These  de  Paris,  1892;  A.  J.  Hall,  "An  Inquiry  into  the  ^Etiology  of  Infantile  Eczema,". 
Brit.  Jour.  Derm.,  1905,  pp.  161,  203,  241,  and  287,  and  1907,  p.  4,  gives  a  full  review 
and  discussion  of  the  subject  with  resume  of  the  opinions  of  other  writers  with  conclu- 
sions unfavorable  to  the  digestive  disturbance  theory.  Towle  and  Talbot's  investiga- 
tions ("Infantile  Eczema  and  Indigestion,"  Amer.  Jour.  Dis.  Children,  Oct.,  1912,  p. 
219)  indicate  that  it  may  have  a  contributing  influence. 


REGIONAL  AND   INFANTILE  ECZEMA 


315 


In  the  following  remarks  on  the  regional  forms  but  little  will  be 
said  as  to  diagnosis,  etc.,  as  such  matters  have  already  been  fully  con- 
sidered, and  to  which  the  reader  is  referred  for  further  information  on 
these  points.  The  generally  accepted  plan  of  discussing  the  external 
therapeutics  of  regional  eczemas  is,  indeed,  in  great  measure  at  least, 
scarcely  necessary  if  the  principles  of  treatment  are  kept  in  mind;  for 
the  selection  of  the  remedial  applications  or  plans  of  treatment  is  to  be 
based,  irrespective  of  locality  involved,  almost  wholly  upon  the  char- 
acter and  grade  of  the  inflammatory  process,  remembering  that  those  of 
the  acute  type  and  many  of  the  subacute  type  require  soothing  and 
protective  applications,  while  those  of  a  sluggish  infiltrated  type  usually 
require  stimulating  applications.  To  a  slight  extent,  it  is  true,  region 


Fig.  64. — Eczema  of  erythematosquamous  and  squamous  variety,  with  considerable  in- 
filtration; of  long  duration. 

does  sometimes  influence  the  first  choice  of  remedy  and  the  method  of 
application,  and  for  such  reason  a  brief  consideration  of  the  various 
regional  eczemas  can  probably  be  profitably  added  to  the  directions  al- 
ready given.  Reference  will  also  be  made,  when  deemed  necessary,  to 
those  remedies  most  frequently  employed  in  children. 

Eczema  of  the  Scalp  (Eczema  Capitis).1— The  disease  in  this  region 
is  to  be  differentiated  from  seborrhea,  psoriasis,  pediculosus,  favus, 
and  ringworm,  chiefly  the  first  two.  In  the  adult  the  most  common 
variety  in  this  region  is  the  erythematosquamous  and  squamous,  and 

1  The  face  and  scalp  are  the  most  common  sites  for  eczema  in  infants,  often  being 
limited  to  a  part  or  whole  of  either  of  these  regions.  Hall  found  in  100  cases  of  mfantih 
eczema  the  eruption  first  appeared  on  cheeks,  forehead,  or  temples  in  56,  on  scalp  or  ears 
in  40,  and  elsewhere  in  4. 


3 1 6  I  NFL  A  AIM  A  TIONS 

the  inflammation,  usually  of  the  subacute  and  chronic  grade.  It  fre- 
quently extends  over  the  forehead  and  mastoid  regions,  in  the  latter 
often  to  the  back  of  the  ears,  presenting,  especially  in  the  fold,  the 
moist  variety.  In  its  management  it  is  not  necessary  to  sacrifice  the 
hair.  If  the  scale  accumulation  is  considerable,  the  free  use  of  olive 
or  almond  oil  or  liquid  petrolatum,  with  i  to  3  grains  (0.065-0.2)  of 
resorcin  or  carbolic  acid  to  the  ounce  (32.),  is,  for  the  first  few  days,  ad- 
visable, followed  by  washing  with  a  mild  soap  and  water.  This  will 
generally  remove  the  accumulations,  and  often  a  continuance  of  this 
plan,  especially  with  a  resorcin-containing  oil,  increasing  this  ingre- 
dient to  5  to  10  grains  (0.33-0.65)  to  the  ounce  (32.),  will  lead  to  marked 
improvement.  After  the  scales  have  been  removed,  washing  is  repeated 
only  as  demanded  by  cleanliness  and  scale  reaccumulation — on  the 
average,  about  once  every  one  or  two  weeks.  In  irritable  cases  this  can 
be  dispensed  with  entirely  and  the  parts  cleansed  by  gentle  rubbing  with 
the  oil.  A  2  to  4  per  cent,  ointment  of  salicylic  acid,  with  5  to  20  grains 
(0.33-1.35)  of  resorcin  to  the  ounce  (32.),  is  often  extremely  useful  in 
these  cases.  In  irritable  cases  in  which  there  is  but  slight  tendency  to 
scale  formation,  the  application  of  a  boric  acid  solution  followed  by  a  plain 
salve,  such  as  cold  cream  or  petrolatum,  can  be  used  satisfactorily  for  a 
time.  Later,  slightly  or  moderately  stimulating  ointment  applications 
are  demanded,  and  among  these  the  best  are  those  of  liquor  carbonis 
detergens,  white  precipitate,  and  calomel,  at  first  weak,  later  stronger. 
In  thickened,  infiltrated,  obstinate  cases  oil  of  cade,  with  i  to  3  parts  of 
olive  oil  or  in  ointment,  is  valuable ;  but  in  private  practice  it  is  quite  fre- 
quently found  objectionable  on  account  of  the  penetrating  tar  odor. 
/5-naphthol  ointment,  i  to  3  per  cent,  strength,  can  be  used  as  a  sub- 
stitute, and  sometimes  satisfactorily,  but  it  at  times  proves  irritating. 
In  the  stubborn,  infiltrated  disease  sometimes  observed  on  the  lower 
occipital  region  verging  on  to  the  neck,  the  tar  and  calomel  preparations 
are  satisfactory,  but  must  often  be  used  quite  strong. 

In  infants  and  children  the  vesicular  and  vesicopustular  eruptions 
are  not  uncommon,  and  are  also  occasionally  met  with  in  the  adult; 
there  is  sometimes  a  good  deal  of  crusting.  If  present,  this  is  to  be 
removed  in  the  manner  already  described  above,  or  if  abundant  and  ad- 
herent, as  described  in  the  preliminary  general  remarks  concerning  ex- 
ternal treatment.  Salicylic  acid  ointments  are  useful  in  such  cases,  and 
also  wrhite  precipitate  and  alumnol  ointments — of  the  first,  3  to  10 
or  more  grains  (0.2-0.65)  and  of  the  latter,  15  to  30  (i.-2.)  grains  to  the 
ounce  (32.).  When  possible  and  feasible,  the  application  of  the  mild 
boric  acid  wash  can  advantageously  be  used  with  it.  In  infants  of  little 
hair  or  when  it  is  short,  the  zinc  oxid  ointment  and  salicylated  paste 
can  be  employed,  but,  as  a  rule,  both  in  children  and  adults,  the  powder- 
containing  salves  are  not  practicable  for  the  scalp  or  other  hairy  regions. 
In  children  and  female  adults  with  a  pustular  eczematous  condition  of 
the  scalp,  especially  posteriorly,  the  possibility  of  the  presence  of  pediculi 
being  the  exciting  factor  should  be  borne  in  mind.  Even  if  these  para- 
sites are  secondary  to  the  eczema,  a  cure  is  not  possible  unless  they  are 
removed. 


REGIONAL   AND  INFANTILE   ECZEMA 


317 


In  irrtable  types,  both  in  the  infants  and  adults,  the  temporary 
use  of  the  mixture  of  equal  parts  of  almond  oil  and  lime-water  with 
i  or  2  grains  of  carbolic  acid  or  resorcin  to  the  ounce  (0.065-0.135  to 
32.)  can  be  employed  temporarily.  On  the  other  hand,  in  extremely 
obstinate  and  sluggish  cases,  a  small  quantity  of  precipitated  sulphur, 
10  to  40  grains  to  the  ounce  (0.65-2.65  to  32.),  can  be  added  to  the  tar 
ointment  or  other  selected  ointment. 

The  best  ointment  base  for  the  scalp  is  one  of  equal  parts  of  petrolatum 
and  cold  cream  or  petrolatum  and  lard,  sometimes  with  the  addition  of 
10  to  20  per  cent,  of  lanolin;  in  sluggish  cases,  and  sometimes  in  other 
cases,  petrolatum  can  be  used  alone. 


65.— Eczema  of  erythematous  and  squamous  variety  in  the  negro. 


Eczema  of  the  Face  (Eczema  Faciei).— The  disease  in  adults  is  to 
be  distinguished  from  seborrhea,  dermatitis  seborrhoica,  dermatitis, 
acne  rosacea,  and  lupus  erythematosus.  The  most  common  types  are  the 
erythematous  and  erythematosquamous,  but  occasionally  the  papular 
and,  rarely,  the  pustular,  and  eczema  rubrum,  are  also  met  with.  An 
erythematosquamous  eczema  of  the  forehead  is  sometimes  observed, 
in  some  instances  of  which  the  hat-band  is  the  exciting  factor.  Occa- 
sionally the  erythematous  variety  limits  itself  to  the  lids  and  immediate 
surrounding  parts  (eczema  palpebrarum)  or  more  frequently,  it  remains 
here  more  obstinately  after  disappearing  from  other  parts  of  the  face. 
Eczema  of  the  lower  part  of  the  face,  usually  with  upper  part  of  the  neck, 
is  occasionally  due  to  the  dye  in  fur  boas,  etc. 


3 1  8  INFLAMMA  TIONS 

The  various  lines  of  treatment  mentioned  under  the  several  inflam- 
matory grade  headings  are  appropriately  indicated  here.  The  lotions 
are  especially  useful,  particularly  the  boric  acid,  calamin-and-zinc-oxid 
lotions,  and  lotio  nigra,  the  first  or  third  conjointly  with  a  salve,  such 
as  cold  cream,  zinc  oxid  ointment,  calamin-zinc-oxid  ointment,  and  the 
salicylated  paste.  For  use  on  these  parts  white  ointments  can  be 
given  a  skin  tinge  by  adding  to  the  ounce  several  grains  or  more  of 
calamin,  or  a  sufficient  quantity  of  Armenian  bole  and  umber  (Brooke).1 
Ointments  can  often  be  employed  alone,  but  the  conjoint  use  .of  especially 
boric  acid  wash  is  often  of  added  advantage.  Cold  cream  is  not  only 
soothing  in  itself  in  many  of  these  cases,  but  it  is  also  a  satisfactory  base 
for  other  remedies.  In  the  acute  types  the  calamin-zinc-oxid  lotion  is 
most  efficient  when  applied  by  means  of  linen  cloths,  and  kept  constantly 
wet  with  it;  and  in  very  irritable  cases,  instead  of  water,  the  basis  of  the 
lotion  can  be  made  up  of  equal  parts  of  lime- water  and  almond  oil.  Weak 
ichthyol  lotions,  i  to  10  per  cent.,  are  also  useful.  The  liquor  carbonis 
detergens,  both  as  wash  and  ointment,  in  the  various  strengths  indi- 
cated, is  often  useful  in  the  erythematous  variety,  and  in  the  infiltrated 
cases  the  stronger  tarry  ointments  may  be  required,  but  here,  as  else- 
where, they  should  be  applied  tentatively  at  first.  The  bassorin,  traga- 
canth,  and  acacia  paints  are  also  useful  in  some  cases.  If  the  patient 
is  obliged  to  go  out,  the  parts  should  be  covered  with  a  layer  of  grease  to 
protect  from  the  air  and  wind ;  if  the  application  being  used  is  disfiguring, 
at  such  times  cold  cream  can  be  applied. 

In  infants  and  young  children  the  vesicopapular,  vesicopustular, 
and  eczema  rubrum  types  are  most  common.  It  is  to  be  distinguished 
chiefly  from  impetigo  contagiosa,  miliaria,  and  less  frequently  dermatitis; 
it  could  scarcely  be  confounded  with  lupus  vulgaris.  The  mild  applica- 
tions named  should  be  always  used  in  the  beginning,  and  frequently  ac- 
complish much,  and  sometimes  lead  on  to  cure;  the  conjoint  treatment 
with  black  wash  and  zinc  ointment  or  boric  acid  lotion  and  zinc  ointment 
is  often  an  admirable  plan.  The  salicylated  paste,  with  3  to  10  grains  of 
carbolic  acid  to  the  ounce  (0.2-0.65  to  5j),  often  acts  satisfactorily.  In 
some  of  the  cases,  and  even  when  the  condition  looks  quite  actively  in- 
flammatory, if  considerably  infiltrated,  a  tar-zinc-oxid  ointment  (tar 
ointment,  3j  (4-)>  zinc  ointment,  3vij  (28.))  brings  about  improvement, 
and  not  infrequently  quite  rapidly;  it  should  be  tried  on  a  small  area  at 
first.  Later,  if  the  benefit  flags,  a  larger  proportion  of  tar  can  be  added. 

An  important  point  in  the  care  of  some  cases  of  eczema  in  infants  is 
the  employment  of  mechanical  restraint  (White,  Hall,  Allen)2  to  pre- 
vent rubbing  and  scratching,  as  by  these  latter  not  only  is  the  appli- 
cation rubbed  off,  but  the  disease  made  worse;  tying  the  hands  loosely 
to  the  lower  part  of  the  body  or  putting  on  loose  mittens  will  serve 

1  Brooke,  "Mittheilung  iiber  eine  Methode  des  Farbens  von  Salben,"  Monatshefte, 
1890,  vol.  xi,  p.  62. 

2  J.  C.  White,  "Some  of  the  Causes  of  Infantile  Eczema,  and  the  Importance  of 
Mechanical  Restraint  in  Its  Treatment,"  Boston  Med.  and  Surg.  Jour.,  1881,  vol.  cv,  p. 
365;  H.  J.  Hall,  "A  Mechanical  Treatment  of  the  Eczema  in  Young  Children,"  ibid., 
1895,  vol.  cxxxii,  p.  59;  C.  W.  Allen,  "The  Treatment  of  Eczema  in  Infants  and  Chil- 
dren," New  York  Med.  Jour.,  1899,  vol.  box,  p.  433. 


REGIONAL  AND  INFANTILE  ECZEMA  319 

to  prevent.  If  these  do  not  suffice,  a  pillow-case  can  be  pulled  over 
the  head,  the  closed  end  having  had  a  hole  sufficiently  large  cut  in  it 
to  permit  the  head  going  through;  the  open  end  is  fastened  around 
the  lower  part  of  the  body  with  safety-pins,  and  while  the  arms  and 
hands  are  somewhat  free,  the  latter  cannot  be  readily  carried  to  the 
face.  In  markedly  itchy  cases,  both  in  children  and  adults,  if  the 
remedies  prescribed  do  not  give  some  relief,  or  if  so  intense  as  to  pre- 
vent sleep,  carbolic  acid,  thymol,  or  resorcin  should  be  added  to  the 
applications  named,  in  the  quantity  already  stated  in  the  general  direc- 
tions for  treatment.  A  short  exposure  to  the  Rontgen  rays  will  some- 
times relieve  the  itching  temporarily;  and  in  obstinate  cases  of  eczema 
of  these  parts  repeated  exposures  at  intervals  of  several  days  may 
have  a  curative  influence.  It  is  not,  however,  a  method  to  be  advised 
in  infants  and  children. 

Eczema  of  the  nares  or  nostrils  (eczema  narium)  is  sometimes  seen 
in  young  children  as  a  pustular  crusted  eruption,  often  in  conjunction 
with  a  similar  eruption  about  the  corners  of  the  mouth,  simulating 
closely  impetigo  contagiosa,  except  that  it  is  chronic  and  persistent. 
It  is  not  infrequent  also  to  see  a  slightly  red,  crusted  condition  of  the 
edge  of  the  eyelids.  It  is  most  frequently  seen  in  badly  nourished  stru- 
mous  subjects.  The  administration  of  cod-liver  oil  is  often  valuable 
in  these  cases.  Locally  the  best  applications  for  the  nose  and  corners 
of  the  mouth  are  boric  acid  ointment,  weak  ointments  (i  to  4  per 
cent.)  of  calomel,  and  white  precipitate.  For  the  edges  of  the  lids 
boric  acid  lotion,  used  freely  and  often,  with  boric  acid  ointment  or  a 
i  to  2  per  cent,  yellow  oxid  of  mercury  ointment.  The  possibility 
of  an  eczematous  condition  of  edges  of  the  lids  being  due  to  the  pediculus 
pubis  is  to  be  remembered,  although  such  instances  are  rare.  In  adults 
eczema  of  the  nasal  outlets  is  treated  similarly.  In  these  cases,  as 
also  in  those  in  children  limited  to  the  nares,  a  nasal  catarrh  is  often 
etiologic. 

Eczema  of  the  Ears  (Eczema  Aurium). — In  some  cases  the  eczema 
is  limited  to  the  ears,  often,  more  especially  in  children,  to  the  poste- 
rior aspect  and  particularly  in  the  crease,  in  which  there  is  frequently 
a  tendency  to  oozing  and  Assuring.  In  this  latter  region  the  boric  acid 
lotion  and  the  calamin-zinc-oxid  ointment  (calamin,  5j  (4-)*  zinc  °xid 
ointment,  3vij  (28.)),  and  salicylated  paste  are  usually  most  efficacious; 
as  the  part  becomes  dry  and  scaly  a  small  portion  of  tar,  preferably, 
at  first,  the  liquor  carbonis  detergens,  can  be  added  to  one  of  these 
ointments,  about  5  to  10  per  cent,  strength.  In  eczema  of  the  auditory 
canal  the  selected  ointment  should  be  free  from  any  great  proportion 
of  pulverulent  substances;  one  of  the  salicylic  acid,  from  loto  20  grains 
(0.65-1.33)  to  the  ounce  (32.),  or  a  i  to  2  per  cent,  ointment  of  white 
precipitate,  calomel,  or  resorcin,  answering  the  purpose  best.  It  may  be 
gently  applied  with  a  piece  of  linen  or  small  piece  of  cotton.  An  occasional 
cleansing  by  gently  wiping  out  the  canal  with  almond  oil,  petrolatum,  or 
cold  cream,  and  from  time  to  time  syringing  the  part  with  a  solution  of 
boric  acid  containing  \  to  2  grains  (0.033-0.133)  of  borax  to  the  ounce 
(32.),  will  be  found  helpful. 


3  2O  INFLAMMA  TIONS 

Eczema  of  the  Lips  (Eczema  Labiorum). — It  is  not  uncommon  to 
see  eczema  limited  to  the  lips  and  immediate  adjacent  parts.  In  these 
cases  the  possibility  of  the  tooth-wash  or  powder  being  an  etiologic 
factor  (Neisser)1  should  be  eliminated.  This  has  been  the  exciting 
cause  in  several  of  my  cases.  Ehrmann2  has  found  eczema  of  the  lips 
usually  in  anemic  individuals,  the  anemia  promoting  increased  salivary 
secretion,  which  acts  as  an  irritant.  The  disease  type  may  be  either 
the  vesicopustular  or  erythematosquamous.  It  is  frequently  seen  in 
conjunction  with  the  eruption  on  other  parts  of  the  face;  exceptionally  it 
is  confined  to  the  upper  lip  and  superjacent  skin,  and  is  attended  with  a 
good  deal  of  persistent  swelling  and  infiltration.  In  the  latter  region 
a  nasal  catarrh  is  sometimes  the  etiologic  factor.  A  not  infrequent  fea- 
ture of  lip  cases  is  the  tendency  to  fissuring. 

In  the  moist  crusted  type  the  treatment  is  essentially  that  described 
under  eczema  of  the  acute  and  subacute  grades — boric  acid  and  resorcin 
lotions,  with  boric  acid  ointment,  calamin-zinc-oxid  ointment,  and 
weak  white  precipitate  ointments.  Later,  when  dry  and  the  active 
inflammatory  character  is  reduced,  the  treatment  can,  if  necessary  be 
changed  to  that  of  the  erythematosquamous  variety.  In  this  latter, 
however,  it  is  well  to  begin  as  above,  and  then,  if  there  is  no  positive 
improvement,  cautiously  go  to  the  tarry  applications.  The  various 
tragacanth,  acacia,  and  gelatin  paints  are  sometimes  of  value.  Like- 
wise the  zinc-oxid  and  boric-acid  salve-mulls.  In  these  cases,  too,  if 
persistent,  an  occasional  painting  with  a  2  to  5  per  cent,  silver  nitrate 
solution  sometimes  brings  a  result,  although  temporarily  disfiguring. 
Applying  a  paint  of  ol.  cadini,  3ss-j  (2.-4.);  collodii,  5j  (32.)  (Hard- 
away),  is  also  an  energetic  measure  that  sometimes  relieves.  The 
same  may  be  said  of  frequent  painting  with  benzoin  tincture,  with  5 
to  10  grains  (0.33-0.65)  of  boric  acid  to  the  ounce  (32.).  In  using 
these  fixed  applications  the  mouth  should  be  gradually  opened  to  its 
widest  capacity,  and  the  lips  then  painted;  if  painted  while  closed 
the  dressing  soon  breaks,  and  the  condition  is  often  aggravated.  The 
Rontgen  ray  treatment  is  occasionally  beneficial  in  lip  eczema. 

Eczema  of  the  Bearded  Region  (Eczema  Barbae). — In  other  cases  the 
eruption  is  more  or  less  confined  to  the  bearded  region,  and  is  usually 
of  the  papulopustular  variety,  of  varying  inflammatory  grade.  It  is 
rarely  limited  to  the  hairy  region,  but  usually  extends  on  to  the  bor- 
dering cheeks,  and  is  often  seen  also  in  association  with  the  eruption 
elsewhere  upon  the  face  and  body.  Many  of  those  cases  in  which  it  is 
said  to  be  confined  to  the  bearded  parts  are  in  reality,  I  believe,  cases 
of  sycosis  vulgaris.  There  is,  however,  sometimes  a  close  relationship. 
In  these  patients  the  beard  should  be  kept  closely  cropped,  and  when  the 
inflammation  has  measurably  subsided,  shaving  is,  as  a  rule,  to  be  advised. 
The  applications  are  to  be,  at  first  at  least,  of  the  mildest  character,  and 
preferably  of  lotions  and  ointments  conjointly,  and  for  the  various  plans 

1  Neisser,  "Lippen-Ekzem  und  Mundwasser,"  Therapeutische  Monatshefte,  1898, 
vol.  xii,  p.  79;  Galewsky,  Munch,  med.  Wochenschr.,  1906,  p.  1360. 

-  Ehrmann,  "Zur  Aetiologie  und  Therapie  des  Mundwinkel-  und  Lippen-Ekzeme," 
Wien.  med.  Blatter,  1895,  v°l-  xviii,  p.  568. 


PLATE   IX. 


Eczema  rubrum  ;  child  eighteen  months  old  ;  duration  one  year  ;  considerable  thickening, 
gummy  oozing,  and  crusting. 


REGIONAL  AND  INFANTILE  ECZEMA  321 

advisable  the  reader  is  referred  to  the  general  directions  concerning  treat- 
ment already  given. 

Eczema  of  the  Hands  (Eczema  Manuum). — The  hands  and  especially 
about  the  fingers  are  extremely  common  sites  for  the  disease;  the  types 
usually  observed  are  the  vesicular,  the  papulovesicular,  and  the  scaly  and 
fissured.  Fissures  in  these  cases  are  quite  frequent.  A  moist,  usually 
symmetric  eczema  of  one  or  more  of  the  interdigital  spaces,  but  usually 
that  between  the  second  and  third  fingers,  and  the  immediately  adjacent 
parts,1  is  not  uncommon.  The  diagnosis  is  rarely  difficult,  as  almost  all 
itchy  eruptions  of  any  chronicity,  limited  to  the  hand  or  hands  and 
the  neighboring  forearms,  are  eczematous.  Occasionally,  however,  a 
patchy  vesicopapular  or  vesicobullous  ringworm,  sometimes  rather  acute 
and  more  or  less  diffused,  may  simulate  eczema  very  closely.  The 
disease  is  to  be  distinguished  chiefly  from  dermatitis  venenata  and 
pompholyx.  In  many  of  these  cases  the  patient's  occupation  is  the 
exciting  factor,  and  very  often  not  much  can  be  done  in  a  permanent 
way  unless  this  is  modified  or  suspended.  In  domestics  who  are  obliged 
to  have  their  hands  in  water  a  great  deal,  loose  rubber  gloves  should  be 
worn  at  such  times.  In  all  cases  the  hands  should  be  protected  from 
cold  and  wind  by  the  use  of  gloves. 

In  the  moist  types  the  conjoint  use  of  black  wash  and  zinc  oxid 
ointment  is  often  serviceable;  so  is  the  use  of  a  boric  acid  wash  or  a 
resorcin  wash,  with  the  supplementary  use  of  an  ointment.  The  wash 
should  be  dabbed  on  thoroughly,  allowed  to  dry  in,  and  then  a  small 
quantity  of  the  salve  smeared  over,  or  preferably  applied  spread  upon 
linen  or  lint.  Used  in  this  manner  a  well-made  diachylon  ointment 
is  often  extremely  valuable.  The  various  mild  ointments,  without  the 
wash,  are  also  beneficial  at  times.  In  the  moist  types,  salicylated  paste 
is  often  an  admirable  application  in  this  region.  So  also  is  the  compound 
stiff  ointment  plaster,  consisting  of  equal  parts  of  lead-plaster,  soap-plas- 
ter, and  petrolatum,  with  10  grains  (0.65)  of  salicylic  acid  to  the  ounce 
(32.),  spread  upon  linen  or  lint  and  closely  adapted  to  the  parts;  with,  if 
there  is  much  thickening,  a  larger  quantity  of  salicylic  acid — up  to  i 
dram  (4.).  In  cold  weather  it  is  necessary  to  increase  the  proportion  of 
petrolatum.  While  the  hands  should  ordinarily  be  washed  as  infrequently 
as  possible,  owing  to  the  damaging  effects  of  soap  and  water,  in  thickened 
and  infiltrated  cases  a  thorough  washing  with  sapo  viridis  and  hot  water 
nightly  or  every  second  or  third  night,  according  to  circumstances,  fol- 
lowed immediately  by  a  mild  salve  application  spread  as  a  plaster,  is  often 
of  great  therapeutic  value. 

For  the  dry,  thickened  types,  especially  observed  on  the  palmar 
aspects  (eczema  palmarum),  one  of  the  best  remedies  is  salicylic  acid, 
applied  as  an  ointment  with  petrolatum  and  benzoated  lard  as  a  base, 
20  to  80  grains  (1.33-5.33)  to  the  ounce  (32.);  it  should  be  well  worked 
in,  and  then  applied  as  a  spread-plaster.  Occasionally  an  addition  of 
10  to  20  per  cent,  of  lanolin  to  the  base  proves  of  advantage.  Calo- 
mel and  white  precipitate  ointments,  usually  strong,  are  likewise  useful. 

1  Dubreuilh,  Annales,  Dec.,  1899,  and  Ciarrocchi,  Trans,  of  Italian  Dermatolog. 
Soc'y  for  1907,  have  called  particular  attention  to  this  variety. 
21 


322 


INFLAMNA  TIONS 


Figs.  66,  67,  and  68. — Chronic  squamous  and  fissured  eczema  of  palms  and  fingers- 
of  various  degrees  and  characters  or  types. 


REGIONAL  AND  INFANTILE  ECZEMA 


323 


Figs.  69,  70,  and  71. — Chronic  squamous  and  fissured  eczema  of  palms  and  fingers 
— of  various  degrees,  characters,  or  types;  with  considerable  thickening;  last  is  of  sebor- 
rheic  type. 


324  INFLAMMATIONS 

Tarry  preparations,  in  ointment  form,  are  sometimes  of  distinct  service, 
but  their  action  is  doubtful  in  a  given  case,  and  they  must  be  experiment- 
ally tried  on  a  small  surface  at  first.  When  there  is  marked  epidermic 
thickening,  applications  of  the  10  to  25  per  cent,  salicylic  acid  rubber 
plaster  or  plaster-mulls  is  applicable,  and,  as  a  rule,  soon  thin  down  the 
parts.  The  same  can  sometimes  be  accomplished  by  painting  on  sali- 
cylated  collodion,  4  to  10  per  cent,  strength;  after  thorough  washing,  two 
or  three  coats  are  painted  on  for  two  or  three  days,  twice  daily,  and  then 
allowed  to  loosen;  it  is  then  repeated,  if  necessary,  continuously  or  from 
time  to  time.  For  the  thickened  palmar  types  Rontgen  ray  exposures 
occasionally  act  admirably. 

In  chapping,  the  mildest  example  of  fissured  eczema,  or  at  least  a 
condition  allied  thereto,  a  weak  glycerin  lotion  or  a  mild  ointment  may 
be  rubbed  in  nightly;  the  hands  should  be  kept  out  of  water  as  much  as 
possible  and,  when  washed,  rubbed  thoroughly  dry.  A  good  formula  for 
these  cases  is:  1$.  Tinct.  benzoin,  co.,  5ss  (2.);  glycerin,  Siiss  (10.);  alco- 
holis,  5iij  (52.) ;  mix. 

In  eczema  of  the  nails  (eczema  unguium)  the  nail  involvement  or 
changes  are  usually  due  to  eczema  of  the  periungeal  region.  The  in- 
volved nails  should  be  closely  filed  or  cut.  The  ordinary  remedies  in 
the  form  of  ointments  can  be  applied,  boric  acid,  salicylic  acid,  resorcin, 
and  ichthyol  being  the  best.  In  obstinate  cases  painting  every  few  days 
with  a  3  to  10  per  cent,  aqueous  solution  of  silver  nitrate  or  a  saturated 
solution  in  sweet  spirits  of  niter  is  often  successful ;  between  the  paintings 
one  of  the  above  ointments  can  be  kept  applied. 

Eczema  of  the  feet  (eczema  padum)  demands  no  special  directions; 
that  on  the  soles  (eczema  plantarum),  in  which  there  is  usually  marked 
epidermic  thickening,  the  treatment  already  outlined  for  the  palms  is 
appropriate;  exceptionally  one  of  the  fungi  of  ringworn  (q.  v.}  has  been 
found  in  plantar  epidermic  thickening. 

Eczema  of  the  toes  may  be  a  part  of  an  eczema  involving  more  or 
less  of  the  feet,  or  it  may  not  infrequently  exist  independently.  While 
all  the  toes  may  be  affected,  the  outer  three,  as  Jamieson  pointed  out, 
seem  more  prone  to  the  disease.  The  interdigital  spaces  are  usually 
especially  involved,  particularly  primarily;  developing  slowly  and 
usually  beginning  as  an  insignificant  repeated  peeling  of  the  skin,  there 
follow,  sooner  or  later,  maceration,  redness,  scaliness,  fissuring,  and 
sometimes  oozing,  with  variable  thickening.  It  generally,  after  some 
time,  extends  on  to  plantar  and  dorsal  surfaces  of  the  toes,  and  may 
spread  slightly,  rarely  extensively,  up  the  foot.  It  is  not  to  be  over- 
looked that  in  some  cases  presenting  the  symptoms  outlined  instead  of 
a  true  eczema  the  malady  is  an  anomalous  ringworm  (q.  v.}.  For  this  re- 
gion, in  addition  to  the  milder  applications,  the  occasional  (every  seven  to 
ten  days)  painting  with  a  saturated  solution  of  silver  nitrate  in  spiritus 
aetheris  nitrosi,  or  as  a  5  to  10  per  cent,  aqueous  solution,  or,  cautiously, 
with  a  5  to  25  per  cent,  alcoholic  solution  of  resorcin,  is  often  especially 
valuable.  Ruggles1  commends,  for  the  milder  cases  in  which  fissur- 
ing is  not  a  prominent  feature,  painting  on  once  or  twice  daily  an 
1  Ruggles,  "Eczema  of  the  Toes,"  Jour.  Cutan.  Dis.,  1909,  p.  105. 


REGIONAL   AND   INFANTILE  ECZEMA 


325 


alcoholic  solution  of  10  per  cent,  of  tannic  acid  and  2  per  cent,  salicylic 
acid. 

Eczema  of  the  Flexures  (Eczema  Articulorum;  Eczema  Intertrigo). — 
Eczema  of  these  parts  is  usually  either  erythematous  or  vesiculopapular, 
sometimes  with  a  resulting  maceration  of  the  surfaces,  simulating  ery- 
thema intertrigo,  and  in  others  developing  into  eczema  rubrum.  A 
tendency  to  fissuring  is  not  uncommon.  As  a  rule,  the  conjoint  use  of 
lotions  and  ointments  yields  the  most  rapid  results.  The  boric  acid 
lotion  and  the  zinc  oxid  ointment,  or  the  salicylic  acid  paste,  should  be 
used  at  first.  The  calamin-zinc-oxid  lotion  often  acts  well  for  several 


F]V  -2  —Eczema  of  a  squamous,  thickened,  sclerous  type,  of  about  a  year  s  dura- 
tion   in  a  woman  aged  fifty.     Marked  infiltration  and  callous  formation  about  the 
heels,  with  deep,  painful  fissuring;  between  some  of  the  toes  the  eruption  was  of  a  mild 
erythematous  type,  occasionally  moist  and  oozing.     In  places  there  was  a  st 
semblance  to  callositas. 

days,  but  it  is  apt  to  be  too  drying  unless  intermitted  and  a  salve  employed 
for  a  day  or  two.  It  can  generally  be  continued  longer  if  glycerin  is 
added,  5  to  15  minims  (0.33-1.)  to  the  ounce  (32.).  The  boric  acid  and 
the  zinc  oxid  salve-mulls  are  extremely  serviceable;  also,  for  a  time,  il 
any  infiltration,  the  salicylated  soap-plaster.  Eczema  under  the  breast: 
in  women  is  similarly  treated.  In  this  region,  as  well  as  in  others  where 
parts  come  in  contact,  the  wearing  of  flattened  thin  cheese-cloth  bags 
filled  with  a  dusting-powder  is  often  of  great  service.  Later,  if  no  bene- 
fit ensues  or  as  soon  as  the  good  effects  of  mild  treatment  begin  to  flag,  an 
ointment  containing  varying  quantities  of  white  precipitate  or  calomel; 
or  the  zinc  oxid  ointment,  with  i  or  2  drams  (4.-8.)  of  tar  ointment  to  the 


326 


INFLAMMA  TIONS 


ounce   (32.);  and  in  thickened,  infiltrated  cases  tar  ointment  itself, 
weakened  at  first,  often  proves  of  marked  advantage. 

Eczema  of  the  Breasts  (Eczema  Mammae  seu  Mammarum)  and  of  the 
Umbilicus  (Eczema  Umbilici). — Eczema  of  the  nipple  and  immediate 
surrounding  skin  in  women  is  most  commonly  observed  during  the 
nursing  period,  and  may  be  of  the  dry  or  moist  type,  more  frequently 
the  latter.  In  some  subjects  the  condition  is  scarcely  eczematous, 
and  presents  merely  fissuring  of  the  nipples,  the  skin  of  the  same  being 
dry  and  inelastic.  The  disease  in  this  region  is  to  be  distinguished 
from  Paget's  disease  (q.  v.).  The  mild  plans  of  treatment  will  be  found 
most  serviceable,  those  designated  in  the  general  directions  as  suitable 


Fig-  73- — Eczema  rubrum,  of  considerable  duration,  involving  scrotum  chiefly, 
together  with  part  of  the  shaft  of  the  penis  and  adjacent  portion  of  the  thighs;  marked 
thickening  and  crusting  (courtesy  of  Dr.  M.  B.  Hartzell). 

for  the  acutely  inflammatory  type  of  the  disease;  ordinarily  a  nipple- 
shield  should  be  worn  at  the  time  of  nursing.  In  some  cases,  especially 
when  more  or  less  confined  to  the  nipples,  with  fissuring,  painting  the 
parts  with  benzoin  tincture,  compound  benzoin  tincture,  or  with  collodion 
will  tend  to  heal  the  fissures  and  improve  the  disease,  and,  at  the  same 
time,  measurably  afford  protection  during  the  act  of  nursing.  In  ob- 
stinate fissures  touching  gently  with  silver  nitrate  or  with  the  saturated 
solution  of  silver  nitrate  in  spiritus  aetheris  nitrosi  can  be  tried,  and  often 
proves  effective.  In  eczema  of  the  umbilicus  the  same  mild  measures 
are  usually  successful,  along  with  frequent  washing  with  boric  acid  lotion. 
In  persistent  cases  the  above  solution  of  silver  nitrate  can  be  used. 


REGIONAL   AND   INFANTILE  ECZEMA  327 

Eczema  of  the  Genital  Region  (Eczema  Genitalium). — The  disease 
about  these  parts  is  usually  of  the  erythematous  variety,  although  the 
erythematopapular  and  erythematosquamous  are  not  uncommon,  and, 
in  fact,  any  type  may  exist.  It  is  to  be  distinguished  from  eczema 
marginatum  (tinea  cruris),  dermatitis  seborrhoica,  pediculosis  pubis, 
and  pruritus.  Itching  is  often  severe  and  a  tendency  to  fissuring  is  not 
uncommon.  Glycosuria  is  to  be  excluded  as  a  factor,  especially  in  women. 
In  males  the  eruption  is  often  confined  to  the  scrotum,  and  more  especially 
to  those  parts  coming  in  contact  with  the  thighs;  it  may,  however,  be 
quite  extensive,  involving  shaft,  glans,  and  neighboring  parts  of  thighs 
and  perineum.  In  women  the  labia  are  usually  the  seat  of  the  malady, 
occasionally  extending  on  to  the  mucous  membrane;  in  some  cases  there 
is  moist  exudation.  Eczema  of  the  vulva  is  sometimes  provoked  or 
kept  up  by  the  use  of  certain  irritating  toilet  papers  women  are  apt  to 
use  for  drying  the  parts  after  urination. 

The  treatment  differs  in  no  way  from  that  of  the  disease  elsewhere, 
but,  owing  to  the  heat,  friction,  and  moisture  of  the  parts,  the  condi- 
tion is  usually  extremely  rebellious.  Lotions  of  calamin-zinc-oxid, 
of  resorcin,  liquor  carbonis  detergens,  boric  acid,  and  ointments  of 
calomel,  calamin,  the  salicylic  acid  paste,  zinc  oxid  and  boric  acid  salve- 
mulls,  and,  later,  ointments  of  tar,  may  be  used.  The  scrotum  should 
be  supported  by  a  suspensory  bag  as  high  as  possible,  so  as  to  keep  the 
surfaces  from  contact.  Sometimes  this  latter  is  best  accomplished  by 
the  use  of  flat  cheese-cloth  bags  containing  dusting-powder,  by  means 
of  which  the  parts  can  be  kept  separated.  In  obstinate  cases  the  oint- 
ments may  be  applied  spread  on  lint  or  linen  and  kept  in  place  by  means 
of  a  bandage.  In  stubborn  cases  a  medicated  paint  of  tincture  of  benzoin, 
with  a  few  grains  of  salicylic  acid  or  20  to  30  grains  (1.33-2.)  of  boric  acid, 
or  \  to  i  dram  (2-4.)  of  oil  of  cade  to  the  ounce  (32.),  may  be  cautiously 
tried.  A  frequently  successful  plan  or  adjuvant  measure  is  the  applica- 
tion, in  scant  quantity,  of  a  2  to  3  per  cent,  solution  of  silver  nitrate  in 
spiritus  setheris  nitrosi;  it  causes  variable  smarting  momentarily.  It  is 
repeated  about  once  weekly,  and  mild  salves  used  in  the  interval.  In 
women  similar  measures  are  employed.  In  addition  to  saccharine  urine 
being  an  occasional  cause,  irritating  vaginal  discharges  are  also  sometimes 
etiologic.  In  both  sexes  an  occasional  cleansing  with  hot  boric  acid  solu- 
tion with  |  to  2  grains  (0.033-0.133)  of  borax  to  the  ounce  (32.)  is  neces- 
sary; such  application,  if  very  hot,  will  also  often  allay  the  itching. 
Soap  and  water  should  be  used  but  seldom. 

Eczema  of  the  Anal  Region  (Eczema  Ani). — Eczema  of  the  anus  is, 
as  a  rule,  a  most  intractable  disease,  and  for  evident  reasons.  It  is  to 
be  distinguished  from  pruritus.  Seat-worms,  hemorrhoids,  fissure, 
and  fistula  should  be  eliminated  as  causes.  Exceptionally  the  use  of 
certain  irritating  toilet  papers  may  provoke  or  keep  the  disease  up. 
After  each  stool  the  part  should  be  gently  cleansed  and  the  remedial 
application  made.  The  application  should  be  repeated  again  at  the  end 
of  eight  or  ten  hours,  without  the  preliminary  washing.  If  moderately 
or  markedly  inflammatory,  the  various  mild  lotions  and  ointments,  such 
-as  named  for  eczema  of  the  genitals,  should  be  at  first  employed;  as  a  rule, 


328  INFLA  MM  A  TIONS 

however,  these  cases  are  sluggishly  inflammatory  and  bear  strong  reme- 
dies. An  ointment  of  liquor  carbonis  detergens,  from  i  to  2  drams 
(4--8.)  to  the  ounce  (32.)  of  simple  cerate  or  prepared  suet,  is  espe- 
cially useful  in  some  of  these  cases.  Resorcin  lotion,  followed  by  a 
mild  ointment,  forms  also  a  good  plan  of  treatment.  Tar  ointment, 
weakened  or  of  full  strength,  or  a  10  to  20  per  cent,  ointment  of  oil 
of  cade,  is  also  valuable  in  some  instances.  The  oil  of  cade  is  often 
serviceable,  too,  when  used  with  almond  or  olive  oil.  In  the  applica- 
tion of  these  preparations  the  excess  can  be  wiped  off,  and  a  dusting- 
powder  used  to  prevent  soiling.  In  this  region  very  frequently  all 
the  various  applications  will  be  tried  before  permanent  relief  is  brought 
about.  For  the  intense  itching  sometimes  present  in  eczema  of  this 
region  applications  of  water  as  hot  as  can  be  borne  may  be  used,  often 
with  prompt  relief,  and  the  boric  acid  solution  containing  borax,  as  ad- 
vised in  Eczema  genitalium,  can  also  often  be  used  here  with  advantage. 
Carbolic  acid  lotions,  thymol  lotions,  and  the  application  of  liquid  petro- 
latum, containing  from  5  to  20  grains  (0.33-1.33)  of  menthol  or  from  2  to 
5  grains  (0.13-0.33)  of  cocain  to  the  ounce  (32.),  will  allay  the  itching  in 
some  cases,  and  also  exhibit  curative  effects.  A  5  to  15  per  cent,  calomel 
cold  cream  sometimes  acts  surprisingly  well.  The  Rontgen-ray  treat- 
ment is  sometimes  valuable. 

Eczema  of  the  Legs  (Eczema  Crurum;  Eczema  Crurale). — The  legs 
are  quite  commonly  the  site  for  eczema  in  those  of  middle  life  and 
advancing  years.  The  condition  is  more  or  less  complicated  by  the 
fact  that  the  circulation  is  less  active  in  dependent  parts;  varicose 
veins  are  not  infrequently  associated,  and  in  some  instances  may  exist 
for  months  or  years  before  the  eczema  (eczema  varicosum)  develops, 
having  in  many  cases  an  undoubtedly  causative  influence.  The  type 
of  disease  most  common  in  this  region  is  eczema  rubrum,  and  not  in- 
frequently the  erythematosquamous  and  squamous;  on  the  lower  part, 
in  the  region  of  the  ankle,  often  extending  on  to  the  foot,  the  thickened, 
scaly,  sclerous,  and  verrucous  forms  are  usually  observed.  There 
is  occasionally  noted  also  a  mild,  persistent,  erythematous  type,  with 
but  little  if  any  tendency  to  scale-formation,  in  which  here  and  there, 
few  or  in  crowded  number,  minute  hemorrhagic  puncta  are  noted; 
sometimes  this  purpura-like  feature  is  of  more  or  less  diffused  character 
over  the  affected  area  or  region.1  The  treatment  of  ordinary  eczema 
rubrum  of  the  leg  differs  very  little  from  that  of  other  parts.  Mild 
applications  should  be  used  at  first,  such  as  boric  acid  lotion,  black  wash, 
or  a  resorcin  lotion,  followed  by  salicylic  acid  paste,  zinc  oxid  ointment, 
calamin  ointment,  or  the  stiff  salicylated  plaster-like  ointment  already 
referred  to.  The  ointment  should  be  spread  upon  lint  or  any  suitable 
material,  and  applied  as  a  plaster,  being  closely  adapted  to  the  parts. 
In  some  cases  the  free  use  of  the  calamin-zinc-oxid  lotion  will  rapidly 
change  the  case  into  a  dry  type.  Occasional  washing  is  necessary,  the 
best  plan  being  to  wipe  off  gently  any  ointment  that  may  have  collected, 
and  to  soak  the  part  in  a  bucket  of  warm  water  made  alkaline  by  the  addi- 

1  See  interesting  paper  by  Klotz,  "Dermatitis  Hasmostatica,"  Jour.  Cutan.  Dis., 
1891,  p.  361;  and  by  Schamberg,  Brit.  Jour.  Derm.,  1901,  p.  i. 


REGIONAL  AND  INFANTILE  ECZEMA 


329 


tion  of  from  i  to  4  drams  (4.-i6.)  of  borax  or  sodium  bicarbonate;  after 
withdrawing  the  part  it  is  to  be  again  gently  wiped  and  tapped  (not 
rubbed)  dry  and  the  remedial  application  again  made.  After  the  diseased 
area  has  lost  its  moist  character  the  ointment  may  be  made  slightly 
stimulating  by  the  addition  of  from  10  to  30  grains  (0.65-2.)  of  white 
precipitate  or  calomel  to  the  ounce  (32.);  later,  in  addition  to  its  applica- 
tion as  a  plaster,  a  small  portion  of  the  salve  may  be  gently  rubbed 
into  the  skin  of  the  affected  area;  or  this  latter  plan  of  rubbing  in 
may  of  itself,  in  the  dry  types,  be  sufficient.  Stronger  remedies 
may  be  gradually  used  if  the  improvement  flags,  and  a  weak  tarry 
ointment  may  be  eventually  employed  in  many  of  these  cases  with 
great  advantage. 

In  eczema  rubrum  with  much  thickening,  and  when  the  irritability 
is  not  great,  vigorous  shampooing  with  hot  water  and  sapo  viridis  may 
be  practised  every  few  days,  even  to  the  extent  of  producing  a  good  deal 
of  temporary  disturbance;  then  rinsing  and  drying  the  part  and  imme- 
diately applying  a  mild  salve  spread  as  a  plaster.  This  plan  will  oc- 
casionally act  with  surprisingly  favorable  effect  upon  the  disease.  In 
dry  eczemas  of  the  leg  ointments  containing  varying  proportions  of 
salicylic  acid,  tar,  calomel,  and  other  stimulating  remedies  may  be 
rubbed  in  twice  daily;  and  in  these  the  application  of  the  salve  as  a 
plaster  is  not,  as  a  rule,  necessary.  A  most  satisfactory  plan  of  treat- 
ment in  the  majority  of  cases  is  that  by  the  gelatin  dressing,  already 
described  in  the  general  section  on  the  treatment  of  eczema  in  discussing 
the  remedies  applicable  to  the  subacute  variety;  this  finds  its  best 
application  when  the  disease  is  dry,  but  it  may  also  be  used  in  the  moist 
type  so  soon  as  its  moist  character  has  measurably  been  controlled. 
The  parts  should  be  free  from  scales  or  crusts  before  applying. 

The  purely  medical  treatment  of  eczema  of  this  part  may,  especially 
in  those  in  whom  a  varicose  condition  of  the  veins  seems  predisposing 
or  causative,  be  considerably  aided  by  giving  support  to  the  leg  by 
means  of  a  properly  applied  roller-bandage  or  by  a  gum  stocking.  The 
gelatin  dressing  referred  to  does  this,  and  this  is  one  of  its  advantages. 
The  rubber  bandage  will  prove  useful  in  a  few  cases,  but  if  applied  directly 
over  the  parts  it  is  likely  to  irritate,  so  that  a  thin  layer  of  bandage 
should  be  placed  next  to  the  skin.  In  ordinary  cases  the  support  to  the 
part  need  be  given  only  during  the  day,  when  the  patient  is  for  most  of 
the  time  in  the  upright  position;  during  the  night  it  is  not  necessary, 
except  in  markedly  varicose  conditions.  As  a  rule,  however,  neither 
gum  stocking  nor  rubber  bandage  is  so  satisfactory  during  the  treatment 
as  the  roller-bandage ;  and  in  my  experience  the  rubber  bandage  is  so  often 
disappointing  and  even  aggravating  in  its  effects  that  it  has  been  practi- 
cally discarded.  The  cotton  elastic  bandage,  however,  can  satisfactorily 
take  its  place. 

In  eczema  of  the  leg  complicated  by  an  ulcer  this  latter  is  to  be 
treated  in  the  ordinary  manner, — "strapping"  is,  however,  as  a  rule, 
not  permissible;  an  excellent  method  in  these  cases  is  by  the  gelatin 
dressing,  leaving  an  opening  over  the  ulcer,  and  treating  this  by  the 
usual  applications. 


3  3O  INFLAMMA  TIONS 

The  sclerous,  verrucous  types  are  to  be  treated  as  already  referred 
to  in  the  general  directions. 

Generalized  or  Universal  Eczema  (Eczema  Universale). — This  term 
is  usually  applied,  as  has  been  already  stated,  to  eczema  involving 
the  whole  or  greater  part  of  the  surface;  it  is  often  more  or  less  acute 
in  character.  Universal  eczema,  strictly  speaking,  is,  however,  rare. 
The  erythematous  and  mild  scaly  types  are  most  common;  eczema 
rubrum,  more  or  less  generalized,  has  also  been  observed;  in  fact,  any 
type  may  exist,  and  in  some  instances  there  is  only  a  preponderance 
of  one  type,  the  disease  upon  different  parts  presenting  different  aspects. 
In  these  cases  the  patient  is  most  comfortable  in  bed,  at  least  until  the 
activity  of  the  inflammation  has  abated.  Lotions  and  dusting-powders 
used  conjointly  are  most  comforting  in  dry  eczema,  while  in  moist  eczema 
lotions  and  ointments  usually  furnish  the  most  relief.  There  is,  however, 
no  set  rule  for  this.  The  remedies  should  not  be  strong.  These  cases 
generally  do  well  at  first,  the  disease  frequently  yielding  rapidly,  except 
upon  one  or  more  regions,  where  it  is  likely  to  persist  for  some  time.  The 
type  (eczema  craquele)  of  more  or  less  generalized  eczema  sometimes 
met  with,  in  which  there  is  practically  but  little,  if  any,  infiltration  of  the 
skin,  being  erythematous  and  in  places  minutely  vesicopapular,  and 
tending  to  crack  superficially  in  irregular  squares  or  blocks,  has  already 
been  referred  to  in  the  description  of  the  varieties.  This  variety  requires 
the  mildest  kind  of  treatment,  the  salicylic  acid  paste,  plain  salicylated 
petrolatum,  5  grains  (0.33)  to  the  ounce  (32.),  and  petrolatum  or  cold 
cream,  containing  i  or  2  drams  (4--8.)  of  powdered  starch  to  the  ounce 
(32.),  acting  most  satisfactorily. 

Eczema  of  the  Adjoining  Mucous  Surfaces.1 — The  mucous  membrane 
is  rarely,  if  ever,  solely  involved,  but  in  conjunction  with  the  neigh- 
boring cutaneous  surface,  as  at  the  nasal  orifices,  the  eyelids,  the  lips, 
about  the  glans  penis,  the  vulvar  orifice,  and  the  anus.  The  membrane 
becomes  inflamed  and  somewhat  thickened,  sometimes  dryer  than  nor- 
mal, and  at  other  times  showing  a  mucopurulent  discharge.  Crusting, 
usually  insignificant,  may  at  times  form,  and  occasionally  there  is  a 
slight  disposition  to  crack.  Exceptionally  the  disease  is  limited  to 
the  vermilion  of  the  lips,  and  is  persistent,  but  this,  I  believe,  belongs 
to  the  domain  of  dermatitis  seborrhoica  and  will  be  again  referred  to 
under  that  head.  The  benign  evanescent  plaques  sometimes  observed 
on  the  tongue  will  be  referred  to  elsewhere. 

Its  continuity  from  the  disease  of  the  cutaneous  surface,  from  which 
it  usually  springs,  would  suggest  a  parasitic  factor.  At  times,  especially 
about  the  nose  and  mouth,  it  would  almost  seem  as  if  it  had  its  com- 
mencement on  the  mucous  surface,  certainly  at  least  at  the  mucocuta- 
neous  junction.  In  the  treatment  of  the  disease  on  these  parts  measures 
vary  somewhat  as  to  locality.  That  of  the  nares  has  already  been 
spoken  of,  as  well  as  that  at  the  edges  of  the  eyelids.  For  the  glans 
penis  and  the  inner  surface  of  the  vulva,  as  well  as,  in  fact,  on  all  other 

1  Vidal,  Gazette  des  hvpitaux,  1880,  p.  68;  Besnier,  Jour,  de  med.  el  de  chirurg., 
Dec.,  1889;  von  Sehlen,  Monatshefte,  1894,  xix,  p.  15;  Hartzell,  Medical  News,  1895, 
i,  p.  460  (with  literature  references). 


DERMATITIS  SEBORRHOICA 


331 


mucous  surfaces,  boric  acid  lotions  and  i  to  5  per  cent,  tannic  acid  solu- 
tions are  valuable;  and  in  persistent  cases  the  silver  nitrate  solutions 
already  referred  to  several  times  are  to  be  kept  in  mind. 

DERMATITIS  SEBORRHOICA 

Synonyms. — Eczema  seborrhoicum;  Seborrhoea  corporis  (Duhring;  some  cases); 
Pityriasis  capitis;  Seborrhoea  sicca  (some  cases). 

Definition. — A  dermatic  inflammation  of  slight  or  moderate 
grade,  beginning  usually  primarily  upon  the  scalp,  characterized  by 
greasy  scaliness,  and,  especially  outside  of  the  scalp  region,  not  infre- 
quently presenting  a  tendency  to  segmental  or  irregular  shapes. 

This  definition  of  this  disease,  compared  to  the  more  comprehen- 
sive one  inferentially  given  by  Unna,1  and  which  was  later  accepted 
by  some  others,  notably  Elliot2  in  this  country,  is  a  narrow  one,  and 
is  intended  to  cover  cases  which  may  well  be  considered  to  present 
the  combined  symptomatology  of  a  mild  eczematous  inflammation 
and  seborrhea.  Along  with  the  majority  of  my  colleagues  I  believe 
that  most  of  the  papular  and  moist  types  which  Unna  especially  would 
also  include  are  more  properly  to  be  placed  under  eczema.  Indeed, 
I  am  inclined  to  share,  in  part  at  least,  Duhring's  opinion3  that  "it  often 
exists  as  a  variable  combination  of  these  two  diseases,  partaking  in  some 
cases  more  of  the  nature  of  seborrhea  than  eczema,  as  shown  by  the  gland- 
ular involvement,  the  regions  affected,  and  the  well-established  observa- 
tion that  it  often  yields  readily  to  the  sulphur  preparations,  so  useful  in 
affections  of  the  sebaceous  glands." 

Sabouraud's  brilliant  investigations4  tend  to  show  that  the  several 
conditions  usually  described  under  the  heads  seborrhea  and  derma- 
titis seborrhoica  of  the  scalp  represent,  in  fact,  several  etiologically 
diverse  conditions:  (i)  Seborrhea — one  form,  the  oily  form,  or  seborrhoea 
oleosa,  due  to  the  microbacillus;  (2)  pityriasis  simplex  capitis — hair 
usually  dry  and  lusterless  with  small  white  or  gray  scales  scattered  over  it, 
clinging  to  the  hair  like  powder,  or  thin  small  flattened  bran-like  scales; 
there  is  no  inflammation,  some  itchiness,  but  the  disease  does  not  cause 
baldness;  caused  by  the  spores  of  Malassez,  identical  with  the  bottle 
bacillus  of  Unna;  the  disease  being  a  hyperkeratosis;  (3)  pityriasis  stea- 
todes — the  scalp  covered  with  distinctly  greasy,  coarse,  yellowish,  usually 
adherent  scales  or  crusts,  in  moderate  to  considerable  amounts;  there  are 
no  inflammatory  signs,  but,  as  a  rule,  tending  to  variable  hair  loss;  pru- 
ritus of  mild  degree;  oiliness  is  often  a  complication;  and  the  malady  may 
develop  into  a  dermatitis  seborrhoica  or  even  into  an  eczema;  Sabouraud 
considered  this  type  as  the  result  of  a  secondary  infection  of  his  pityriasis 

1  Unna,  "Seborrhea]  Eczema,"  Jour.  Cutan.  Dis.,  1887,  p.  449;  and  later  paper  in 
Volkmann's  klinische  Vortrage,  No.  79,  Sept.,  1893— full  abstract  translation  in  Brit. 
Jour.  Derm.,  1894,  p.  23. 

2  Elliot,  New  York  Med.  Jour.,  1891,  vol.  liii,  p.  174,  and  Morrow's  System,  vol.  m 
(Dermatology),  p.  273. 

3  Duhring,  Cutaneous  Medicine,  part  ii,  p.  323. 

4  Jackson  and  McMurtry,  "Seborrhcea  Capitis,"  Jour.  Cutan.  Dis.,  1912,  p.  608, 
give  a  good  account  of  Sabouraud's  views;  also  in  their  recent  book,  Diseases  of  the 
Hair,  1912. 


332 


IN  FLA  MM  A  TIONS 


simplex  with  his  polymorphous  coccus  with  gray  colonies  (considered  iden- 
tical with  Unna's  morococcus) ;  every  case  shows,  therefore,  these  two  or- 
ganisms— the  spores  of  Malassez  and  the  polymorphous  coccus;  the  lat- 
ter appears  as  a  morococcus,  a  diplococcus,  or  in  groups  of  four,  and  oval, 
club,  or  dumbbell  in  shape.  (4)  Dermatitis  seborrhoica,  characterized 
by  small  or  large  patches,  discrete,  grouped,  or  coalescent,  often  forming 
serpiginous  or  polycyclic  areas,  with  more  or  less  greasy,  adherent,  gray- 
ish or  yellowish  scales  or  crusts,  with  the  underlying  skin  red  or  yellow- 
ish red;  the  whole  scalp  may  be  involved  or  only  in  parts;  and  it  frequently 
spreads  to  other  parts  of  the  body;  the  malady  is  attributed  to  the 
presence  of  a  combination  of  the  three  organisms  already  named — the 
microbacillus,  the  spores  of  Malassez,  and  the  polymorphous  coccus. 

While,  therefore,  Sabouraud's  great  work  has  tended  to  clear  up  a 
much  discussed  and  much  disputed  class  of  cases,  there  is  still  sufficient 


Fig.  74. — Dermatitis  seborrhoica,  involving  sides  and  angles  of  the  nose,  the  eye- 
brows, and,  to  a  slight  extent,  the  chin  and  other  hairy  parts  of  the  face.  Slight  to 
moderate  scaliness  of  a  greasy  character,  with  underlying  mildly  inflammatory  condi- 
tion. Scalp  is  also  involved. 

lack  of  corroboration  and  want  of  unanimity  that  for  the  present  it  seems 
advisable  to  present  the  subject  matter  in  the  same  manner  and  under  the 
same  headings  as  in  the  former  editions  of  this  treatise. 

Symptoms. — The  clinical  appearances  presented  by  dermatitis  seb- 
orrhoica are  somewhat  variable  according  to  the  region  involved,  and 
probably  also  dependent  upon  the  cutaneous  irritability  of  the  individual 
skin.  The  special  seat  of  the  malady  is  the  scalp.  It  may  consist  of  mere 
branny  scaliness,  with  skin  practically  of  the  normal  color  or  slightly 
irritated  and  reddened  (pityriasis  capitis;  some  cases  of  dandruff),  or 
there  may  be  considerable  scale-formation,  under  which  the  skin  is 
found  to  be  somewhat  inflamed  and  even  infiltrated.  It  sometimes 
exists  in  areas  of  small  or  large  extent,  or  it  may,  as  it  does  in  some 
instances,  involve  the  entire  scalp,  extending  over  to  the  ears  and  on  to 
the  forehead.  The  scales  are  grayish  or  a  dirty  white  color,  and  greasy 


DERMATITIS  SEBORRHOICA  333 

or  unctuous  to  the  touch.  In  the  mild  types — pityriasis  capitis — the 
scales  are  often  rather  dry,  as  likewise  is  the  hair.  As  a  rule,  however, 
although  the  scaliness  varies  from  almost  dry  to  oily,  the  hair,  if  the 
disease  is  at  all  marked,  is  noted  to  become  oily  or  greasy  and  to  need 
frequent  washing.  There  are  exceptional  cases,  however,  in  which  the 
hair  seems  dry,  lifeless,  and  lusterless  throughout.  In  those  of  marked 
scaliness  the  hair-shaft,  at  and  near  the  scalp,  is  often  encircled  with  thin 
scales ;  and  in  almost  all  instances  there  is  more  or  less  scaly  dust  scattered 
through  the  hair,  readily  falling  on  the  shoulders.  In  persistent  cases 
hair  loss,  moderate  or  considerable  in  extent,  is  a  frequent  accompani- 
ment. In  extreme  types  the  eczematous  aspect  is  the  more  pronounced, 


Fig.  75. — Dermatitis  seborrhoica,  of  more  inflammatory  type  than  shown  in  pre- 
ceding illustration,  involving  the  whole  face  and  scalp,  but  especially  pronounced  about 
the  nose. 

and  there  is  sometimes  serous  exudation.  The  disease  is  frequently 
irregularly  diffused,  and  with  a  gradual  lessening  toward  the  borders, 
which  is  commonly  more  noticeable  toward  the  forehead;  on  the  other 
hand,  the  edge  may  be  more  pronounced,  slightly  elevated,  and  gyrate  or 
irregularly  segmented,  and  when  red,  as  such  a  border  usually  is,  becomes 
quite  conspicuous  and  disfiguring.  Exceptionally  scattered  over  the 
scalp  region,  the  malady  may  present  segmental  or  ring-like  patches, 
slightly  inflammatory  in  character.  The  disease  often  remains  limited 
to  the  scalp,  remaining  as  a  mild  pityriasis  type  throughout,  with,  in 
some  cases,  an  occasional  exacerbation  in  which  the  skin  becomes  acutely 
inflamed  and  the  scaliness  more  pronounced,  but  of  a  distinctly  greasy 
character.  The  skin,  instead  of  seeming  to  be  thickened,  often  has  a 


3  34  1NFLAMMA  TIONS 

thin,  inelastic  appearance.  In  some  cases  in  which  these  exacerba- 
tions take  place  the  process  extends  on  to  the  face,  partly  or  completely 
invading  it,  and  with,  at  times,  areas  of  moist  exudation,  presenting, 
in  fact,  the  appearance  of  a  mildly  acute  eczema  supervening  upon  a 
seborrhea. 

While  the  disease  frequently  confines  itself  to  the  scalp  and  in  most 
instances  occurs  primarily  on  this  region,  it  is  not  uncommon  for  the 
region  of  the  side  of  the  nose  and  the  immediate  neighboring  surface  to 
show  scaliness,  merely  furfuraceous  or  crusty  in  character,  with  a  scarcely 
reddened  skin  beneath  or  with  the  part  slightly  hyperemic  and  even  in- 
flamed and  somewhat  oily;  the  glandular  outlets  are  frequently  enlarged 
or  patulous,  and  occasionally  the  overlying  scales  show  projections,  ex- 
tending in  the  duct  openings.  In  some  cases,  more  particularly  in  chil- 
dren, the  manifestation  on  the  face  consists  of  several  or  more  small,  ill- 
defined,  rounded,  scurfy  patches,  especially  about  the  mouth  region, 
sometimes  in  association  with  similar  lesions  on  the  upper  trunk.  The 
eyebrows  are  also  often  the  seat  of  furfuraceous  or  moderate  scaliness,  and 
in  the  male  adult  the  mustache  and  beard  often  display  the  same  char- 


Fig.  76. — Persistent  exfoliation  of  the  lips  (dermatitis  seborrhoica — cheilitis  exfoliativa). 

acters.  The  ear  canal,  as  well  as  the  ears  themselves,  may  also  be 
the  seat  of  the  disease.  The  scales,  especially  those  about  the  alae 
nasi,  are  usually  quite  oily  and  of  a  yellowish  cast;  in  fact,  this  yellow- 
ish tinge  is  often  characteristic  of  this  disease  not  only  on  this  region, 
but  elsewhere  on  the  surface.  Instead  of  the  types  just  described,  the 
disease  is  sometimes  quite  inflammatory,  and  has  a  decidedly  eczema- 
tous  aspect. 

Exceptionally  the  vermilion  border  of  the  lips  is  involved  with 
other  parts,  and  covered  with  thin  or  somewhat  thick  adherent  scales 
or  crusts,  and  it  may  be  attended  with  a  slight  or  marked  tendency  to 
fissuring;  there  is  rarely  any  puffiness  or  swelling  of  the  parts,  as  often 
observed  in  eczema  of  this  region.  In  rare  instances  the  disease  is 
limited  to  the  lips,  scarcely  extending  on  to  the  cutaneous  surface,  usually 
with  a  coexistent  eruption  of  the  scalp.  In  two  instances  recently  under 
my  care1  it  was  limited  to  the  vermilion  of  the  lips  (cheilitis  exfoliativa) , 
neither  overstepping  the  mucous  portion  of  the  mouth  nor  the  cutaneous 

1  Stelwagon,  "A  Report  of  Two  Cases  of  Persistent  Exfoliation  of  the  Lips,"  Jour. 
Culan.  Dis.,  June,  1900;  "A  Peculiar  Eczematoid  Eruption  of  the  Lip  Region,"  ibid.. 
Aug.,  1904  (illustrated;  lips  and  contiguous  cutaneous  surface). 


PLATE  X. 


An  unusual  case  of  dermatitis  seborrhoica  of  a  psoriasiform  type. 


DERMATITIS  SEBORRHOICA  335 

integument,  and  consisted  of  persistent  and  repeated  thin  exfoliation; 
there  was  an  associated  slight  involvement  of  the  scalp  in  both  cases,  and 
in  one  case  transitory  mild  patches  upon  the  face. 

On  the  breast  the  disease  is  frequently  limited  to  one  or  two  irregu- 
larly rounded  areas  over  the  sternum;  it  is  scaly,  with  frequently  slight 
elevation,  and  the  skin  reddened  to  a  variable  degree.  On  removing  the 
crust,  projections  are  frequently  noted  extending  into  the  sebaceous 
gland  outlets.  It  is  also  not  infrequent  upon  the  back,  especially  be- 
tween the  scapulae.  Instead  of  only  several  areas,  they  may  be  quite 
numerous,  and  may  coalesce  here  and  there,  and  form  patches  made  up 
of  irregular  segments  and  circles  or  festooned  areas,  often  with  distinctly 
inflammatory  base,  particularly  at  the  periphery.  As  thus  seen  upon  the 
chest,  it  constitutes  the  so-called  seborrhcea  corporis  (Duhring),  the 
lichen  circumscriptus  (Willan  and  Bateman),  lichen  annulatus  (Wilson), 
lichen  gyratus  (Biett  and  Cazenave) ,  and  seborrhcea  papulosa  seu  lichen- 
oides  (Crocker),  seborrhoea  figuree  (Brocq) — names  which  convey  a  fair 
portrayal  of  the  clinical  appearances.  The  umbilicus  is  also  a  not  un- 
common seat  of  a  dry,  scaly,  or  oily  moist  form. 

The  disease  on  other  parts — as,  for  instance,  the  genitocrural  and 
axillary  regions — varies  but  slightly  from  its  appearance  elsewhere, 
except  that  the  heat,  moisture,  and  friction  of  the  parts  tend  to  give 
it  more  the  appearance  of  ordinary  eczema.  It  frequently  begins  as 
small,  branny,  scaly,  slightly  reddened  spots,  which  often  enlarge,  and 
sometimes  have  somewhat  elevated  borders,  and  occasionally  with  a 
clearing  center.  They  sometimes  coalesce,  and  then  a  slightly  or  moder- 
ately inflamed  area  is  presented,  with  scaly  or  crusted  surface,  and  usually 
a  rather  sharply  defined  border;  the  scaliness  or  crusting  being  of  a  yellow- 
ish, greasy  character,  and  rarely  abundant.  The  skin  itself,  both  under- 
lying the  patches  and  immediately  adjacent  thereto,  often  is  yellowish  or 
has  a  yellowish  tinge.  In  fact,  in  these  regions  there  is  a  resemblance  to 
both  erythema  or  eczema  intertrigo  and  eczema  marginatum  (tinea 
trichophytina).  In  infants  it  is  not  infrequent  in  the  erythema  intertrigo 
regions;  the  color  is  apt  to  be  a  brighter  red,  with  often  a  granular- 
looking  surface,  usually  due  to  the  presence  of  small,  moist  or  greasy, 
yellowish  or  yellowish-gray  scales.  On  the  hands  and  also  the  feet 
the  disease  is  usually  of  a  patchy  character,  sometimes  ill  defined,  at 
other  times  quite  well  marked,  and  the  patches  rather  sharply  circum- 
scribed. Here,  as  elsewhere,  coalescence  sometimes  occurs  and  larger 
irregular  areas  result;  and  occasionally  vesiculation  and  serous  exudation 
are  noted. 

In  exceptional  instances  dermatitis  seborrhoica  is  distinctly  psoriasi- 
form  in  appearance,  with  scattered,  variously  sized  patches  over  the 
general  surfaces,  usually  sparing  the  extensor  surfaces  of  the  elbows 
and  knees— favorite  sites  for  the  true  psoriasis  lesions.  In  these  cases 
patches  are  commonly  seen  in  the  axillae,  about  the  genitalia,  and  in 
other  places  where  psoriasis  lesions  are  not  generally  observed.  ^  Some- 
times they  are  flat,  scaly  spots  or  papules,  often  disk-like  or  circinate, 
with  but  a  slight  or  moderate  amount  of  scaliness,  which  is  usually 
of  a  yellowish  tinge,  and  greasy  or  unctuous  in  character.  In  excep- 


336 


INFLAMMA  TIONS 


tional  instances  dermatitis  seborrhoica  may  be  quite  extensively  diffused 
and  involve  large  surfaces,  and  be  more  or  less  polymorphous.  The  favor- 
ite localities  are,  however,  those  already  named — scalp,  eyebrows,  region 
of  the  nose,  sternal  and  interscapular  regions,  the  genitocrural  region, 
and  axillae,  and  in  male  adults  the  hairy  parts  of  the  face.  In  most 
instances  it  is  upon  the  upper  half  of  the  body.  While  it  begins  primarily 
on  the  scalp  in  most  cases,  and  from  here  tends  to  spread  downward  or 
develop  on  other  regions,  in  the  minority  of  cases  it  starts  at  the  eyebrows, 
axillae,  or  the  genitocrural  region. 

As  a  rule,  itching  is  not  a  troublesome  symptom,  and  often  it  is 
extremely  slight,  and  sometimes  entirely  wanting.  It  is  noted  most 
frequently  with  the  disease  on  the  scalp,  and  is  not  uncommon,  when 
the  patient  is  heated,  on  the  sternal  and  interscapular  regions,  and 


Fig.  77. — Dermatitis  seborrhoica  of  the  sternal  region,  a  not  uncommon  site;  shows 
the  tendency  to  irregular,  ring-like  formation  of  the  patches  and  scales.  The  scaliness 
is  slight  and  of  a  greasy  character;  affected  surface  reddened  and  mildly  inflammatory. 

probably  less  frequent  with  the  disease  in  the  axillae  and  genitocrural 
parts.  It  is  sometimes  entirely  absent  with  the  eruption  on  the  hand. 

The  course  of  the  malady  is  usually  persistent,  varying  somewhat 
in  severity  and  extent,  and  exceptionally  with  periods  of  relative  quies- 
cence or  abatement. 

Etiology. — The  disease  is  quite  common,  especially  in  its  milder 
types  on  the  scalp.  It  is  met  with  in  both  sexes  and  at  all  ages,  although 
more  frequent  between  the  ages  of  early  youth  and  thirty  or  thirty- 
five  years.  Systemic  disturbances,  especially  those  of  the  alimentary 
tract, — indigestion,  dilatation  of  the  stomach,  constipation, — men- 
strual disorders,  anemia,  and  general  debility  are  to  be  considered  as 
favoring  factors.  Elliot  does  not  place  much  importance  upon  constitu- 
tional influences;  Unna  considers  them  slightly  predisposing.  My 
own  observations  place  a  good  deal  of  stress  upon  the  systemic  condition 
as  an  influencing  element,  especially  digestive  irregularities;  very  often, 
in  the  milder  cases,  a  variability  can  be  gauged  by  the  state  of  the  ali- 


DERMATITIS  SEBORRHOICA 


337 


mentary  tract.  Of  probably  greater  importance  are  the  external  factors 
of  lack  of  care,  want  of  cleanliness,  the  infrequent  use  of  soap,  irritating 
barber-shop  and  patent  tonic  applications  to  the  scalp,  and,  on  the  body, 
the  wearing  of  too  heavy  woolen  underwear.  Sweating,  especially  when 
retained  for  a  long  time  in  contact  with  the  body,  as  often  observed  in 
winter  in  the  use  of  thick  flannel,  is  a  potent  favoring  factor  in  the  disease 
upon  the  sternal  and  interscapular  regions.  It  is  not  improbable  that  the 
cautious,  and  therefore 
usually  imperfect,  wash- 
ing of  soiled  woolen  under- 
wear to  prevent  shrink- 
ing is  not  without  con- 
tributory import  on  cov- 
ered regions. 

While  the  disease  is 
met  with  at  all  times  of 
the  year,  it  is  more  com- 
mon during  the  "over- 
clad"  and  indoor  season; 
in  summer  the  outdoor 
life,  the  better  ventila- 
tion, and  the  more  fre- 
quent bathing  are  un- 
favorable to  its  produc- 
tion. In  a  measure  the 
malady  is  to  be  viewed 
as  contagious,  and  there- 
fore parasitic,  and  bar- 
ber-shops, hair-dressing 
establishments,  the  combs 
and  brushes  in  the  gen- 
eral toilet-rooms  of  hotels, 
etc.,  are  doubtless  respon- 
sible for  its  communica- 
tion in  some  instances. 
As  is  to  be  inferred  from 
the  remarks  on  the  de- 
scription of  the  disease, 
the  scalp  is  the  starting- 
point  in  most  cases,  and 
the  disease  here  has,  therefore,  an  important  etiologic  bearing  upon  the 
development  of  the  eruption  on  other  parts. 

Pathology.— The  prevailing  view  of  former  years  that  all  the 
conditions  observed  in  this  affection  were  the  result  of  functional  disease 
of  the  sebaceous  glands— a  seborrhea— is  no  longer  tenable.  Van 
Harlingen1  was  the  first  to  demonstrate  that  pityriasis  capitis  was  not  a 
true  seborrhea,  although  his  careful  work  has  been  lost  sight  of  in  the 

1  Van  Harlingen,  "A  Contribution  to  the  Pathology  of  Epithelium,"  Amur.  Jour. 
Med.  Sci.,  July,  1876;  "Pathology  of  Seborrhea,"  Arch.  Derm.,  April,  1878. 
22 


Fig.  78. — Dermatitis  seborrhoica  of  the  scalp  of 
the  lightest  grade,  known  commonly  as  pityriasis 
capitis.  A  somewhat  hyperplastic,  loosely  coherent, 
corneous  layer,  filling  up  and  causing  slight  funnel- 
like  dilatation  of  the  follicular  opening,  and  envelop- 
ing the  hair-shaft  at  the  orifice.  Slight  inflamma- 
tory cell-infiltration  in  the  corium,  especially  along 
the  hair-follicle  (courtesy  of  Dr.  Geo.  T.  Elliot). 


338 


INFLAMMA  TIONS 


recent  and  more  complete  investigations  of  Unna,  Elliot,  and  others; 
and  Duhring  first  called  attention  to  the  fact  that  the  disease  on  the  chest 
(his  seborrhcea  corporis)  was  associated  with,  and  often  followed,  the 
disease  upon  the  scalp,  thus  foreshadowing  the  work  of  other  observers, 
although  he  did  not  place  the  same  interpretation  upon  the  clinical 
facts. 

The  essential  pathogenic  factor  of  dermatitis  seborrhoica  must  be 
considered  parasitic,  and  this  view  is  strengthened  by  the  tendency  in 
many  cases  to  assume  the  circinate,  segmental,  and  spreading  forms. 

Its  origin  primarily  in  the 
scalp  in  most  cases,  and  its 
tendency  to  develop  from 
this  region  to  another,  and  its 
infrequent  occurrence  prim- 
arily simultaneously  upon 
several  parts,  are  also  sug- 
gestive. Unna  and,  following 
him,  Leredde  believed  that 
his  morococci  and  the  flask 
bacilli  (Malassez's  spores)  are 
the  parasitic  agents.  The  in- 
vestigations of  Torok,  Sabou- 
raud,1  and  others  threw  doubt 
upon  the  pathogenic  import- 
ance of  these  organisms,  and, 
as  Galloway2  and  others  have 
contended,  it  is  more  than 
probable  that  this  coccus — 
morococcus — is  a  mere  sapro- 
phyte. Both  Merrill3  and 
Whitfield4  have  found  a 
coccus  of  variable  size,  ar- 
ranged usually  in  pairs,  and 
also  in  groups  and  short 
chains,  grayish  white,  and 
sometimes  developing  into  a  yellowish  color.  Whitfield  found  it  in 
12  cases  examined  by  him,  but  experiments  at  inoculation  on  him- 
self were  without  result.  Merrill  found  constantly  diplococci,  espe- 
cially two  varieties,  one  chromogenic  and  the  other  non-chromogenic, 
and  states  that  in  a  fair  proportion  of  his  inoculative  experiments  he 
succeeded  in  producing  the  disease. 

The  clinical  appearances  suggest  an  inflammation  of  the  skin,  usu- 
ally of  a  slight  or  moderate  grade, — a  mild  dermatitis, — and  appar- 
ently with  an  associated  disturbance  of  the  oil-secreting  glands.  Unna 
claims  that  the  coil-glands  are  those  implicated,  and  to  which  the  oily 

1  Sabouraud's  views  have  somewhat  changed— see  introductory  part  of  this  chapter. 

2  Galloway,  Discussion  Harveian  Society,  Brit.  Med.  Jour.,  Feb.  25,  1899. 

3  Merrill,  New  York  Med.  Jour.,  1897,  vol.  Ixv,  p.  322;  and  vol.  Ixii,  1895,  p.  528. 

4  Whitfield,  Brit.  Jour.  Derm.,  1900,  p.  406. 


Fig.  79. — Dermatitis  seborrhoica,  section  of  a 
small  papule  in  the  type  commonly  known  as 
"seborrhcea  corporis."  A  hyperplastic  horny 
layer  and  dense  inflammatory  cell-infiltration  in 
more  or  less  of  the  entire  corium,  with  slight 
edema  (courtesy  of  Dr.  Geo.  T.  Elliot). 


DERMATITIS  SEBORRHOICA  339 

secretion  is  due.  From  his  studies  he  states  that  there  does  not  exist 
any  hypersecretion  of  the  sebaceous  glands  which  can  clinically  be  called 
dry  seborrhea,  due  to  a  deposit  upon  the  surface  of  firm  products  from 
these  structures.  Dermatitis  seborrhoica,  in  which  he  includes  all  forms 
of  seborrhea  except  seborrhcea  oleosa,  is  due,  he  believes,  to  hypersecre- 
tion of  oil  from  the  sweat-glands,  and  not  the  sebaceous  glands,  together 
with  an  inflammation  of  the  skin  due  to  parasitic  invasion ;  the  oil  secre- 
tion permeating  the  cutaneous  tissues,  as  well  as  mixing  with  the  surface 
scales  and  crusts,  and  that  to  this  excessive  secretion  the  yellow  tinge  is 
to  be  attributed.  His  views  as  to  the  sole  implication  of  the  sweat-glands 
have  not,  however,  found  general  acceptance. 

The  pathologic  anatomy  has  been  studied  by  Unna,  Elliot,  and 
others,  and  with  findings,  upon  the  whole,  essentially  similar.  Unna1 
states  that  four  factors  are  found:  (i)  Parakeratosis  of  the  epidermis; 


Fig.  80.— Dermatitis  seborrhoica  of  the  upper  part  of  the  back  and  mterscapular 
region,  a  not  uncommon  site;  shows  the  irregular  ring  tendency  and  rather  sharply 
denned  borders.  The  scaliness  is  slight  and  of  a  greasy  character;  affected  surface 
reddened  and  mildly  inflammatory. 

(2)  epithelial  proliferation  (acanthosis) ;  (3)  inflammation  of  the  derma, 
varying  in  depth;  (4)  augmentation  of  the  fatty  secretion  of  the  skin,  to- 
gether with  increased  activity  of  the  coil-glands.  The  first  three  are 
also  typical  of  eczema.  The  fourth  gives  the  character  to  the  sebor- 
rheic  disease,  but,  as  already  stated,  there  is  difference  of  opinion  as  to 
the  source  of  the  fat  or  oil  secretion.  In  addition  he  notes  an  increase  in 
size  in  the  panniculus  adiposus;  and  only  after  the  total  disappearance  of 
the  hair  that  the  sebaceous  glands  take  part  and  the  sebum  accumulates. 
This  last  he  considers  is  not  an  essential  part  and  is  only  observed  in 
cases  of  long  standing.  Elliot2  has  failed  to  confirm  Unna's  observatu 
as  to  fatty  infiltration  in  the  tissues  or  in  the  sweat-glands;  he  found 
disorganization  of  these  glands,  but  considered  this  only  an  evidence 

1  Quoting  from  abstract  of  his  paper  in  Brit.  Jour.  Derm.,iSg4,  P-  2.3- 

*  Elliot,  Jour.  Cutan.  Dis.,  1893,  P-  205  (with  several  good  histologic  cuts). 


34O  INFLAMMA  TIONS 

their  participation  in  the  inflammatory  process,  but  not  necessarily  in  the 
line  of  excessive  fat-production. 

Diagnosis. — The  diagnostic  features  of  dermatitis  seborrhoica  are 
its  almost  invariable  occurrence  primarily  upon  the  scalp,  its  spread 
from  this  region  downward,  the  mildly  inflammatory  character,  the 
absence  of  pronounced  infiltration,  the  greasy  nature  of  the  scales  or 
crusts,  and  the  tendency,  in  many  cases,  to  disc-like  or  segmental  con- 
figuration, and  the  relatively  moderate  amount  of  itching.  The  disease 
is  to  be  distinguished  from  seborrhea,  eczema,  pityriasis  rosea,  ringworm, 
and  psoriasis.  The  acceptance  of  dermatitis  seborrhoica  as  a  distinct 
entity  has  almost  obliterated  seborrhea.  But  there  are  still  some 
cases  of  this  latter,  in  the  scalp  especially,  in  which  an  inflammatory 
element  cannot  be  detected,  and  which  are,  therefore,  to  be  distinguished 
by  the  entire  absence  of  inflammatory  symptoms  and  of  signs  of  irritation. 
The  skin  is  found  paler  than  normal,  extremely  oily,  and  often  slate 
colored,  the  scaliness  being  soft  and  oily.  The  oily  variety  of  seborrhea, 
not  uncommon  on  the  scalp  and  nose,  is  distinguished  by  the  entire  lack 
of  scale  formation  and  freedom  from  inflammatory  signs. 

Dermatitis  seborrhoica  is  to  be  differentiated  from  ordinary  eczema 
by  the  absence  of  markedly  inflammatory  characters,  the  practical 
absence  of  infiltration,  its  tendency  to  be  somewhat  sharply  marginate 
and  often  segmental  or  of  irregular  outline,  and  by  the  fact  of  its  first 
appearance  upon  the  scalp.  The  scaliness  is  less  abundant  and  usu- 
ally of  yellowish  tinge  and  greasy  looking  to  the  sight,  and  unctuous 
to  the  touch.  In  cases  of  any  extent  the  sternal  and  interscapular 
regions  rarely  escape,  parts  that  are  seldom  involved  in  ordinary  eczema 
except  in  generalized  cases.  Upon  the  hands,  especially  on  the  palmar 
aspects,1  the  differentiation  is  sometimes  extremely  difficult,  but  the 
scurfy  or  scaly  patch-formation  here,  irregular  outlines,  and  usually 
the  presence  of  the  characteristic  disease  on  other  parts  will  be  of  aid. 
In  the  axillae  and  genitocrural  regions  eczema  is  rarely  ever  sharply  defined, 
segmental,  or  patchy,  as  generally  obtains  in  dermatitis  seborrhoica;  and 
the  latter's  frequent  mode  of  beginning  here  in  ringworm-like  patches  is 
unlike  eczema.  Moreover,  seborrheic  dermatitis  is,  on  these  regions  and 
also  elsewhere,  except  the  scalp,  seldom  itchy  to  the  extent  of  being  a 
troublesome  symptom,  while  in  eczema  it  is  constantly  so. 

Pityriasis  rosea  begins  on  the  trunk  almost  invariably,  comes  out 
more  or  less  acutely  in  the  course  of  a  few  days,  and  presents  numer- 
ous maculosquamous  and  papulosquamous  patches,  tending  to  spread, 
and  here  and  there  coalesce,  rarely  involving  face,  never  the  scalp,  and 
seldom  regional  just  over  the  sternum,  as  so  often  observed  in  dermati- 
tis seborrhoica.  The  early  patches  of  pityriasis  rosea  are  never  seg- 
mental, as  in  seborrheic  dermatitis,  and  tend  more  decidedly  to  develop- 
ing into  spreading  rings,  and  they  are  not  covered  with  the  same  greasy 
or  unctuous  scales  of  the  latter  disease.  Its  course,  after  full  develop- 
ment, is,  as  a  rule,  rapidly  toward  full  recovery,  whereas  in  dermatitis 
seborrhoica  this  natural  tendency  to  a  self-limited  duration  is  not  ob- 

1  Stelwagon,  "Observations  Concerning  Some  Palmar  Eruptions"  (illustrated). 
Jour.  Cutan.  Dis.,  Jan.,  1905. 


DERMATITIS  SEBORRHOICA  341 

served.  Nevertheless  it  must  be  conceded  that  at  times  the  two  con- 
ditions present  puzzling  similarity,  which  is  only  positively  solved  by 
several  days'  or  one  or  two  weeks'  observation. 

Ringworm  patches,  especially  in  their  early  stage  and  particularly 
in  children  about  the  face,  resemble  patches  of  seborrheic  dermatitis, 
but  in  the  former  the  almost  invariable  tendency  to  a  complete  clearing 
up  of  the  central  portion  as  it  spreads  peripherally,  and  the  usually  more 
pronounced  and  elevated  border  are  generally  sufficiently  character- 
istic. From  eczema  marginatum — ringworm  of  the  genitocrural  and 
axillary  regions — the  differentiation  is  not  always  readily  made,  but  in 
ringworm  the  border  is  usually  quite  elevated,  distinctly  marginate,  and 
outside  of  the  confluent  areas  typical  ringworm  patches  are  generally  to 
be  found.  Moreover,  confluent  ringworm  of  these  regions  is  usually 
more  distinctly  inflammatory,  and  the  infiltration  more  marked,  than  in 
dermatitis  seborrhoica.  In  all  suspected  and  difficult  cases  an  examina- 
tion of  the  scales  from  the  edges  will  be  the  crucial  test;  the  ringworm 
fungus  can  be  found  if  it  be  that  disease,  if  the  examination  be  thor- 
oughly and  carefully  made. 

More  or  less  generalized,  small,  patchy  seborrheic  dermatitis  simu- 
lates psoriasis  at  times  quite  closely,  but  the  favorite  regions  of  pso- 
riasis— the  extensor  surfaces  of  the  kness  and  elbows — are  rarely  invaded 
in  dermatitis  seborrhoica.  Moreover,  the  patches  of  this  latter  disease 
are  rarely  so  sharply  circumscribed  as  psoriasis  patches,  and  the  scales 
are  usually  yellowish  and  greasy,  instead  of  white,  silvery,  or  grayish, 
and  hard  and  dry,  as  in  psoriasis.  In  such  cases  of  seborrheic  dermatitis 
the  disease  on  the  scalp  rarely  shows  the  same  character,  but  on  this  region 
it  is  more  of  the  nature  of  a  mild  or  moderate  generalized  scaliness,  and 
not  patchy,  as  in  psoriasis. 

Prognosis.— The  disease,  is,  as  a  rule,  more  readily  managed 
than  ordinary  eczema,  often  responding  rapidly  to  treatment.  But 
there  is  usually  a  decided  tendency  to  recurrence,  which  Unna  con- 
siders to  be  due  to  the  fact  that  the  parasitic  element  may  remain 
quiescent  in  the  glandular  structures  (in  his  opinion,  the  coil-glands), 
and  again,  favored  by  some  unknown  contributory  influence,  give  rise 
to  a  recurrence.  Elliot  believes  there  is  another  reinfection.  It  is 
more  probable  that  the  patient's  constitutional  condition  is  an  import- 
ant favoring  factor;  if  in  good,  strong,  vigorous  health,  with  digestion 
being  well  performed  and  the  bowels  regular,  relapses  are  not  apt  to 
occur.  The  application  of  a  weak  resorcin  lotion,  2  to  5  per  cent,  strength, 
at  intervals  of  several  days  or  a  week,  and  the  use  of  a  boric  acid  or 
resorcin  soap  for  shampooing  and  for  occasional  toilet  washing,  are 
advisable  in  those  cases  showing  a  strong  tendency  to  recur.  The 
hair  loss  which  is  often  observed  in  connection  with  the  disease  on  the 
scalp  can  generally  be  replaced  by  proper  management  (see  Alopecia), 
provided  the  disease  has  not  been  too  long  continued. 

Treatment.— Believing,  as  I  do,  that  the  state  of  the  general 
health,  and  especially  the  condition  of  digestion,  has  in  many  cases  an 
important  etiologic  bearing,  the  line  of  constitutional  treatment  to  be 
adopted  depends  upon  indications  in  the  individual  cases— differing 


342  INFLAMMA  TIONS 

in  no  respect  from  the  general  plan  advised  in  eczema,  to  which  the 
reader  is  referred.  The  bowels  should  be  kept  free,  and  some  attention 
given  to  diet. 

The  most  important  external  remedies — and,  of  course,  the  external 
treatment  is  the  essential  part  of  the  management  of  the  disease — 
are  sulphur,  salicylic  acid,  and  resorcin.  Upon  the  scalp,  resorcin,  in 
the  form  of  a  lotion  made  up  of  5  to  30  grains  (0.33  to  2.),  i  to  2  drams 
(4.-8.)  of  alcohol,  and  water  to  make  an  ounce  (32.),  is  one  of  the  most 
valuable  remedies  we  possess;  it  may  even  be  used  stronger,  but  in  all 
the  stronger  proportions  some  care  is  necessary  at  first,  as  exceptionally 
irritation  is  produced.  It  should  be  applied  once  or  twice  daily.  In 
some  instances  the  lotion  is  too  drying,  and  is  to  be  supplemented  every 
second  or  third  day  by  an  application  of  plain  petrolatum ;  or  an  ointment 
medicated  with  10  to  30  grains  (0.7-2.)  of  resorcin  to  the  ounce  (32.) 
can  be  employed,  either  occasionally  in  conjunction  with  the  lotion  treat- 
ment or  alone.  The  objection  to  resorcin,  especially  in  lotion  form,  is 
that  in  those  with  gray  or  decidedly  blonde  hair,  a  dirty  yellow  staining, 
lasting  several  weeks  or  longer,  sometimes  is  noticeable  after  prolonged 
use.  If  employed  carefully  and  hi  scant  quantity,  this  is  not  so  likely 
to  occur;  in  such  patients,  however,  other  plans  are,  for  this  reason,  pref- 
erable. Sulphur,  the  precipitated  or  sublimed,  in  the  form  of  an  oint- 
ment, \  dram  to  2  drams  (2. -8.)  to  the  ounce,  is  often  curative,  but  this 
drug  irritates  in  some  cases.  On  the  scalp  region,  too,  salicylic  acid,  10 
to  40  grains  (0.65-2.65)  to  the  ounce  (32.)  of  petrolatum,  is  valuable;  and 
very  often  a  compound  salve  containing  both  resorcin  and  saliclylic  acid 
is  the  best  of  all.  A  0.5  to  2  per  cent,  solution  of  salicylic  acid  in  equal 
parts  of  alcohol  and  wTater  is  sometimes  useful  in  the  scalp  disease.  Along 
with  the  remedial  applications  occasional  washing  with  soap  and  water 
is  necessary,  the  frequency  depending  upon  the  rapidity  of  the  scale  re- 
accumulation  and  the  demands  of  cleanliness.  For  this  purpose  a  boric 
acid  or  a  resorcin  soap  may  be  used ;  in  sluggish  cases  the  tincture  of  green 
soap  is  permissible,  and  it  can  be  medicated  with  5  to  10  grains  (0.33- 
0.65)  of  resorcin  to  the  ounce  (32.). 

Upon  non-hairy  regions  the  conjoint  use  of  a  lotion,  similar  but 
somewhat  weaker  than  those  named,  along  with  a  salve,  usually  gives  the 
best  result.  The  ointment  for  these  parts  should  also  be  weaker  than 
for  the  scalp.  In  these  cases  sulphur  often  irritates  unless  used  very 
weak,  10  to  60  grains  (0.65-4.)  to  the  ounce  (32.).  It  frequently  acts 
more  satisfactorily  and  is  better  borne  when  prescribed  with  a  paste  as: 

fy     Sulphur,  praecip.,  gr.  xxx-lx  (2-4.); 

Ac.  salicylic!,  gr.  x  (0.65); 

Pulv.  amyli, 

Pulv.  zinci  oxidi,  aa  3iss  (6.); 
Petrolati,  3iv  (16.). 

In  obstinate  patches  an  occasional  application  of  a  10  to  50  per 
cent,  alcoholic  solution  of  resorcin,  as  advised  by  Frickenhaus,1  is  some- 
times valuable,  but  the  stronger  proportions  are  to  be  used  cautiously, 

1  Frickenhaus,  Monatshefte,  June  i,  1899. 


HERPES  SIMPLEX 


343 


as  aggravation  can  occur;  exfoliation,  usually  after  a  few  applications, 
results,  and  then  petrolatum  or  cold  cream  can  be  used  for  a  few  days, 
and,  if  necessary,  the  treatment  repeated.  Occasionally,  in  obstinate 
cases  of  the  disease  on  the  face  and  trunk,  an  ointment  containing  chrys- 
arobin,  5  to  30  grains  (0.33-2.)  to  the  ounce  (32.)  of  the  paste  above 
named,  may  be  used  with  advantage,  for  a  time  at  least,  and  then  other 
treatment  of  milder  character  employed.  About  the  face  this  remedy 
should,  however,  be  used  with  great  care.  In  persistent  body  patches 
I  have  frequently  employed  chrysarobin  in  collodion,  as  advised  in  psori- 
asis. In  some  face  cases  which  proved  obstinate  I  have  found,  even 
when  seemingly  quite  inflammatory,  the  cautious  use  of  the  compound 
lotion  of  zinc  sulphate  and  potassium  sulphuret  (see  Acne),  with  an  occa- 
sional application  of  cold  cream,  of  signal  benefit.  Short  Rontgen-ray 
exposures  (two  to  five  minutes,  with  a  soft  to  medium  tube,  at  a  distance 
of  8  to  10  inches),  at  intervals  of  several  days  or  a  week,  are  a  help  in  ob- 
stinate face  cases. 

In  children,  as  well  as  in  adults,  of  sensitive  skin  the  applications 
should  be  extremely  weak  at  first;  the  malady  is  usually  most  irritable 
on  the  face  and  genitocrural  region.  The  disease  upon  the  lips  must 
also  be  treated  cautiously  at  first,  but  in  persistent,  stubborn  cases  an 
occasional  application  of  the  strongest  remedies  becomes  necessary; 
strong  silver  nitrate,  resorcin,  and  lactic  acid  solutions  are  useful  here 
— silver  nitrate  and  resorcin,  2  to  20  per  cent,  strength,  and  lactic  acid, 
at  first  with  10  to  20  parts  water;  later,  if  necessary  and  not  too  irritating, 
in  stronger  proportions;  in  the  interim  mild  ointments  are  to  be  used; 
daily  washing  with  sapo  viridis,  and  immediately  applying  diachylon 
ointment  is  of  distinct  value  in  some  cases.  In  the  auditory  meatus 
the  resorcin  lotion,  applied  scantily,  and  supplemented  with  a  weak  re- 
sorcin salve,  constitutes  the  most  successful  plan,  but  the  disease  here  is 
often  obstinate,  and  frequently  requires  change  of  remedies  before  final 
success  is  achieved. 

HERPES  SIMPLEX1 

Synonyms. — Herpes,  Fever  blisters;  Fr.,  Herpes  vulgaire;  Ger.,  Blaschenflechte. 

Definition. — An  acute  inflammatory  affection  characterized  by 
the  formation  of  pin-head-  to  small  pea-sized  vesicles,  grouped,  and 
occurring  about  the  face  or  genitalia. 

Symptoms.— The  eruption  is  commonly  foreshadowed  by  a  feel- 
ing of  heat  and  burning  in  the  part.  It  generally  consists  of  but  one 
or  two  groups,  which  may  be  small  or  large;  or  several  or  more  clusters 
may  present.  The  vesicles,  which  are  usually  seated  upon  a  hyper- 
emic  or  mildly  inflammatory  base,  are  pin-head  or  slightly  larger  in  size, 
often  crowded  close  together  so  that  sometimes  it  may  be  somewhat 
difficult  to  make  out  their  individuality;  this  is  especially  so  on  the  lips, 
but  on  other  parts  of  the  face  the  lesions,  while  grouped,  are  quite  clearly 
discrete.  They  are  distinctly  vesicular,  with  clear  contents,  subsequently 

1  Knowles,  "Herpes  Simplex,"  New  York  Med.  Jour.,  Aug.  7,  1909  (full  review  of 
the  subject). 


344 


INFLAMMA  TIONS 


becoming  more  or  less  milky,  and  may  exceptionally  change  to  a  seropuru- 
lent  or  purulent  character.  They  show  no  tendency  to  spontaneous 
rupture,  but  should  they  be  broken  open,  a  superficial  abrasion  or  excori- 
ation results,  crusts  over,  the  crust  subsequently  falling  off.  As  a  rule, 
however,  they  remain  unbroken  throughout,  and  gradually  dry  to  thin 
crusts  of  a  yellowish  or  brownish  color,  which  finally  drop  off  and  leave 
no  trace.  In  some  cases  in  which  the  lesions  may  be  few  and  the  conse- 
quent group  small  and  insignificant,  the  contents  may  be  reabsorbed,  and 
the  disease  be  shortened  or  aborted.  There  are,  as  a  rule,  no  systemic 
disturbances;  never  in  the  cases  in  which  the  eruption  is  upon  the 
genitalia,  probably  for  the  reason  that  it  is  always  scanty;  on  the  face, 
when  the  eruption  is  somewhat  extensive,  there  may  be,  in  severe  cases, 
more  or  less  malaise,  pyrexia,  and  chilliness  preceding  and  accompanying 
the  early  part  of  the  outbreak. 


Fig.  81. — Herpes  simplex  of  somewhat  extensive  development  in  a  girl  of  ten  years, 
of  four  days'  duration.  Outbreak  preceded  by  slight,  evanescent  febrile  action.  Char- 
acteristic grouping  and  coalescence;  crusting  stage  already  reached  on  the  lips. 


While  the  facial  and  progenital  region  are  the  usual  seats  of  herpes 
simplex,  yet  instances  are  not  rare  in  which  the  eruption  (usually  a 
single  patch)  occurs  on  other  parts.  In  occasional  instances  there  is  not 
only  a  tendency  to  recurrence,  but  to  recurrence  on  the  same  spot;1 
the  lips,  chin,  cheek,  and  buttock  are  favorite  localities  for  this  recurrent 
type.  I  have  seen  several  children  in  whom  a  patch  had  so  presented  on 
the  cheek  once  or  twice  yearly  for  several  years  or  more. 

Herpes  Facialis. — The  herpetic  clusters — one  or  several — may  be 
limited  to  the  lips  (herpes  labialis) ;  or  appear  on  the  skin  near  the  mouth, 
chin,  under  or  near  the  ala  of  the  nose,  or  on  the  cheek,  or  elsewhere 

1  Dubreuilh,  "De  1'herpes  recidivant  de  la  face  chez  les  enfants,"  Jour,  de  Med.  de 
Bordeaux,"  Aug.  n,  1907,  records  several  such  instances  and  refers  to  several  other 
papers  of  his  own  and  others  recording  cases  in  which  the  recurrence  was  in  the  same 
place;  Adamson,  Brit.  Jour.  Derm.,  1909,  p.  321,  records  4  cases  of  a  patch  of  herpes 
recurring  on  the  fingers,  in  2  of  which  had  been  previous  attacks  in  the  same  place; 
and  adds  to  these  and  reviews  subject,  with  bibliography,  ibid.,  1911,  p.  322,  "Recur- 
rent Herpes  of  the  Buttocks." 


HERPES  SIMPLEX 


345 


on  the  face.  Occasionally  the  seat  of  the  patch  or  patches  is  the  ear, 
commonly  the  auricle.  When  on  other  parts  than  the  lips  or  mucous 
membrane,  the  eruption  is  occasionally  quite  abundant.  The  skin  is 
hyperemic  or  slightly  inflamed.  The  malady  is  also  seen  in  the  mouth, 
and  shows  two,  several,  or  more  vesicular  lesions  crowded  close  together. 
At  first  small,  the  lesions  often  increase  in  the  course  of  some  hours  or 
one  or  two  days  to  the  size  of  a  small  French  pea.  There  is  heat  or  burn- 
ing and,  rarely,  itching. 

After  several  days,  or  earlier  in  slight  cases,  they  begin  to  dry  up, 
and  form  a  thin  crust,  which  in  the  course  of  two  or  three  days  drops 
off.  Sometimes  one  or  two  of  the  vesicles  are  broken  and  the  patch 
is  then  excoriated  at  these  points,  serum  oozes  out,  which  dries  to  a 
thin  yellowish  crust.  In  some  instances,  especially  on  other  parts 
than  the  lips,  the  lesions  may  coalesce  and  form  a  small  bleb;  as  a  rule, 
however,  this  does  not  take  place.  Unless  irritated,  the  crust  formed 
drops  off  in  from  several  to  ten  days  after  the  disease  has  first  presented. 
When  near  or  at  an  angle  of  the  mouth,  from  the  act  of  opening  and 
shutting  the  mouth,  slight  fissuring  is  sometimes  noticed,  and  the  con- 
stant irritation  of  the  food  and  saliva  may  keep  the  part  macerated  and 
sore  for  one  or  two  weeks  or  longer.  In  some  instances  of  considerable 
eruption  slight  febrile  action  precedes.  A  form  of  "herpetic  fever"  has 
been  recorded  from  time  to  time,  occurring  epidemically  (Savage,  Sea- 
ton)  /  usually  preceded  by  a  rigor  or  distinct  chill  and  other  symptoms 
of  general  disturbance;  the  outbreak  is  generally  limited  to  the  lips  and 
region  of  the  mouth,  in  some  cases  involving  also  the  ears. 

Herpes  Progenitalis. — Herpes  about  the  glans  and  prepuce  in  the 
male,  and  the  vulva  in  the  female,  is  also  not  uncommon.  It  may 
consist  variously  of  one  or  several  groups,  but  it  is  rarely  seen  in  such 
abundance  as  frequently  observed  on  the  face.  Slight  burning  and  itch- 
ing are  usually  first  noted,  rapidly  followed  by  the  appearance  of  a  slightly 
red,  and  sometimes  a  little  puffy  inflamed  area,  upon  which  are  soon  seen 
several  or  more  minute  vesicular  points,  which  slowly  increase  to  the  size 
of  a  pin-head,  sometimes  larger.  They  dry  up,  or  the  contents  are  ab- 
sorbed; slight  crusting  ensues,  and  the  disease,  under  favorable  circum- 
stances, in  the  course  of  several  days  or  so  disappears.  Or  the  lesions  may 
be  rubbed  or  chafed,  rupturing  taking  place,  giving  rise  to  one  confluent 
excoriated  surface  or  several  excoriated  points;  and  then  the  duration  is 
usually  much  longer,  inasmuch  as  the  surface  is  continually  irritated  by 
the  secretions  and  probably  occasionally  by  the  urine,  and  resulting  in  a 
slight  abrasion  or  even  superficial  ulceration,  which  may  give  rise  to  con- 
fusion with  a  soft  chancre.  The  eruption  may  be  seated  upon  the  outer 
prepuce  or  inner  prepuce  (herpes  praeputialis)  or  the  glans  in  the  male;  and 
on  the  labia  minora  or  labia  majora  in  the  female;  in  the  former,  too,  a 
patch  is  sometimes  observed  further  down  on  the  sheath  of  the  organ,  and 
in  women  just  beyond  the  labia  majora. 

Btiology  and  Pathology.— Herpes  facialis  is  often  observed  in 
association  with  other  diseases,  such  as  colds  (cold  sores),  fevers  (herpes 

1  Savage,  Lancet,  Jan.  20,  1883;  Jour.  Cutan.  Dis.,  1883,  p.  253;  Seaton,  Trans. 
Clin.  Soc.,  London,  1886,  p.  26. 


346  INFLAMMA  TIONS 

febrilis,  fever  sores),  lung  disease,  malaria,  and  digestive  disturbances.1 
In  some  individuals  an  attack  of  indigestion  will  lead  to  an  outbreak. 
Long  exposure  to  the  sun,  more  especially  when  on  the  water,  is  some- 
times provocative.  An  irritable  or  decayed  tooth  seems  in  some  instances 
of  recurrent  cases  the  exciting  factor. 

Herpes  progenitalis  is  believed,  in  the  male  subject  at  least,  to  be 
much  more  common  in  those  who  have  previously  had  some  venereal 
disease  (Greenough,  Diday  and  Doyon,  Fournier,  and  others),2  more 
especially  gonorrhea;  while  this  is  unquestionably  true,  doubtless  this 
apparent  overwhelming  frequency  may,  in  part,  be  explained  by  the 
fact  that  individuals  addicted  to  sexual  indiscretions  are  readily  alarmed 
by  the  appearance  of  any  lesion  on  this  part,  and  thus  come  more  fre- 
quently under  the  eyes  of  the  physician  than  those  who  have  no  reason 
to  be  suspicious.  A  long  prepuce  predisposes  to  it,  and  coitus  is  also 
often  the  exciting  factor;  in  some  instances  an  attack  follows  each  in- 
dulgence. Bergh3  found  that  in  women  an  outbreak  is  concomitant 
with,  precedes,  or  follows  menstruation,  and  that  in  women  it  is  not  a 
"professional"  (prostitute)  disease,  although  Unna's4  experience  does  not 
agree  with  this.  As  to  relative  frequency  in  the  two  sexes,  it  is  the 
general  opinion  that  it  is  much  more  common  in  the  male,  although 
Unna's  and  Bergh's  statistics  do  not  bear  this  out,  the  last  named,  in 
fact,  believing  it  more  common  in  women. 

Herpes  is  certainly  neurotic.  It  is  possible  that  it  may  depend 
upon  reflex  irritation  of  the  neighboring  sympathetic  ganglia,  due  to 
local  or  internal  irritation.  In  fact,  the  disease  is  considered  by  some 
to  be  an  abortive  or  irregular  zoster,  a  view  scarcely  to  be  accepted. 
Kopytowski5  found  considerable  histologic  analogy  between  herpes 
progenitalis  and  zoster. 

Ravaut  and  Darre,6  from  their  experimental  study  of  26  cases  (7 
men,  19  women)  of  lumbar  puncture  in  genital  herpes,  found  that  all 
cases  accompanied  by  any  nerve  symptoms  (as  well  as  many  without 
such  symptoms)  presented  some  modification  in  the  cephalorachidian 

1  E.  F.  Wells,  "Pneumonic  Fever — Its  Symptomatology,"  Jour.  Amer.  Med.  Assoc., 
May  26,  1894;  statistics  of  his  own  cases  and  those  of  others  quoted  show  that  herpes  is 
observed  in  a  large  proportion;  Arthur  Powell,  "Prognostic  Value  of  Herpes  in  Malarial 
Fevers,"   Brit.  Jour.   Derm.,   1897,  p.  354    (always   favorable);    Schamberg,  "The 
Nature  of  Herpes  Simplex  and  the  Diagnostic  and  Prognostic  Significance  in  Various 
Infectious  Diseases,"  Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlviii,  p.  746  (with  refer- 
ences); Rolleston,  "Herpes  Facialis  in  Diphtheria,"  Brit.  Jour.  Derm.,  1907.  p.  375 
(in  4.2  per  cent,  of  his  cases;  with  brief  review  and  references);  Knowles,  "Herpes 
Simplex,"  New  York  Med.  Jour.,  Aug.  7,  1909  (with  bibliography) ;  Rolleston,  "Herpes 
Facialis  in  Scarlet  Fever,"  Brit.  Jour.  Derm.,  1910,  p.  309  (in  6.5  per  cent,  of  his  cases; 
bibliography). 

2  Greenough,  "Herpes  Progenitales,"  Arch.  Derm.,  i88i,p.  i;  Diday  and  Dpyon, 
Les  herpes  genitaux,  Paris,  1886;  Fournier,  Gaz.  med.  de  Paris,  1896,  Jan.  to  May. 

_3  Bergh,  "Ueber  Herpes  menstrualis,"  Monatshefte,  1890,  vol.  x,  p.  i  (a  complete 
review  with  many  references). 

4  Unna,  "Herpes  Progenitalis,  Especially  in  Women,"  Jour.  Cutan.  Dis.,  1883, 
p.  321.  This  paper,  and  the  several  preceding,  all  on  genital  herpes,  are  full  and 
exhaustive  and  give  many  literature  references. 

6  Kopytowski,  Archiv,  1904,  vol.  Ixviii,  pp.  55  and  387  (clinical  and  pathologic 
study  of  24  cases  of  herpes  progenitalis). 

6  Ravaut  and  Darre,  "Les  reactions  nerveuses  au  cours  des  herpes  genitaux," 
Annales,  1904,  p.  480. 


HERPES  SIMPLEX 


347 


fluid— numerous  cell  elements  (lymphocytes);  they  consider  their  re- 
search is  strong  evidence  that  the  central  nervous  system  plays  an 
important  role  in  genital  herpes.  A  microbic  origin  has  also  been  sus- 
pected in  herpes,  but,  while  possible,  it  does  not  seem  probable. 

Diagnosis. — Herpes  facialis  is,  as  a  rule,  readily  recognized,  espe- 
cially when  on  the  lip.  On  neighboring  skin  there  is  also  rarely  any 
difficulty.  It  can  scarcely  be  confused  with  vesicular  eczema,  as  this 
latter  disease  is  made  up  of  closely  crowded  small  vesicles,  which  tend 
to  coalesce,  but  with  no  tendency  to  form  distinct  groups;  is  slow, 
as  a  rule,  in  its  appearance,  usually  presents  some  inflammatory  thick- 
ening, the  vesicles  are  smaller  and  rupture  spontaneously  and  give 
rise  to  gummy  exudation.  The  crusted  patch  of  herpes  and  that  of 
impetigo  often  look  closely  alike,  but  the  scattered  patches  of  impetigo 
and  the  history  of  its  appearance  and  course  are  distinctive;  moreover, 
impetigo  rarely  is  seen  on  the  lip;  herpes,  commonly. 

Herpes  of  the  genitalia  presents  similar  features  to  that  of  the  face; 
the  presence  of  several  or  more  small  vesicles  on  a  red  or  inflamed  base 
scarcely  permits  of  error.  When  abraded  and  irritated  by  the  moisture 
or  secretions  of  the  part,  or  cauterized  by  some  overzealous  physician, 
there  is  sometimes  great  difficulty  to  distinguish  it  from  a  soft  sore  and 
possibly  from  hard  chancre.  The  absence  of  glandular  enlargement  in 
herpes  or,  at  the  most,  of  slight  transitory  swelling  is  a  differential  point 
of  value.  Chancroids  are  usually  multiple,  with  distinct  ulceration. 
In  doubtful  cases,  when  a  hurried  opinion  is  necessary,  auto-inoculation 
experiments  can  be  made.  Ordinarily  the  beginning  induration  of  a 
syphilitic  chancre  will  serve  to  differentiate,  together  with  the  history  of 
its  appearance.  In  some  instances  it  must  be  acknowledged  it  is  not 
possible  to  give  a  definite  opinion  at  once,  but  the  application  of  the 
appropriate  treatment  for  herpes  will  soon  heal  this  disease,  whereas  much 
time  is  necessary  for  both  chancroid  or  chancre  to  bring  about  such  result ; 
for  the  latter  an  examination  for  spirochaetae  would  settle  the  matter.; 

Prognosis  and  Treatment. — The  disease,  both  on  face  and 
genitalia,  soon  subsides,  usually  in  five  to  ten  days,  but  there  is  often  a 
distinct  tendency  to  recurrence,  more  especially  in  herpes  progenitalis. 
Herpes  labialis  in  fevers,  lung  disease,  etc.,  is  not  now  thought  to  be  of 
any  prognostic  importance. 

Ordinary  herpes  occurring  about  the  lips  or  other  parts  of  the  face 
rarely  requires  more  than  external  applications;  in  persistent  and  oft- 
recurring  cases,  however,  the  general  health  of  the  patient  must  be  looked 
after,  special  attention  being  given  to  the  state  of  the  digestive  tract  and 
to  possible  malarial  conditions.  Ordinarily  the  application,  several  times 
daily,  of  spirits  of  camphor,  cologne-water,  a  lotion  of  zinc  sulphate,  from 
i  to  5  grains  (0.065^.33)  to  the  ounce  (32.)  of  water  or  water  and  alco- 
hol, will  be  sufficient  to  bring  about  a  disappearance  of  the  lesions;  the 
first  two  named,  if  frequently  applied  in  the  earliest  stage,  will  occasionally 
abort  the  outbreaks,  more  particularly  the  spirits  of  camphor.  Painting 
over  the  affected  part  tincture  of  benzoin  is  also  useful,  and  it  is  especially 
valuable  when  the  lesions  are  seated  at  the  mouth  angle,  showing  a 
tendency  to  fissuring;  the  mouth  is  slowly  and  carefully  opened  as  widely 


348  INFLAMMA  T1ONS 

as  possible,  and  the  benzoin  tincture  painted  over  two  or  three  times,  and 
allowed  to  dry,  while  the  mouth  remains  open ;  it  is  repeated  two  or  three 
times  daily.  When  the  crusting  stage  is  reached,  ointments,  such  as 
cold  cream,  camphor  ice,  etc.,  can  be  used,  the  crusts  usually  separating 
more  quickly  under  such  applications. 

Occurring  about  the  genitalia,  the  treatment  is  somewhat  different. 
Cleanliness  is'  of  the  first  importance,  not  only  in  promoting  the  dis- 
appearance of  an  attack,  but  in  preventing  new  outbreaks;  the  parts 
should  be  gently  washed  two  or  three  times  daily.  Various  powders 
are  useful  here,  such  as  boric  acid,  alone  or  with  from  i  to  5  grains 
(0.065-0.33)  of  zinc  sulphate  to  the  ounce  (32.);  or  zinc  oxid,  with  or 
without  from  5  to  10  per  cent,  of  calomel.  Lotions  are  also  valuable,  the 
most  efficient  being  a  saturated  solution  of  boric  acid,  and  one  containing 
from  5  to  10  grains  (0.33-0.65)  each  of  calamin  and  zinc  oxid  and  from 
\  to  i  dram  (2. -4.)  of  alcohol  in  each  ounce  (32.)  of  saturated  solution 
of  boric  acid.  A  layer  of  lint  or  borated  cotton  should  be  placed  over  the 
part. 

In  obstinate  and  recurring  genital  cases  daily  applications  of  the  gal- 
vanic current  will  prove  of  value;  the  positive  electrode  is  placed  over 
the  lower  lumbar  region,  and  the  negative  over  the  affected  part,  the 
current  being  mild — \  to  2  milliamperes.  A  mustard  plaster  over  the 
lower  spine,  daily  or  every  few  days,  is  sometimes  useful  in  this  class 
of  cases.  The  same  may  be  said  of  the  administration  of  arsenic,  both 
in  herpes  facialis  and  herpes  progenitalis.  In  markedly  recurrent  cases 
of  the  latter  in  the  male  circumcision  is  advisable. 


HERPES  ZOSTER 

Synonyms. — Zona;  Zoster;  Shingles;  Ignis  sacer;  Fr.,  Zpna;  Ger.,  Giirtelaus- 
schlag;  Feuergiirtel. 

Definition. — An  acute  inflammatory  self-limited  disease,  char- 
acterized by  the  appearance  of  several  or  more  groups  of  vesicles  on 
slightly  elevated  and  inflamed  areas,  of  unilateral  distribution,  and 
corresponding  to  the  peripheral  and  intertwining  branches  of  one  or 
two  cutaneous  nerves. 

Symptoms. — In  many  instances  there  is  more  or  less  neuralgic 
pain  in  the  region  for  one  or  several  days  preceding  the  cutaneous  lesions. 
This  may  continue  through  the  course  of  the  disease,  being  continuous 
or  intermittent  in  character,  or  it  may  abate  when  the  eruption  is  fully 
out.  In  other  cases  the  outbreak  of  the  vesicles  and  neuralgic  pains  are 
synchronous.  Not  infrequently  the  pain  may  be  so  slight  as  to  give  rise 
to  no  complaint,  or  sometimes  it  is  entirely  absent;  this  is  observed  more 
especially  in  children  (Bohn) .  In  some  of  the  more  extensive  cases  there 
may  be,  in  the  beginning,  mild  febrile  action,  chilliness,  and  a  variable 
degree  of  malaise.  Swelling  of  the  neighboring,  and  occasionally  other, 
lymphatic  glands  is  frequently,  and  probably  always,  noted  (Barthelemy, 
Strumpfell,  Blaschko,  Winfield,  Hay,  and  others).1  The  eruption 

1  Barthelemy,  Annales,  1891,  p.  21,  and  1892,  p.  168. 


HERPES  ZOSTER 


349 


makes  its  appearance  suddenly,  usually  as  several  or  more  hyperemic 
or  slightly  inflammatory  patches,  upon  which  are  seated  usually  10 
to  20  papules  or  vesicopapules,  irregularly  grouped;  these,  generally 
before  the  cases  is  seen  by  the  physician,  soon  become  clearly  denned 
vesicles,  of  the  size  varying  from  a  pin-head  to  a  pea;  two  or  three  closely 
crowded  together  sometimes  become  confluent,  and  form  a  bean-sized 
bleb.  They  show  no  tendency  to  spontaneous  rupture.  New  vesicles 
and  patches  may  come  out  for  several  days  or  longer,  although  in  most 
cases  all  the  patches  are  concomitant  or  are  out  within  forty-eight  hours. 
The  disease  reaches  its  full  development  in  five  to  ten  days,  and  then  be- 


Fig.  82. — Herpes  zoster  (dorsopectoralis) ,  left  pectoral  region,  in  a  youth  of  sixteen, 
of  about  one  week's  duration.  The  grouping  and  cluster  tendency  are  shown;  a  few 
lesions  in  the  patch  on  the  side  slightly  hemorrhagic.  There  were  also  a  few  groups  on 
the  same  level  posteriorly. 


gins  to  subside.  The  contents  of  the  lesion  are  clear,  becoming  slightly 
milky,  and  rarely  puriform;  at  the  end  of  one  to  two  weeks  they  have 
dried  to  thin,  yellowish  or  brownish  crusts,  which  in  several  days  drop 
off,  leaving  red  spots,  which  gradually  fade,  in  most  instances  no  perma- 
nent trace  remaining.  Sometimes,  however,  there  may  be  a  variable 
amount  of  scarring  left  to  mark  the  site  of  the  vesicles.  Occasionally 
the  eruption  does  not  go  beyond  the  vesicopapular  stage  (abortive  zoster). 
In  some  cases,  more  especially  in  old  people  and  in  those  in  a  depraved 
condition  of  health,  the  lesions,  or  some  of  them  are  hemorrhagic  (herpes 
zoster  haemorrhagicus),  and  contain  an  admixture  of  blood  and  pus; 
in  other  exceptional  instances  there  is  a  slight  or  marked  degree  of  gan- 


350 

grenous  action  (herpes  zoster  gangrasnosus),1  and  several  such  gangrenous 
vesicles  may  coalesce,  producing  areas  of  ulceration,  usually  superficial 
in  character,  but  which  may  finally  result  in  considerable  scarring.  In 
this  latter  class  of  cases,  especially,  there  is,  as  a  rule,  more  or  less  con- 
stitutional disturbance  of  fever,  loss  of  appetite,  nausea,  and  chilliness, 
and  in  rare  instances  the  patient  becomes  septicemic  and  succumbs. 
Exceptionally  lymphangitis,  furuncles,  carbuncles,  and  phlegmon  have 
been  noted  as  complications  (Besnier  and  Doyon,  von  During). 

There  is  frequently  a  sense  of  soreness  or  burning  at  the  seat  of  the 
malady,  and  exceptionally  itching.  The  neuralgic  pain  may  in  some  in- 
stances continue  long  after  the  complete  disappearance  of  the  lesions. 


Fig.  83. — Herpes  zoster  (dorsopectoralis)  of  right  pectoral  region,  in  a  male  adult, 
of  about  five  days'  duration,  showing  the  erythematous  plaques  with  the  numerous  vesi- 
cles, some  coalescent.  A  few  patches  also  anteriorly  (courtesy  of  Dr.  M.  B.  Hartzell). 

The  eruption  may  appear  upon  any  portion  of  the  body,  following  the 
course  of  a  nerve  or  of  two  or  more  nerves;  it  is,  therefore,  always  limited 
in  extent,  in  some  cases,  however,  much  more  extensive  than  in  others; 
exceptionally,  however,  it  has  been  noted  to  involve  a  greater  part 
(Wetherill)  or  the  entire  half  of  the  trunk  (Wilson),  several  or  more  nerves 
being  implicated.  In  slight  cases,  on  the  other  hand,  there  may  not  be 
more  than  two  or  three  small  groups.  With  rare  exceptions  the  eruption 
is  unilateral,  with,  in  rare  instances,  a  few  lesions  seen  at  a  distance  from 
the  seat  of  the  disease  (Jamieson,  Girandeau,  Jeanselme,  and  Leredde). 

1  Baum,  "Herpes  Zoster  Gangraenosus,"  Medicine,  1895,  P-  I  (with  colored  plate), 
describes  a  case,  and  refers  briefly  to  Kaposi's  and  other  similar  instances. 


PLATE  XL 


HERPES  ZOSTER 


351 


Sometimes  one  or  two  groups  are  seen  just  beyond  or  overstepping  the 
median  line.  Exceptionally  it  is  bilateral  (Moers,  Bryant,  Squire, 
Stabell,  Finny,  Elliot,  Carpenter,  Hallopeau  et  Barrie,  Colcott  Fox' 
and  others),1  and  usually  on  the  same  plane,  but  cases  have  also  been 
observed  when  the  eruption  on  one  side  (usually  chest  or  abdomen)  was 
higher  or  lower  than  that  on  the  other.  These  exceptions  to  the  unilateral 
distribution  are,  however,  extremely  rare,  many  observers,  including  my- 
self, of  large  clinical  opportunities  never  having  met  with  a  single  instance. 

In  very  rare  instances,  in  addition  to  the  characteristic  unilateral 
zoster  eruption  of  a  region,  there  appear  along  with  it  discrete  and 
scattered,  small  to  large  pea-sized,  vesicles  over  the  general  surface, 
usually  somewhat  scanty  in  number.2 

The  most  common  sites  for  herpes  zoster  are  the  thoracic,  lumbar, 
and  supra-orbital  regions.  Various  regional  names  are  given  to  the 
malady,  simply  to  indicate  the  locality  on  which  the  eruption  occurs. 
The  principal  of  these  are  zoster  capillitti,  zoster  faciei,  zoster  ophthal- 
micus,  zoster  frontalis,  zoster  nuchae,  zoster  colli  (seu  cervicalis),  zoster 
brachialis,  zoster  pectoralis,  zoster  abdominalis,  zoster  femoralis,  etc. 

The  general  features,  behavior,  and  course  of  the  eruption  are  the 
same  whatever  the  region  affected.  Zoster  occurring  about  the  head 
and  face  is  to  be  considered  more  serious  in  character.  In  zoster  ophthal- 
micus  disastrous  consequences  sometimes  ensue,  even  to  the  extent 
of  complete  destruction  of  the  eye,  pyemia,  meningitis,  and  death 
(Hutchinson,  Hybord,  Wyss).  In  the  facial  variety  lesions  may  be 
found  within  the  nose  and  mouth,  and  exceptionally  the  eruption  is  limited 
to  these  mucous  membranes  (Fournier,  Ponzin,  Lermoyez,  and  Barozzi). 
In  zoster  frontalis  the  eruption  follows  the  course  of  the  supra-orbital 
nerve,  showing  groups  over  the  brow  from  the  eye  upward  on  to  the  scalp. 
In  facial  and  inframaxillary  zoster  there  may  exceptionally  be  loss  of 
teeth  and  even  necrosis  of  the  jaw  (Paget,  Singer).  In  a  few  of  the  head 
cases  persistent  anesthesia  has  been  noted  (Zeisler),  and  about  the  eye 
and  brow  scarring  is  seen  most  frequently,  but  not  invariably,  as  has  been 
stated  (Thibierge);  the  neuralgic  pain,  preceding,  accompanying,  and 
following,  is  also  apt  to  be  more  marked.  In  zoster  brachialis  (zoster 
cervicobrachialis)  the  eruption  is  often  abundant  and  seated  upon  the 
neck,  shoulder,  and  upper  arm  regions,  and  exceptionally  may  extend 
down  to  the  fingers. 

1  Bilateral  zoster  cases:  Moers,  Deutsches  Archiv  fur  klin.  Medicine,  1867,  vol.  iii, 
p.  163,  and  1868,  vol.  iv,  p.  249;  Bryant,  Medical  Times  and  Gazelle,  1865,  i,  p.  335; 
Squire,  ibid.,  1873,  i,  P-  495!  Stabell,  Tijdskrifl  for  prak.  Medicin,  No.  13,  1884,  ab- 
stract in  Archiv,  1885,  p.  316;  Finny,  Brit.  Med.  Jour.,  1885,  p.  67;  Elliot  (relapsing), 
Jour.  Cutan.  Dis.,  1888,  p.  324;  Carpenter,  Brit.  Jour.  Derm.,  1892,  p.  23;  Hallo- 
peau et  Barrie,  Annales,  1892,  p.  296;  Colcott  Fox,  Brit.  Jour.  Derm.,  1898,  p.  252; 
Varney  and  Tamieson,  Jour.  Amer.  Med.  Assoc.,  July  30,  1910,  p.  372;  Mobley,  ./owr. 
Amer.  Med.  Assoc.,  Sept.  14,  1912,  p.  878  (asymmetric  left  facial  and  postauncular, 
and  right  middle  intercostal  region). 

2 1  have  met  with  two  such  instances,  one  in  association  with  a  supraorbital  zoster 
and  one  with  a  thoracic  zoster.  Fasal,  "Herpes  Zoster  Generalisatus,  Arcktv,  1909, 
vol.  xcv,  p.  27,  reports  a  case  of  supra-orbital  zoster  with  this  associated  generalized 
chicken-pox-like  eruption;  he  also  refers  to  cases  seen  by  Haslund,  Beyer  Colombims, 
Ehrmann,  Ullmann,  and  Weidenfeld;  Schamberg,  Jour.  Amer  Med.  Assoc.,  1910, 
liv,  No.  7,  also  records  a  case  (man  aged  sixty-eight)  of  zoster  of  left  scapular  regio 
with  generalized  herpes. 


352 


INFLAMMA  TIONS 


The  nervous  disturbances  in  zoster  are  usually  sensory,  consisting  of 
pain  of  varying  degree,  but  this  is  not  always  present.  Motor  involve- 
ment1— paralysis,  atrophy — has  also  been  occasionally  noted,  and  this 
more  especially  with  zoster  of  the  facial  regions  (Hunde,  Wangler,  Lesser, 
Tryde,  Greenough,  Striibung,  Porzig,  Ebstein,  Eichorst,  Eulenberg, 
Vernon,  Tay,  Voight,  Besnier,  Truffi,  and  others),  but  it  has  also  occurred 


Fig.  84. — Herpes  zoster  (cervicobrachialis) ,  in  a  young  man  aged  about  twenty-five, 
involving  neck,  shoulders,  and  upper  part  of  the  arms,  of  eight  days'  duration.  The 
vesicles  are  small  and  numerous,  some  not  going  beyond  the  papulovesicular  stage,  and 
closely  grouped  and  coalescent;  some  hemorrhagic. 

in  zoster  of  the  extremities,  especially  the  upper  (Schwimmer,  Gibney, 
Broadbent,  Joffroy,  Weiss,  and  others),  and  in  connection  with  truncal 
zoster;  exceptionally  hemiplegia,  paralysis  of  bladder,  etc.,  have  been 
noted  (Duncan,  Davidsohn). 

Btiology.2 — Herpes  zoster  occurs  at  all  ages  and  in  both  sexes,  but 

1  Striibung's    paper,    "Herpes    Zoster    und    Lahmungen    motorischen    Nerven," 
Deutsches  Archiv  fur  klin.  Medicin,  1885,  vol.  xxxvii,  p.  513,  refers  to  most  cases  pub- 
lished up  to  that  date;  Ebstein,  "Zur  Lehre  von  den  nervosen  Storungen  beim  Herpes 
Zoster  mit  besonderer  Beriicksichtigung  der  dabei  auftretenden  Facialslahmungen," 
Virchow's  Archiv,  1895,  vol.  cxxxix,  p.  505,  also  gives  review  of  the  subject  and  litera- 
ture references;  Hunt,  Jour.  Amer.  Med.  Assoc.,  1900,  vol.  liii,  p.  1456,  gives  a  short 
preliminary  analytic  note  of  158  collated  cases. 

2  Clinical  analyses  bearing  upon  frequency,  etiologic  factors,  regions  involved,  etc.; 
Greenough  (255  cases),  Boston  Med.  and  Surg.  Jour.,  Oct.  5,  1889 — abstract  in  Jour. 
Cutan.  Dis.,  1889,  p.  426;  Cantrell  (193  cases — observed  in  services  of  Duhring,  Van 
Harlingen,  Stelwagon,  and  Cantrell),  Philada.  Med.  Jour.,  March  26,  1898.     Of  the  62 
zoster  pectoralis  cases  in  CantrelFs  analysis,  58  were  in  males.     Max  Joseph,  ibid., 
1902,  vol.  x,  p.  597;  W.  Pick,  Prag.  med.  Wochenschr.,  1904,  p.  219.     Among  the 


HERPES  ZOSTER 


353 


is  much  more  common  in  males.  It  is  probably  most  frequent  between 
the  ages  of  eight  and  thirty  and  not  at  all  uncommon  after  forty;  it  is 
only  exceptionally  observed  in  early  infantile  life.  It  is  not  an  uncom- 
mon disease,  constituting  about  i  to  1.5  per  cent,  of  all  skin  cases.  It 
seems  much  more  frequent  during  spring  and  late  autumn  and  winter, 
and  especially  during  damp,  changeable  weather.  Many  causes  are 
given  by  different  observers  for  the  production  of  this  disease;  among 
the  most  important  may  be  mentioned  atmospheric  changes,  exposure 
to  cold  and  wet,  sudden  checking  of  perspiration,  traumatism,  peripheral 
nerve  irritation  or  injuries  (Weir  Mitchell,  Keen,  Picaud,  Janin,  Bulkley, 
Liveing,  Kobner,  Teuton1),  pulmonary  disease  (Leudet,  Leroux),  in- 
testinal parasites  (Duryee),  malaria  (Colombini,  Winfield2),  carbonic 
acid  gas  poisoning  (Leudet,  Sattler),  and  the  administration  of  arsenic 
(Hutchinson,  Dutworth,  Gerhardt,  Crocker,  Zeisler,  Nielsen,  O'Donovan, 
and  many  others).3  I  have  myself  met  with  several  instances  of  its 
arsenical  production.  It  may  also  doubtless  arise  from  reflex  irritation, 
from  functional  or  organic  disease  of  other  organs  (Bulkley,  Jewell). 
In  recent  years  there  has  been  a  growing  belief  that  the  disease,  some- 
times at  least,  is  of  infectious  origin,  which  I  believe  must  be  accepted 
as  probable. 

Pathology. — The  pathology  of  this  disease  has  received  consid- 
erable study  (Baerensprung,  Kaposi,  Haight,  Robinson,  Danielssen, 
Weidner,  Wyss,  and  others).  The  conclusions,  in  the  main,  are  that 
the  disease  is  usually  a  descending  acute  neuritis,  provoked  by  various 
causes,  and  that  the  process  has  its  beginning  most  frequently  in  the 
ganglionic  system — in  the  cervical  or  spinal  ganglia — finally  reaching 
the  terminal  branches  with  a  production  of  the  cutaneous  phenomena. 

valuable  papers  on  etiology,  of  recent  date,  must  be  mentioned  that  by  W.  G.  Hay, 
Jour.  Cutan.  Dis.,  1898,  p.  i  (with  good  bibliography);  Van  Harlingen  (etiology  and 
nature),  Amer.  Jour.  Med.  Sci.,  1902,  vol.  cxxiii,  p.  141;  Head,  Clifford  Allbutt's  Sys- 
tem  of  Medicine,  vol.  viii;  Evans,  Brit.  Jour.  Derm.,  1905,  p.  198;  Knowles,  "Herpes 
Zoster;  A  Report  of  286  Cases,  with  a  Review  of  the  Unusual  Features  of  the  Disease," 
Penna.  Med.  Jour.,  May,  1912  (with  references);  males  205  in  286  cases,  52  cases  be- 
tween ages  of  twenty  to  thirty,  3  cases  under  the  age  of  one,  the  youngest  in  a  male 
aged  four  months;  the  most  cases  (34)  occurred  in  August,  the  smallest  number 
(13)  in  December,  and  80  of  the  cases  were  observed  in  three  summer  months. 

1  Weir  Mitchell,  Injuries  of  the  Nerves  and  their  Consequences,  Philadelphia,  1872; 
Picaud,  Des  eruptions  cutanees  consecutives  aux  lesions  traumatiques ,  Paris,  1875. 

2  Winfield's  investigations,  New  York  Med.  Jour.,  1902,  vol.  Ixxvi,  p.  191  (33  cases), 
indicate  that  40  per  cent,  of  cases  show  malarial  plasmodia  in  the  blood;  the  literature  is 
reviewed 

3  Nielsen,  "Ueber  das  Auftreten  von  Herpes  Zoster  wahrend  Arsenikbehandlung," 
Monatshefte,  1890,  vol.  xi,  p.  302;  abbreviated  translation  in  Sydenham  Soc'y's  Selected 
Monographs  on  Dermatology,  London,  1893,  p.  167.     The  writer  gives  10  cases  of 
his  own,  and  references  of  other  cases.     The  paper  is  valuable  as  proving  conclu- 
oiiraUr  fV.ot  .,,-,  ,.IM',.  ^OT.  r^iv-v/^ii^o  -»r>ctor-  in  f  f  i  ncnri  a  si  5  rasps  takinET  arsenic,  10  cases  ot 


sively  that  arsenic  can  produce  zoster;  in  557  psoriasis  cases  taking  arsenic,  10  cases 


blaschenformige,    gruppenweise    Hautausschlage    nach    Arsenvergiftung,      Chante- 
Annalen,  Berlin,  19,  Jahrgang,  1894;  Sequeira,  Brit.  Jour.  Children  s  Dis.,  Apnl,  1904, 
records  an  attack  of  zoster  associated  with  a  generalized  bullous  eruption,  except  I 
face  and  extremities,  from  prolonged  administration  of  arsenic;  the  zoster  was  in  the 
lumbar  region  corresponding  to  Head's  first  lumbar  area  on  the  right  side,     bee  also 
Zeisler's  paper  ("Zoster  Arsenicalis,"  Jour.  Cutan.  Dis.,  1907,  P-  5^5,  with  ref(         esj, 
reporting  n  cases. 
23 


354  INFLAMMATIONS 

Investigations  (Mackenzie,  Head)1  point  to  a  relationship  between  the 
tender  areas  of  visceral  disease  and  the  eruptive  patches  of  zoster,  the 
pain  fibers  of  the  skin  and  viscera  being  in  close  connection  or  associa- 
tion.2 Clinical  observation  shows  that  the  eruption  does  not  always  fol- 
low the  distribution  of  one  nerve,  nor  even  that  of  interbranching  nerves, 
and  sometimes  the  eruption  lightly  overlaps  the  median  line;  this  is 
doubtless  due,  as  J.  Mackenzie's  investigations,3  and  also  those  of  Head 
and  Campbell,4  show,  to  some  interlocking  of  nerve-fibers  at  their  origin. 
In  most  cases  of  zoster  the  ganglia  usually  show  softening,  enlarge- 
ment, and  inflammation,  and  the  nerves  are  inflamed  and  thickened. 
In  the  traumatic  and  also  in  other  instances  the  ganglia  are  not  involved, 
the  peripheral  nerves  alone  being  the  seat  of  pathologic  changes  (Charcot, 
Weir  Mitchell,  Pitres  and  Vaillard,  Curschmann  and  Eisenlohr).  It  is 
probable,  I  think,  that  future  observations  and  investigations  will  show 
that  many  of  the  zoster-like  eruptions,  among  which  are  probably  to  be 
placed  the  recurrent  cases,  are  not  examples  of  true  zoster,  as  already 
pointedly  suggested  by  Grindon,  Hartzell,  Duhring,  Hay,  and  others,  but 
that  if  those  due  to  traumatism  and  other  mechanical  irritative  causes  are 
eliminated,  there  will  remain  the  clear-cut  typical  cases  representing  a 
systemic  disease  of  infectious  origin.  Numerous  examples  and  clinical 
grounds  support  this  view  (Rohe,  Erb,  Jamieson,  Landouzy,  Earth, 
Walther),  and  it  receives  further  strength  from  the  fact  that  the  disease 
occasionally  is  observed  in  epidemic  form  (Neligan,  Gauthier,  Kaposi, 
Weis,  Blaschko).5  The  fact  that  zoster  occurs  but  once  in  a  lifetime,  the 

1  Mackenzie,  Med.  Chronicle,  1892,  vol.  xvi,  p.  293;  Head,  Brain,  parts  i  and  \\f 
1893,  vol.  xvi,  p.  129,  and  (Herpes  Zoster)  Cliff ord-Allbutt,  System  of  Medicine. 

2  Curtin,  "Herpes  Zoster  and  Its  Relation  to  Internal  Inflammation  and  Diseases, 
Especially  of  the  Serous  Membranes,"  Amer.  Jour.  Med.  Sci.,  1902,  cxciii,  p.  264, 
reports  cases  having  a  clinical  bearing  on  this  point;  10  cases  associated  with  various 
diseases,  as  pleuritis,  peritonitis,  Bright's  disease,  appendicitis,  and  esophageal  cancer. 
In  this  connection  it  is  interesting  to  note  that  Riehl,  Miinch.  med.  Wochenschr.,  1904, 
p.  1 105,  states  that  in  481  cases  of  croupous  pneumonia  in  the  Munich  Hospital  in  from 
30  to  40  per  cent,  herpes  zoster  occurred,  generally  appearing  on  the  third  or  fourth 
day,  and  most  commonly  in  the  areas  supplied  with  the  second  and  third  divisions  of 
the  trigeminus,  especially  that  supplied  by  the  infra-orbital  nerve;  it  had  no  prognostic 
significance;  and  it  is  scarcely  ever  encountered  in  the  pneumonia  of  children  and  old 
people;  see  also  paper  on  similar  subject  by  Howard,  Amer.  Jour.  Med.  Sci.,  1903,  vol. 
cxxv,  p.  256. 

3  James  Mackenzie,  "Herpes  Zoster  and  the  Limb  Plexuses  of  Nerves,"  Jour,  of 
Path,  and  Bacterial,  1893,  vol.  i,  p.  332. 

4  Head  and  Campbell,  The  Pathology  of  Herpes  Zoster  and  Its  Bearing  on  Sensory 
Localization,  Brain,  1900,  vol.  xxiii,  p.  333  (with  illustrations). 

6  Some  literature  bearing  upon  its  infectious  and  epidemic  character:  Walther,  Allg. 
med.  Central-Zeitung,  1878,  vol.  xlvii,  p.  394,  an  observation  of  12  to  15  cases  (all 
students)  in  three  months — no  other  cases  in  a  period  of  nine  months;  in  one  series 
especially  reported,  a  student,  after  having  had  an  attack,  moved  from  his  dwelling; 
another  later  moving  in  developed  the  disease;  circumstances  requiring  this  student  to 
leave,  the  next  student  taking  the  same  quarters  shortly  after  presented  an  outbreak. 
Kaposi,  Wien.  med.  Wochenshr.,  1889,  PP-  902  and  1002  (an  epidemic  of  40  cases); 
Weis,  Archiv,  1890,  vol.  xxii,  p.  609  (epidemic  of  15  cases  and  some  literature  refer- 
ences); Erb,  Neurologisches  Centralblatt,  1882,  vol.  i,  p.  529  (2  instances  in  which 
mother  and  daughter  developed  the  disease  at  about  the  same  time) ;  Pfeiffer,  Die  Ver- 
breitung  des  Herpes  Zoster  langs  der  Hantgebiete  der  Arteries,  Jena,  1889  (based  upon  117 
cases);  also  refers  to  its  epidemic  and  infectious  character,  and  refers  to  cases;  Barth, 
Union  medicate,  1883,  vol.  xxxvi,  p.  809;  Rohe,  Arch.  Derm.,  1877,  p.  318;  Landouzy, 
Semaine  medicate,  Sept.,  1883;  Hay,  loc.  cit.;  Wasielewski,  Herpes  Zoster  und  dessen 
Einreihung  unter  die  Infections- Krankheiten,  Jena,  1892;  Sachs  (epidemic  in  Breslau, 
69  cases),  Zeitschr., f ur  Heilk.,  1904,  p.  383. 


HERPES  ZOSTER 


355 


usually  associated  adenopathy,  and  not  infrequently  observable  sys- 
temic disturbance,  though  slight,  are,  as  Hay  states,  in  favor  of  the  infec- 
tious character  of  the  disease.  Exceptionally,  it  is  true,  recurrences 
have  been  noted  (Kaposi,  Behrend,  During,  Nieden,  Fernet,  Crocker, 
Hartzell,  Grindon,  and  others),1  but  it  is  not  improbable,  as  Hartzell 
intimates,  that  many  such 
cases  are  of  traumatic  origin. 
It  seems,  indeed,  that  any- 
thing which  may  bring 
about  an  irritable  or  in- 
flamed state  of  the  Gasse- 
rian  ganglion,  spinal  gang- 
lia, nerve-tract,  or  per- 
ipheral branches  may  be 
responsible  for  the  erup- 
tion. 

This  requisite  nerve  irri- 
tation may  also  be  produced 
by  pressure  of  tumors 
(Eisenlohr  and  Cursch- 
mann).  The  disease  has 
also  been  observed  to  occur 
in  myelitis  (Hardy,  Weid- 
ner),  hemiplegia  (Duncan, 
Payne),  and  in  tapes  (West- 
phal,  Bernhardt). 

The  lesions  show  (Biesiadecki,  Haight,  Robinson,  Lesser,  Kopp, 
Lassar,  Hartzell,  Gilchrist,  Unna)  some  differences  from  the  vesicles 
of  other  diseases.  The  process  begins  in  the  lower  rete  layer,  and 
apparently  in  the  papillary  layer,  but  the  inflammatory  involvement 
of  this  latter  is  thought  to  be  secondary.  The  epithelial  cells,  through 
colliquation,  undergo  enlargement, — ballooning  (Unna), — and  finally, 

1  Grindon,  "Recurrent  Zoster,"  Jour.  Cutan.  Dis.,  1895,  PP-  I9I  an(l  252>  gives  an 
admirable  analysis  of  recorded  cases — 61  in  all.  It  shows  that  most  of  such  cases 
cannot  be  considered  as  examples  of  true  zoster;  a  good  bibliography  is  appended. 
Vorner,  "  Uber  wiederauftretenden  Herpes  Zoster,  insbesondere  iiber  Zoster  ery- 
thematosus  und  Zoster  vegetans,"  Munch,  med.  Wochenschr.,  1904,  p.  1734,  reports  3 
cases  of  3  recurrences  in  the  same  region;  nervus  auricularis  magnus;  nervus  frontalis; 
zoster  buccalis.  In  one  instance  the  relapses  were  of  erythematosus  patches  (zoster 
erythematosus  recidivus) ;  and  in  the  case  of  zoster  buccalis  in  one  relapse  the  lesions 
were  of  a  vegetating  character  (zoster  vegetans).  See  also  paper,  "Du  zona  recidivant," 
by  Hirtz  and  Salomon,  Bull,  el  mem.  soc.  d.  Hop.  de  Paris,  1902,  35,  vol.  xix,  p.  206; 
and  Fabre,  "Les  recidives  du  zona,"  Butt.  Acad.  de  med.,  3d  S.,  vol.  xlix,  p.  589,  and 
Bull,  med.,  1903,  vol.  xvii,  p.  376;  Einis,  "Ueber  Herpes  Zoster  recidivus,"  Allg.  med. 
Centr.-Ztg.,  1904,  vol.  Ixxiii,  p.  313;  Duhring  believes  (Cutaneous  Medicine,  part  ii,  p. 
482)  that  these  anomalous,  neurotraumatic  cases  should  be  classed  distinct  from 
zoster,  and  suggests  the  name  "dermatitis  vesiculosa  neurotraumatica,"  an  example 
of  which  he  recently  reported  (Internal.  Med.  Mag.,  March,  1892);  Spitzer,  "Ein  Fall 
von  recidivirendem  Herpes  Zoster  am  Zeigefinger  der  linken  Hand,"  Dermatolog. 
Centralbl.,  1904,  vol.  viii,  p.  74,  reports  a  case  in  point — there  were  5  recurrences  in  a 
year  in  the  district  of  the  musculus  radiobrachialis  on  the  index-finger,  with,  at  the 
same  time,  a  tenderness  of  the  forearm,  with  a  distinct  hyperesthesia  of  the  surface 
corresponding  to  the  ramifications  of  the  radial  nerve;  tactile  pain,  and  thermic  senses 
much  more  intense  than  on  the  sound  side.  Grindon  (supplementary  paper),  Jour. 
Missouri  State  Med.  Assoc.,  1906,  No.  8. 


Fig.  85. — Herpes  zoster;  degenerated  epithe- 
lial, protozoa-like  cells  found  at  the  sides  and  base 
of  vesicle;  one  resembling  a  sporocyst  (courtesy  of 
Dr.  M.  B.  Hartzell). 


356  I  NFL  AM  MA  TIONS 

from  pressure  and  traction,  assume  various  shapes.  Some  of  the  degene- 
rating cells  are  thinned  or  flattened  out,  and  small  cavities  result;  soon 
these  division  walls  break,  and  the  complete  vesicle  is  produced.  The 
base  of  the  lesion  may  be  a  thin  layer  of  the  smaller  ballooned  epithelial 
cells  or  the  papillse,  which  latter  may  project  slightly  into  the  cavity; 
the  roof-wall  is  formed  of  the  corneous  layer,  to  which  may  be  attached 
some  of  the  degenerate  epithelia.  The  contents  of  the  lesion  consist  of 
serum,  epithelial  cells,  and  later  some  or  many  pus-corpuscles,  and,  in  the 
hemorrhagic  cases,  blood-corpuscles.  In  more  especially  these  latter 
cases  the  upper  and  sometimes  the  entire  corium  undergoes  degenerative 
and  destructive  action,  and  ulceration  and  consequent  scarring  result. 
Some  of  the  peculiar  epithelial  cells  found  resemble  protozoa,  but  their 
alleged  parasitic  character  (Pfeiffer)  has  been  disproved,  as  they  have  been 
shown  to  be  degenerated  or  altered  epithelia  (Torok,  Hartzell,  and 
Gilchrist).1 

Diagnosis. — The  usual  features  of  herpes  zoster — the  frequently 
prodromal  or  accompanying  neuralgic  pain,  the  grouped  vesicles  on 
inflammatory  patches  following  the  peripheral  distribution  of  one  or 
two  nerves,  and  exhibiting  no  tendency  to  spontaneous  rupture,  and  the 
limitation  to  one  side  of  the  body — are  quite  characteristic  and  render  the 
diagnosis  a  matter  of  no  difficulty.  On  the  face  it  might  be  confounded 
with  an  extensive  herpes  facialis,  but  in  this  latter  the  one-sided  distri- 
bution of  zoster  is  usually  wanting,  likewise  the  neuralgic  pain;  the  dis- 
tribution on  or  about  the  lips,  common  in  herpes  facialis,  is  infrequent 
in  zoster.  But  it  must  be  confessed  that  occasional  cases  are  encountered 
in  this  region  which  are  somewhat  puzzling  and  which  could  apparently 
be  placed  under  either  head. 

In  those  instances  in  which  there  may  be  but  two  or  three  patches, 
and  in  which  the  lesions  are  small  and  abortive,  scarcely,  if  at  all,  reach- 
ing the  vesicular  stage,  a  slight  resemblance  to  papular  or  vesicopapular 
eczema  is  noted.  Eczema,  however,  rarely  consists  of  distinct  or  such 
sharply  defined  patches  or  areas,  and  is  slow  in  its  advent,  course,  and 
disappearance,  and  the  subjective  symptom  of  troublesome  itching,  al- 
most invariable  in  eczema,  is  usually  wanting  in  zoster.  While  abortive 
zoster  is  abortive  as  regards  the  lesions,  it  possesses  the  other  features  of 
the  disease,  as  named  above.  The  beginning  symptoms — pain  and 
neuralgia — of  zoster  pectoralis  have,  sometimes  been  mistaken  for  incip- 
ient pleurisy,  and  such  error  should,  therefore,  be  guarded  against. 

Prognosis. — This  is  almost  invariably  favorable,  the  symptoms 
usually  disappearing  in  two  to  four  weeks.  In  extensive  cases,  and  in 
those  in  which  new  outcroppings  present  for  several  days  or  more, 
however,  the  duration  is  prolonged  to  one  or  two  months ;  and  in  hemor- 
rhagic and  ulcerative  cases,  especially  in  old  people,  in  whom  these  types 
are  commonly  seen,  while  the  termination  is,  as  a  rule,  favorable,  a  fatal 
ending  through  exhaustion  or  septic  conditions  is  possible.  In  zoster 
involving  the  eye  the  outlook  is  not  always  certain,  as  uselessness  or 

1  Pfeiffer,  Monatshefte,  1887,  vol.  vi,  p.  589;  Torok  (quoted  in  Brooke's  Hamburg 
letter),  Brit.  Jour.  Derm.,  1890,  p.  120;  Hartzell,  Jour.  Cutan.  Dis.,  1894,  p.  369; 
Gilchrist,  Johns  Hopkins  Hospital  Reports,  1896,  vol.  i,  p.  365. 


HERPES  ZOSTER 


357 


destruction  of  this  organ  may  ensue,  and  exceptionally  septic  infection, 
meningitis,  and  death.  The  possibility  of  persistent  neuralgia  or  other 
sensory  and  rarely  motor  disturbances  following  the  eruption  is  to  be 
kept  in  view.  It  is  to  be  said,  however,  that  in  a  large  number  of  the 
cases  observed  the  disease  is  benign,  and  the  patients  go  about  and  suffer 
but  little  inconvenience. 

Treatment. — The  mild  cases  rarely  require  any  constitutional 
treatment.  In  those  more  severe  systemic  remedies  should  always 
be  prescribed,  the  character  of  the  treatment  depending,  for  the  most 
part,  upon  the  indications  presented  by  the  individual  patient.  The 
chief  remedies  prescribed,  independently  of  general  principles,  are  those 
directed  toward  invigorating  the  nervous  system.  Zinc  phosphid,  \ 
grain  (0.013)  (Thomsom,  Bulkley)  every  three  or  four  hours,  seems 
at  times  to  be  of  service.  In  other  cases  large  doses  of  quinin  and 
strychnin  will  be  found  to  be  useful;  arsenic  is  also  thought  to  be  of 
service.  Zinc  phosphid  and  quinin  prescribed  together  has  seemed  to 
me  beneficial  and  a  good  routine  practice.  In  cases  in  which  pain  is 
an  urgent  symptom,  it  may  be  necessary  to  prescribe  potassium  bro- 
mid,  chloral,  sulfonal,  and  even  morphin;  in  extreme  instances  of  this 
character  the  hypodermic  administration  of  the  last-named  drug  will 
be  demanded.  Antipyrin,  phenacetin,  and  acetanilid  may  also  be  used 
for  this  purpose,  and  these  several  drugs,  it  has  been  alleged,  not  only 
relieve  the  pain,  but  may  favorably  influence  the  disease.  Jarisch 
speaks  well  of  the  conjoint  administration  of  7  or  8  grains  (0.465-0.53) 
each  of  antipyrin  and  sodium  salicylate,  three  or  four  times  daily.  Lassar 
commends  highly  full  doses  of  sodium  salicylate. 

External  applications  are  of  importance  in  all  except  the  extremely 
mild  and  abortive  cases;  these  latter  usually  require  but  little,  if  any, 
treatment.  The  lesions  rarely  need  to  be  opened.  As  a  rule,  the  sole 
object  in  view  in  the  use  of  local  applications  is  protection  to  the  parts. 
This  may  be  accomplished  in  mild  or  average  cases  by  the  free  use  of 
a  dusting-powder  of  equal  parts  of  zinc  oxid,  boric  acid,  and  talc,  over 
which  may  be  placed  a  layer  of  cotton  thoroughly  drenched  with  the 
same  powder;  this  is  kept  in  place  by  a  gauze  bandage.  This  is  to  be 
changed  daily  or  every  few  days,  without  disturbing  the  parts  unless 
soiled  or  offensive,  in  which  event  washing  with  saturated  solution  of 
boric  acid  is  advisable;  this  is,  however,  rarely  required.  In  mild  cases 
but  one  or  two  renewals  of  the  dressings  are  necessary.  A  wet  dressing 
of  carbolized  alcohol  (Leloir),  0.5  to  i  per  cent,  strength,  or  one  to  several 
grains  of  menthol  to  the  ounce  of  alcohol,  may  be  used;  this  is  applied 
on  compresses  and  covered  with  gutta-percha  tissue,  and  renewed 
several  times  daily.  In  other  cases  ointments  seem  to  give  the  most  com- 
fort, such  as  zinc  oxid  ointments,  with  i  or  2  drams  (4--8.)  of  starch  to 
the  ounce  (32.),  and  to  which  also  in  painful  cases  may  be  added  from  5 
to  20  grains  (0.32-1.3)  of  opium,  or  from  3  to  10  grains  (0.2-0.66)  of 
menthol  to  each  ounce  (32.).  Such  a  dressing  need  be  changed  but  once 
or,  at  most,  twice  daily.  Fabre  commends,  for  allaying  the  pain,  painting 
over  the  areas  a  mixed  solution  of  i  per  cent,  adrenalin  and  2\  per  cent, 
cocain.  A  valuable  method  of  treatment  consists  in  the  application. 


358  INFLAMMATIONS 

five  to  ten  minutes  daily,  or  twice  daily,  of  a  mild  galvanic  (constant) 
current,  i  to  3  milliamperes,  the  positive  electrode  being  placed  as  near 
as  possible  to  the  main  nerve-supply  of  the  part,  and  the  negative  being 
gently  move  to  and  fro  over  the  diseased  area ;  it  favorably  influences  the 
pain  and  seems  to  modify  the  course  of  the  disease.  For  the  pain  that 
sometimes  follows  in  the  wake  of  the  disease  the  galvanic  current  also 
often  gives  prompt  relief. 

HYDROA  VACONIFORME 

Synonyms. — Recurrent  summer  eruption  (Hutchinson) ;  Hydroa  aestivale. 

Definition. — A  recurrent,  usually  vesicular,  scarring  summer 
eruption,  beginning  in  early  life,  almost  always  in  males,  and,  as  a  rule, 
disappearing  toward  adult  age. 

This  rare  disease1  was  first  clearly  described  by  Bazin,  later  by 
Hutchinson,  Handford,  Jamieson,  Brooke,  Crocker,  Bowen,  White, 
and  others,  and  while  in  some  of  the  reported  cases  there  are  minor 
divergences,  they  all  present  vesicles,  usually  pronounced,  and  with 
central  depression,  but  sometimes  papules  with  slight  vesicular  cap- 
ping, and  are  followed  by  slight  scarring. 

Symptoms. — The  eruption  is  entirely  or  for  the  most  part  on  un- 
covered regions,  especially  the  nose,  cheeks,  and  ears,  although  excep- 
tionally it  may  be  sparsely  scattered  over  the  general  surface.  It  is  in 
almost  all  cases  of  vesicular  nature,  and  an  outbreak  may  be  preceded 
by  arthritic  or  other  systemic  symptoms  of  slight  character.  The 
lesions  often  begin  with  a  preceding  feeling  of  burning  of  the  part,  as 
discrete  or  grouped  red  spots  or  elevations  on  which  a  vesicle  or  small 
bulla  develops;  many  show  a  surrounding  red  areola.  As  a  rule,  subject- 
ive symptoms,  are,  however,  slight  or  entirely  wanting;  rarely  there  may 
be  some  itching.  The  lesions  are  variable  as  to  size,  from  that  of  a  pin- 
head  to  a  pea ;  at  first  with  clear  contents ;  later  milky  and  sometimes  sero- 
purulent.  In  a  number  of  the  vesicles,  and  in  some  cases  in  most  or  all  of 
them,  there  occurs  a  slight  sinking  in  or  umbilication  in  the  central  portion, 
drying  here  to  a  thin  reddish  or  blackish  crust,  while  the  periphery 
consists  of  a  surrounding  wall  of  fluid,  which  may  extend  slightly,  re- 
sembling somewhat  a  small  vaccine  vesicle,  finally  crusting.  Others 

1  Literature:  Bowen,  Jour.  Cutan.  Dis.,  1894,  p.  89  (a  good  review  of  the  subject, 
histologic  examination,  with  cut;  and  with  literature  references  to  cases  of  Bazin,  Hutch- 
inson, Handford,  Jamieson,  Berliner,  Buri,  Broes  van  Dort,  Brooke,  Boeck,  Crocker; 
and  also  a  comparison  of  some  of  the  reported  cases  of  acne  necrotica,  acne  varioli- 
formis);  Jarisch,  Verhandl.  des  V.  Cong.  Deutsch.  dermal.  Gesell.,  1895;  Colcott  Fox, 
Brit.  Jour.  Derm.,  1894,  p.  236;  1897,  p.  476;  1898,  p.  409;  1899,  p.  464;  Graham, 
Jour.  Cutan.  Dis.,  1896,  p.  41  (good  review  of  subject);  Mibelli,  Giorn.  ital.,  1896, 
fasc.  vi,  p.  690  (histologic  examination) — abstract  in  Annales,  1897,  p.  672;  J.  C. 
White,  Jour.  Cutan.  Dis.,  1898,  p.  514;  McCall  Anderson  (two  brothers),  Brit.  Jour. 
Derm.,  1898,  p.  i;  Crocker,  ibid.,  1900,  p.  39;  Adamson,  "On  Cases  of  Hydroa  yEstivale 
of  Mild  Type:  Their  Relationship  with  Hutchinson's  'Summer  Prurigo'  and  with 
'Hydroa  Vacciniforme'  of  Bazin,"  Brit.  Jour.  Derm.,  1906,  p.  125  (5  cases,  histologic 
cut,  review,  and  full  bibliography);  Kanoky,  Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlix, 
p.  1774,  reports  a  case  in  female  child  of  eight,  beginning  at  age  of  four,  in  which  the 
face  was  free,  the  lesions  being  found  on  legs,  forearms,  and  dorsal  surfaces  of  both 
hands.  Tapken,  "Ueber  ein  Fall  von  Hydroa  Vacciniforme  (Bazin),  Inaug.  Disser- 
tation," Miinchen,  1911  (review  and  discussion,  with  the  report  of  a  case). 


HYDRO  A    VACCINIFORME 


359 


dry  up  evenly  and  become  crusted,  and  others  again  may  rupture  ac- 
cidentally or  spontaneously  and  slowly  crust  over.  Frequently  two 
or  three  closely  grouped  lesions  coalesce  and  form  a  flattened,  irregu- 
larly outlined,  somewhat  large  bleb.  The  crusts,  which  have  usually 
formed  in  three  or  four  days  from  the  first  appearance  of  the  lesions, 
may  be  yellowish  to  a  red  color;  they  drop  off  after  a  variable  period, 
usually  several  days  or  a  week  or  more,  disclosing  a  red,  pit-like  per- 
manent scar,  which  in  the  course  of  time  becomes  white. 

The  process  in  some  spots  may  halt  at  the  erythematous  stage 
and  disappear  without  trace.  The  fresh  outbreaks  may  take  place 
almost  continuously,  or  the  attack  last  two  to  four  weeks,  to  recur 
again  upon  moderate  or  prolonged  exposure  to  sun  or  wind;  or  the 
disease  go  on  indefinitely,  at  least  up  to  youth  or  manhood,  when  the 
tendency  subsides.  Numerous  scars  and,  in  some  cases,  a  good  deal  of 
cicatricial  disfigurement  of  the  nose  and  ears  remain  as  permanent 
factors,  as  in  cases  reported  by  McCall  Anderson  and  J.  C.  White. 

In  some  cases  (summer  prurigo),  similar  or  somewhat  allied,  the 
eruption  may  consist  of  conic  papules  of  a  pale-red  color,  and  with, 
in  some,  a  disposition  to  minute  central  vesiculation;  in  disappearing 
they,  in  most  instances,  leave  insignificant  scars.  Itching  is  usually  a 
feature,  although  not  always  present.  It  is  in  many  respects  similar 
to  the  vacciniforme  eruption  just  described,  except  that  the  lesions 
are  more  distinctly  papular,  with  less  tendency  to  group;  and  it  is  apt 
to  be  more  extensively  distributed. 

The  hydroa  puerorum1  of  Unna,  while  classed  by  most  writers  as 
synonymous  with  these  cases  described,  differs  in  important  particu- 
lars: There  is  no  predilection  for  exposed  parts;  recurrence  of  attacks 
does  not  seem  to  be  dependent  upon  external  influences;  there  is  a 
distinct  tendency  to  a  coalescence  of  the  vesicles  to  form  blebs;  and 
the  lesions  are  superficial,  with  no  disposition  to  pitting  or  scarring.2 
In  some  of  its  clinical  aspects  it  bears  more  resemblance  to  a  mild  der- 
matitis herpetiformis. 

Etiology  and  Pathology.— The  disease  is  rare,  and  begins,  with 
few  exceptions,  in  the  first  several  years  of  life,  and  is  occasionally 
seen  in  two  members  of  the  same  family.  It  is  an  eruption  in  which 
exposure  to  the  sun  and  the  wind  is  an  important,  if  not  essential,  etio- 
logic  factor.  It  is,  therefore,  as  a  rule,  a  disease  of  the  summer,  the 
outbreaks  usually  disappearing  toward  cool  weather;  in  some  instances, 
however,  attacks  occur  during  the  cold  season  as  well.  It  recurs  the  fol- 
lowing year,  and  so  continues,  becoming  less  active  as  puberty  is  ap- 
proached, and  disappearing  when  adult  age  is  reached.  Exceptionally 
it  has  been  observed  to  begin  later  in  life,  and  to  continue  to  a  later  stage. 
In  a  few  cases  (McCall  Anderson's)  the  urine  during  the  outbreak  of 
the  efflorescences  was  noted  to  be  dark  wine-colored,  and  to  contain 
hematoporphyrin.  It  is  seen  almost  exclusively  in  boys.  It  has  some 

1  Unna,  "Hydroa  Puerorum,"  Monatshefte,  1889,  vol.  ix,  p.  108. 

2Haase  and  Hirschler,  "Hydroa  Puerorum"  (Unna),  Jour.  Cutan.  Dis.,  1908,  p. 
199,  go  over  the  ground  carefully,  maintaining  the  distinct  character  of  the  disease  (witt 
review  of  the  subject  and  references). 


3  60  INFLAMMA  TIONS 

features  in  common  with  erythema  bullosum  and  dermatitis  herpeti- 
formis,  and,  in  some  cases,  to  a  slight  extent  with  acne  varioliformis. 

The  pathologic  anatomy,  studied  by  Bowen,  Mibelli,  Adamson,  and 
others,  shows  that  the  process  is  an  inflammatory  one,  beginning  in  the 
rete  and  upper  corium,  with  sometimes  distinct  edema  and  cellular  infil- 
tration of  the  papillary  layer,  resulting  in  vesicle  formation  in  the  rete 
and  subsequent  circumscribed  necrosis  extending  deeply  in  the  derma  and 
sometimes  into  the  subcutaneous  tissue. 

Diagnosis. — Its  occurrence  solely  or  most  severely  in  summer, 
usually  in  boys  and  in  early  life,  the  distribution,  characters,  and  course 
of  the  lesions,  with  scars  usually  following,  and  its  repeated  recurrence 
are  diagnostic  features;  scars  do  not  form  in  erythema  bullosum  or  in 
dermatitis  herpetif ormis,  besides  differing  in  some  of  the  other  characters 
named. 

Prognosis  and  Treatment.— The  patient  can  usually  be  made 
more  comfortable  by  proper  measures,  and  the  attacks  less  active  and 
frequent  by  avoidance  of  the  sun,  heat,  and  wind,  but  so  far  the  ap- 
proach to  adult  age  seems  the  only  factor  which  stays  the  disease. 
As  the  chemical  rays  of  the  sun  may  be  of  some  causative  influence, 
the  wearing  of  orange  or  red  or  dark-colored  veils,  as  has  been  sug- 
gested, can  be  tried.  Treatment  is  to  be  mild  in  character,  and  is 
essentially  the  same  as  used  in  other  vesicular  and  bullous  diseases. 

POMPHOLYX 

Synonyms. — Cheiropompholyx  (Hutchinson) ;  Dysidrosis  (Tilbury  Fox);  Fr., 
Dysidrose. 

Definition. — A  rare  acute  inflammatory,  affection  of  vesicular 
and  bullous  character,  limited  to  the  hands  and  feet,  more  especially 
the  palmar  and  plantar  aspects.1 

Symptoms. — The  most  common  sites  of  the  disease  are  the  palms 
and  lateral  surfaces  of  the  fingers,  occasionally  extending  on  to  the 
dorsal  surface.  Not  infrequently  the  soles  of  the  feet  are  involved 
also.  Exceptionally  it  may  be  limited  to  the  latter  region.  It  is  gen- 
erally symmetric.  The  eruption  is  usually  foreshadowed  by  slight 
burning  of  the  part;  soon  small,  somewhat  deep-seated  vesicles  are  seen, 
usually  close  together,  which  enlarge,  and  which  in  appearance  may  often 
be  readily  likened  to  boiled  sago  grains.  The  parts  are  reddened,  and 
sometimes  swollen.  The  lesions  vary  somewhat  in  size  between  a  pin- 
head  and  a  large  bean.  As  a  rule,  new  vesicles  continue  to  arise  for 
several  days  or  a  few  weeks,  some  of  the  older  small  ones  becoming 
milky  and  disappearing  by  absorption;  or  some  becoming  larger,  the 
contents  milky  and  later  purulent.  When  closely  crowded,  the  result  is 

1  Principal  literature:  Tilbury  Fox,  Amer.  Jour,  of  Syph.  and  Derm.,  1873,  vol.  iv, 
p.  i;  Hutchinson,  Illustrations  of  Clinical  Surgery,  1876,  vol.  i,  p.  49;  Robinson,  Arch. 
Derm.,  1877,  p.  289;  Fox  and  Crocker,  Trans.  London  Patholog.Soc'y,  1878,  vol.  xxix, 
p.  264;  Hoggan  (G.  and  F.  E.),  Monatshefte,  1883,  pp.  no  and  148,  with  full  bibliog- 
raphy to  date;  Unna,  Histopathologie,  p.  176  (based  chiefly  upon  the  investigations  by 
Williams  and  by  Santi  in  Unna's  laboratory);  Williams.  Brit.  Jour.  Derm.,  1891,  p.  303; 
Santi,  Monatshefte,  1892,  vol.  xv,  p.  93  (with  references). 


POMPHOL  YX  36 1 

coalescence,  and  the  formation  of  large  flat  blebs  or  an  undermining  of  the 
upper  skin  with  serous  exudation.  The  smaller  lesions  show  little  if  any 
tendency  to  spontaneous  rupture ;  the  larger  blebs  are  usually  accidentally 
broken,  discharge  their  contents,  and  disclose  the  reddened  corium  or 
lower  rete  layer,  with  no  underlying  thickening.  Gradually  the  process 
declines  and  complete  recovery  ensues,  generally  in  the  course  of  a  few 
weeks  to  a  few  months.  All  grades  of  the  disease  are  met  with,  from  that 
in  which  the  lesions  are  somewhat  scanty,  superficial,  or  deep-seated,  to 
that  in  which  not  only  the  entire  palmar  aspect  of  the  hands  is  involved, 
but  a  great  part  of  the  dorsal  surface  as  well,  together  with  the  soles  of 
the  feet. 

In  some  instances  the  eruption  will  present  on  one  or  both  the  palms 
but  several  pin-head  to  pea-sized  lesions,  which  enlarge  slightly,  two 


Fig.  86.— Pompholyx  in  an  adult  of  forty,  of  a  few  weeks'  duration;  recurrent. 

or  three  may  become  confluent,  the  contents  of  all  in  the  course  of  a  few 
days  becoming  purulent;  there  is  a  slight  inflammatory  areola  surround- 
ing the  lesions,  one  or  two  may  be  absorbed,  or  they  are  broken,  especially 
the  larger  ones,  and  the  covering  exfoliates,  the  skin  soon  regaining  its 
normal  condition.  An  abortive  type  is  sometimes  observed  on  the 
lateral  aspects  of  the  fingers. 

The  subjective  symptoms  are  usually  burning  and  a  feeling  of  ten- 
sion; itching  is  rarely  a  marked  feature.  There  is  no  constitutional 
disturbance,  although  the  patient's  health,  especially  in  the  extensive 
cases,  is  noted  to  be  below  the  normal. 

Etiology  and  Pathology.— The  disease  is  most  common  in 
those  between  advanced  adolescence  and  middle  age;  it  is  scarcely 
seen  in  children,  and  not  often  in  old  age.  It  is  a  somewhat  rare  dis- 


362 


INFLAMMA  TIONS 


ease.  It  is  observed,  as  a  rule,  in  those  whose  health  is  below  par, 
and  especially  in  those  lacking  nervous  strength.  In  such  patients, 
after  one  attack,  every  decided  departure  from  the  normal  standard, 
through  worry,  fatigue,  or  exhaustion,  is  apt  to  be  followed  by  an  out- 
break, slight  or  severe  in  character.  It  has  been  noted  in  many  of 
the  patients  that  the  feet  and  hands  sweat  freely.  It  is  much  more 
frequent  in  women. 

The  tendency  of  the  lesions  to  group  and  its  usually  symmetric 
character,  and  its  occurrence  in  neurotic  subjects,  would  properly  lead 
to  the  belief  that  the  disease  is  a  neurosis.  Unna  states  that  he  has 
constantly  found  in  the  vesicle  sections  made  in  his  laboratory  by  Santi 
and  Williams  a  bacillus,  resembling  the  tubercle  bacillus,  but  thicker, 
which  he  considers  the  essential  pathogenic  factor. 


Fig.  87. — Pompholyx,  showing  vesicle  (e)  formed  in  the  upper  two- thirds  of  the  rete 
(c),  breaking  through  the  stratum  lucidum  (b),  with  the  covering  corneous  layer  (a), 
between  the  strata  of  which  are  seen  lacunae  caused  by  escaped  sweat  or  from  transuda- 
tion  from  the  papillae.  The  vesicle  contains  at  first  clear  serum,  from  the  underlying 
papillary  blood-vessels,  which  later,  from  the  invasion  of  leukocytes,  becomes  opaque. 
The  papillae  are  slightly  edematous,  and  the  upper  part  of  the  corium  (d)  shows  slight 
inflammatory  changes  with  perivascular  cell-infiltration  (courtesy  of  Dr.  A.  R.  Robin- 
son). 

Its  supposed  connection  with  the  sweat-gland  gave  the  name  of 
dysidrosis  (Tilbury  Fox,  Crocker),  but  later  and  confirmed  investiga- 
tions (Robinson,  Hutchinson,  Thin,  Unna,  Williams,  and  Santi)  show 
no  special  association  with  these  structures,  but  indicate  that  it  is  an 
inflammatory  disease  in  which  the  lesions  take  their  origin  in  the  rete, 
the  fluid,  which  is  at  first  pure  serum,  coming  from  the  papillary  blood- 
vessels, and  collecting  between  the  rete  cells.1  The  effusion  gives  rise 
to  degeneration  of  some  of  these  cells,  and  the  others  are  gradually 
pushed  asunder  to  give  room  for  the  fluid  collection.  The  upper  cells 
may  rupture,  and  some  serum  also  escape  into  the  corneous  layers. 
The  lesions  later  become  purulent  from  the  addition  of  pus-corpus- 
cles, and  contain  some  fibrin  and  a  large  amount  of  albumin;  the  con- 

1  Nestorowsky  (Dermatolog.  Zeitsch.,  March,  1906,  el  seq. — abstract  in  Jour.  Cutan. 
Dis.,  1906,  p.  491),  from  histologic  examination  of  many  specimens,  calls  this  in  ques- 
tion— he  considers  it  a  disease  of  the  sweat-glands  and  the  vesicles  as  closely  con- 
nected with  their  ducts. 


POMPHOL  YX  363 

tents  are  never  acid.  They  never  contain  sweat.  The  inflammatory 
changes  are  slight. 

Diagnosis. — The  beginning  deep-seated  lesions,  their  increase 
in  size,  and  usually  in  number,  some  coalescing  and  forming  blebs, 
and  gradually  becoming  purulent,  together  with  the  localization  of  the 
eruption,  make  a  pretty  clear  picture  of  the  malady,  and  usually  render 
the  diagnosis  a  matter  of  no  difficulty.  It  is  to  be  distinguished  from 
acute  eczema,  which,  however,  it  can  scarcely  be  said  to  resemble  greatly; 
but  in  this  latter  disease  the  lesions  are  small,  are  markedly  acute,  in 
great  numbers,  crowded  together,  with  usually  considerable  inflamma- 
tory action  and  some  infiltration;  tend  to  rupture  spontaneously,  and 
leave  the  characteristic  oozing  surface  of  eczema;  the  dorsal  surfaces  of 
the  hands  and  fingers  are  also,  as  a  rule,  involved,  whereas  in  pompholyx 
these  parts  are  rarely  affected  to  a  great  extent,  and  frequently  not  at  all. 
There  are,  however,  mild  cases  of  both  disorders,  the  slight  type  of  pom- 
pholyx, with  small  and  scanty  lesions,  and  subacute  eczema  of  limited 
character  which  sometimes  approach  each  other  in  appearance ;  the  boiled- 
sago-grain  character  is  usually  characteristic  of  pompholyx,  but  it  is 
not  an  absolute  factor,  as  some  of  the  deep-seated  lesions  of  eczema  on  the 
fingers  at  times  show  a  similar  appearance. 

It  is  also  to  be  distinguished  from  rhus  poison,  but  the  markedly 
acute  and  inflammatory  character  of  this  latter,  and  the  fact  that  it 
usually  involves  other  parts,  and  a  history  of  exposure,  and  its  course 
are  different  from  the  symptoms  of  pompholyx. 

Prognosis. — The  prognosis  for  the  immediate  attack  of  pom- 
pholyx is  favorable,  as  the  disease  subsides  spontaneously  in  the  course 
of  several  weeks  or  one  or  two  months;  and  its  duration  and  course, 
especially  in  severe  cases,  may  be  modified  or  shortened  by  appropriate 
treatment.  As  to  future  freedom,  the  prospect  is  uncertain,  recurrences 
at  irregular  intervals  being  not  infrequent;  if  a  good  state  of  health  is 
maintained  and  overfatigue  and  nervous  exhaustion  guarded  against, 
fresh  outbreaks  rarely  present  themselves. 

Treatment. — In  the  management  of  the  disease  the  condition  of 
health  must  be  looked  after,  tonics  having  an  invigorating  effect  upon 
the  nervous  tone,  and  nutrition  being  especially  indicated.  Hence 
quinin,  iron,  strychnin,  arsenic,  and  cod-liver  oil  are  the  remedies  com- 
monly prescribed,  more  especially  arsenic  in  moderate  doses  and  strych- 
nin in  tolerably  full  doses.  Cod-liver  oil  and  iron  are  often  extremely 
useful  in  debilitated  subjects  with  frequent  recurrences.  The  digestion 
should  receive  attention,  and  constipation  be  corrected.  A  mild  saline 
purge  in  the  beginning  of  an  attack  is  often  of  service.  A  generous  diet 
should  also  be  advised. 

The  external  treatment  has  mainly  in  view  the  protection  of  the  parts. 
Soothing  applications,  such  as  are  employed  in  acute  eczema,  are  the 
most  satisfactory.  Strong  and  stimulating  remedies  have  no  place  in 
the  treatment  of  the  disease,  and  aggravation  would  follow  their  use. 
Mention  may  be  made  of  applications  of  lead-water  and  laudanum,  boric 
acid  solution,  zinc  oxid  ointment  containing  a  dram  (4.)  of  calamm  to 
the  ounce  (32.),  salicylic  acid  paste,  and  diachylon  ointment.  The  last 


364  INFLAMMA  TIONS 

named  and  the  following  are  useful  in  those  cases  in  which  a  distinctly 
sedative  ointment  is  indicated: 

R.     Menthol.,  gr.  ij  (0.133); 

Acidi  salicylici,  gr.  x  (0.65); 

Emplastri  plumbi, 

Emplastri  saponis,  aa  oiss  (0.6); 
Petrolati,  3v  (20.). — M. 

This  should  be  spread  thickly  upon  lint  or  other  suitable  material 
and  kept  constantly  applied  as  a  plaster;  or  ceratum  plumbi  subace- 
tatis  similarly  applied  is  also  of  value  in  such  cases.  In  fact,  what- 
ever ointment  is  prescribed,  it  should  be  employed  in  this  manner,  the 
effect  being  much  more  decided  than  is  obtained  by  simply  smearing 
it  on.  If  lotions  are  used,  the  parts  should  be  first  thoroughly  dabbed 
therewith,  and  then  linen  cloths  or  patent  lint  wet  in  the  solution  ap- 
plied and  kept  wet  with  it.  The  conjoint  use  of  a  lotion  and  an  oint- 
ment, first  dabbing  on  the  lotion,  allowing  it  to  dry  on,  and  then  applying 
the  ointment  in  the  manner  described,  is  an  efficient  method  of  treat- 
ment. 

The  parts  should  be  gently  cleansed  once  daily  with  warm  water, 
and  every  few  days  by  dipping  for  a  few  minutes  in  a  basin  of  warm 
water  with  one-fourth  to  one-half  teaspoonful  of  sodium  bicarbonate 
dissolved  therein. 


DERMATITIS  HERPETIFORMIS 1 

Synonyms. — Hydroa  bulleux  (Bazin);  Hydroa  herpetiforme  (Tilbury  Fox); 
Duhring's  disease;  Dermatitis  multiformis  (Piffard);  Herpes  gestationis;  Pemphigus 
pruriginosus;  Herpes  circinatus  bullosus  (Wilson);  Pemphigus  circinatus  (Rayer); 
Herpes  phlyctaenodes  (Gilbert);  Pemphigus  prurigineux  (Chausit,  Hardy);  Pemphigus 
compose  (Devergie);  Dermatite  polymorphe,  Dermatite  herpetiforme  (Brocq). 

Definition. — Dermatitis  herpetiformis  is  a  rare  inflammatory 
disease,  with  or  without  slight  or  grave  systemic  disturbance,  char- 
acterized by  an  eruption  of  an  erythematous,  papular,  vesicular,  pus- 
tular, bullous,  or  mixed  type,  with  a  decided  tendency  toward  group- 
ing, accompanied  usually  by  intense  itching  and  burning  sensations, 
with  more  or  less  consequent  pigmentation,  and  pursuing  a  persistent, 
chronic  course  with  exacerbations. 

Symptoms. — The  onset  and  the  exacerbations  may  or  may  not 
be  preceded  for  a  few  days  by  symptoms  of  general  disturbance,  such 
as  malaise,  loss  of  appetite,  constipation,  chilliness,  flushings  and  heat 

1  Most  of  Professor  Duhring's  papers,  establishing  a  fixed  place  in  classification  for 
this  disease,  have  been  republished  in  Selected  Monographs  on  Dermatology,  issued  by 
New  Sydenham  Society,  London,  1893,  pp.  170-297.  A  most  excellent  French  exposi- 
tion of  the  subject,  with  numerous  literature  references  and  brief  recital  of  most  pub- 
lished cases,  is  that  by  Brocq,  entitled  "De  la  dermatite  herpetiforme  de  Duhring,"  An- 
nales,  1888,  pp.  i,  65,  133,  209,  305,  434,  and  493.  A  graphic  and  succinct  descrip- 
tion of  the  disease  read  by  Jamieson  before  the  London  Dermatological  Society,  and  the 
discussion  thereon,  present  the  English  views  of  the  subject,  Brit.  Jour.  Derm.,  1898, 
pp.  73  and  118.  As  one  of  the  earliest  contributions  must  be  mentioned  the  suggestive 
and  elaborate  paper  by  Tilbury  Fox,  "Clinical  Study  of  Hydroa,"  Arch.  Derm.,  1880, 
p.  16  (a  posthumous  paper,  edited,  with  notes,  by  Colcott  Fox). 


Dermatitis  herpetiformis  of  the  vesicular  and  papulovesicular  variety  in  a  male  adult  aged 
forty,  of  about  five  years'  duration  ;  shows  the  herpetic  grouping  of  the  lesions. 


PLATE   XIII. 


Dermatitis  herpetiformis  ;  erythematovesicular  and  pustular  varieties  in  combination 
Woman,  middle  age.  Eruption  more  or  less  generalized  (courtesy  of  Dr.  Louis  A. 
Duhring). 


DERMATITIS  HERPETIFORMIS  365 

sensations,  rise  of  temperature,  and  often  the  subjective  symptom  of 
itching.  During  the  first  several  days  of  the  cutaneous  outbreak  such 
symptoms  may  in  greater  or  less  degree  continue;  and  in  the  more  severe 
and  extensive  types  of  the  disease,  especially  in  the  pustular  and  bullous 
varieties,  the  constitutional  symptoms  may  be  of  a  graver  character  and 
more  or  less  persistent.  Cases  in  which  the  general  symptoms  give  rise 
to  anxiety  are,  however,  it  must  be  said,  infrequent,  and  in  most  instances 
are  entirely  wanting  or  extremely  slight. 

The  eruption  may  be  erythematous,  papular,  vesicular,  bullous,  pus- 
tular, or  mixed;  it  is  never  ulcerative.  Very  rarely  purpuric  lesions  are 
intermingled  or  follow  in  the  pigment  stains  from  the  vesicles  and  blebs, 
and  the  latter  lesions  are  exceptionally  slightly  hemorrhagic  (Brocq, 
Tenneson,  Hallopeau,  Leredde,  Perrin).  The  vesicular  variety  is  the 
most  common.  In  some  cases  the  same  type  with  which  the  eruption 
begins  may  persist  or  be  preponderant  throughout  the  course  of  the 
malady;  there  is  in  many,  however,  a  distinct  tendency  to  change  from 
one  to  another,  in  some  cases  completely,  in  others,  partially.  The 
onset  of  the  outbreak  may  be  sudden,  or  it  may  be  preceded  for  several 
days  or  weeks  by  slight  cutaneous  irritation,  such  as  itching,  one  or 
several  insignificant  erythematous  patches,  groups  of  vesicles,  or  urti- 
carial  lesions;  or  the  first  lesions  are  all  of  one  variety.  When  fully 
developed,  the  eruption  may  cover  almost  the  entire  surface;  or  it 
may  be  more  or  less  limited  in  extent,  involving  a  greater  part  or  the 
entire  trunk;  or  the  trunk  may  be  but  slightly  invaded,  and  the  limbs, 
especially  the  legs,  bear  the  brunt.  C.  Boeck1  has  observed  a  special 
predilection  for  the  regions  of  the  elbow,  shoulder,  lower  sacral,  and 
poplitea,  and  thinks  this  so  constant  as  to  be  almost  diagnostic.  It 
is,  however,  in  every  way,  both  as  regards  violence  and  extent,  variable — 
slight  or  severe,  limited  or  extensive.  Itching  is  usually  a  constant 
and  a  most  troublesome  feature;  pigmentation  sooner  or  later  is  noted  in 
most  cases.  After  several  days  or  weeks  of  violent  activity  the  disease 
tends  to  become,  slowly  or  rapidly,  less  active,  and  a  period  of  compara- 
tive comfort  and  freedom  of  uncertain  duration  is  passed.  These 
remissions  or  intermissions  are  irregular  and  capricious;  in  some  instances 
scarcely  one  violent  outbreak  is  in  full  development,  when  another,  equally 
active  and  extensive,  follows,  and  this  may  continue  in  rapid  succession 
for  several  months  or  longer  before  a  period  of  comparative  or  complete 
quiescence  intervenes. 

The  vesicles,  pustules,  and  blebs,  especially  the  vesicles  and  blebs, 
are  somewhat  peculiar  as  to  shape;  they  are,  or  many  of  them  at  least, 
usually  of  a  strikingly  irregular  outline,  oblong,  stellate,  quadrate, 
semilunar,  or  rarely  ring-shaped,  distended,  or  flaccid,  and  when  drying 
are  apt  to  have  a  puckered  appearance.  They  are  herpetic,  in  that  they 
show  little  disposition  to  spontaneous  rupture;  occur  mostly  in  groups 
of  two,  three,  or  more,  and  not  infrequently  are  seated  upon  erythematous 
or  inflammatory  skin.  Occasionally  some  of  the  lesions,  especially  in 
the  graver  cases,  contain  a  slight  admixture  of  blood.  They  may  dis- 
appear by  absorption,  or,  if  ruptured  or  broken,  leave  abrasions  which 
1  Boeck,  Monatsfiefle,  1907,  vol.  xlv,  p.  277. 


366  INFLAMMA  TIONS 

may  secrete  for  a  short  time  and  dry  up ;  or  they  may  dry  to  crusts  which 
fall  off,  the  sites  being  marked  by  erythematous  spots,  which  in  turn 
fade  or  leave  behind  slight  pigmentation.  In  size  the  vesicles  are  rarely 
smaller  than  a  pin-head,  and  are  usually  the  size  of  small  peas.  The 
blebs  may  be  almost  any  dimension  from  a  pea  to  a  hen's  egg,  and  may 
arise  as  a  single  lesion  from  sound  or  erythematous  or  erythematopapular 
skin,  or  may  have  their  origin  in  the  confluence  of  several  closely  con- 
tiguous vesicles  or  small  blebs.  Scattered  pustules  may  be  large,  but 
more  commonly  are  all  small  in  size,  resembling  in  this  respect  vesicular 
lesions;  they  often  begin  as  pustules,  or  may  have  their  origin  in  vesicles. 
The  mucous  membrane  of  the  mouth,  throat,  nose,  and  eyes  is  in  some 
instances — more  especially  the  bullous  cases — involved,  and  in  excep- 
tional cases  the  mucous  membrane  of  the  trachea  and  the  larger  bronchial 
tubes  also. 

The  erythematous  type  lesions  are  similar  to  those  of  a  general- 
ized erythema  multiforme,  and  it  could  be  very  aptly  designated  a 
chronic  form  of  that  affection,  except  that  at  times  it  is  noted  to  change 
completely  into  one  of  the  other  varieties;  urticarial  lesions  are  now  and 
then  interspersed.  It  is  sometimes  a  beginning  type;  quite  often  it 
appears  as  a  break  of  short  or  long  duration  between  active  vesicular 
or  bullous  outbreaks;  and  not  infrequently  it  is  the  type  permanently 
assumed  after  the  violent  character  of  the  disease  has  disappeared. 

In  children  (in  whom  the  disease  has  been  especially  studied  by 
Gottheil,  Meynet  and  Pehut,  Halle,  Bowen,  Knowles,  Gardiner,  and 
others)1  the  element  of  multiformity  is  often  wholly  lacking,  the  erup- 
tion being  of  a  vesicular  and  bullous  character  without  admixture  of 
other  types.  The  eruption  in  many  of  these  cases  is  frequently  pre- 
dominant on  certain  regions,  as  about  the  nose,  mouth,  neck,  axillary 
folds,  genitalia,  wrists,  and  hands;  and  occasionally  it  is  limited  to  these 
parts.  Subjective  symptoms  are  often  absent  and  only  rarely  trouble- 
some; and  pigmentation  is  seldom  a  feature. 

Ktiology. — The  disease  is  rare,  but  not  so  rare  as  formerly  thought. 
It  is  met  with  in  both  sexes  and  almost  all  ages.  It  is  most  frequent 
during  the  period  of  active  adult  life,  although  it  is  exceptionally  seen 
in  the  very  young  (one  aged  three — Pringle;  one  aged  four — Bowen). 
In  some  cases  there  is  found  nothing  of  import  in  the  previous  or  present 
condition  of  the  patient's  health  to  explain  the  cutaneous  phenomena; 
in  fact,  in  some  the  general  health  seems  undisturbed.  Still,  enough  is 

1  Gottheil,  Arch.  Pedlat.,  June,  1901,  reports  2  cases  in  children — in  one  aged  nine, 
beginning  when  aged  four;  Meynet  and  Pehut,  Annales,  1903,  p.  893,  in  reporting  a  case 
in  a  child,  give  a  resume  of  previously  reported  cases  in  children,  with  references;  Halle, 
Arch,  de  med.  d.  enfant,  1904,  vol.  vii,  p.  385,  reviews  the  character,  etc.,  of  the  disease 
in  children,  of  which  he  has  seen  5  cases;  Bowen,  "Dermatitis  Herpetiformis  in  Chil- 
dren," Jour.  Cutan.  Dis.,  1905,  p.  381,  records  15  cases,  with  review  of  some  other 
cases,  and  allied  conditions,  with  references;  Knowles,  "Dermatitis  Herpetiformis  in 
Childhood,"  Jour.  Cutan.  Dis.,  1907,  p.  246  (report  of  a  case,  with  2  illustrations,  and 
a  complete  summary  and  analytic  review  of  57  collated  cases,  with  bibliography); 
Gardiner,  "Dermatitis  Herpetiformis  in  Children,"  Brit.  Jour.  Derm.,  Aug.,  1909,  p. 
237  (report  of  4  cases,  with  7  illustrations);  Sutton,  "Dermatitis  Herpetiformis  in 
Early  Childhood,"  Amer.  Jour.  Med.  Sci.,  Nov.,  1910,  vol.  cxl,  p.  727  (case  report — 
child  three  and  one-half  years,  beginning  when  nine  months  old;  numerous  tiny 
scars;  review  and  references  of  early  cases). 


PLATE   XIV. 


Dermatitis  herpetiformis  ;  vesicobullous  variety.     Irregular  bullous  lesions,  resem- 
bling those  of  erythema  multiforme  bullosum.      Eruption  general.      Patient,  a 
( courtesy  of  Dr.  Louis  A.  Duhring). 


DERMATITIS  HERPETIFORMIS  367 

known  to  indicate  that  the  disease  is  essentially  neurotic,  for  in  other 
instances — in  a  large  number,  in  fact — it  manifests  itself  after  severe 
mental  strain,  emotion,  and  nervous  shock,  as  frequently  recorded 
(Tilbury  Fox,  Duhring,  Elliot,  Devergie,  Crocker,  Vidal,  Tenneson, 
Brocq,  and  others).  Its  connection  with  the  nervous  system  is  also 
shown  by  the  cases  in  which  pregnancy  is  the  factor,  the  malady  often 
disappearing  in  the  interim,  of  which  many  examples  are  on  record 
(Milton,  Bulkley,  Liveing,  W.  G.  Smith,  Duhring,  White,  Perrin,  and 
others).  The  possible  reflex  origin  in  some  instances  is  suggested  in 
the  case  of  a  child  reported  (Roussel)  in  which  phimosis  was  apparently 
the  factor,  a  cure  resulting  after  circumcision.1  Nephritic  disease  has 
been  associated  or  recorded  as  an  etiologic  factor,  as  shown  by  glyco- 
suria  (Winfield)  and  albuminuria  (Wickham,  Abraham).  According  to 
Besnier,  there  is  always  scantiness  of  urine,  with  diminution  of  urea  and 
uric  acid.  Engman2  found  indicanuria  an  almost  constant  feature. 
Physical  or  nervous  breakdown,  exposure  to  cold,  and  septicemia  have 
been  apparently  etiologic  in  some  of  my  cases.  Cases  apparently  septic 
in  origin  have  also  been  reported  by  others  (Sherwell,  Kerr,  and  others). 
That  some  septic  or  otherwise  toxic  agent  is  sometimes  responsible  for 
dermatitis  herpetiformis  (or  at  least  a  similar  or  allied  condition,  showing 
often  a  combination  of  the  symptomatology  of  erythema  multiforme, 
herpes,  and  pemphigus,  and  resembling  dermatitis  herpetiformis)  seems 
.shown  by  the  occasional  examples  following  vaccination,  as  observed  by 
Dyer,  Pusey,  Bowen,  myself,  and  others.3  Auto-intoxication,  usually 
gastro-intestinal  in  origin,  may  be  responsible  for  this  as  well  as  for  other 
allied  disorders.4  The  condition  of  the  thyroid  gland  should  be  noted — 
as  its  hypertrophy  or  atrophy  may  be  the  source  of  the  toxic  agent. 
Sequeira5  has  recorded  the  case  of  bullous  eruption  in  a  child  of  three, 
suggestive  of  a  beginning  dermatitis  herpetiformis;  developing  acute 
symptoms  of  appendicitis  (apparently  a  chronic  case  of  some  duration) ; 
operation  was  performed,  and  with  no  return  of  the  eruption  since 
operation.  In  some  instances  general  debility  and  debilitating  influences 
may  rightly  be  considered  as  responsible,  in  part  at  least,  for  a  continu- 
ance of  the  disease.  On  the  other  hand,  striking  amelioration  has  been 
noted6  by  a  physician  in  his  own  case  during  attacks  of  malarial  fever  and 
other  intercurrent  disorders. 

1  Kirby-Smith,  New  York  Med.  Record,  Aug.  17,  1912  (i  case— with  illustration; 
promising  result  following  circumcision). 

2  Engman,  Jour.  Cutan.  Dis.,  1906,  p.  216,  and  1907,  p.  178,  reports  upon  the  con- 
stant presence  of  indican  in  the  urine,  and  these  amounts  seemed  to  have  relationship 
with  the  eosinophilia;  Loth  and  Grindon  have  also  noted  the  presence  of  mdican. 

3  Dyer,   New  Orleans  Med.  and  Surg.  Jour.,  1896-97,  vol.  xxiv,  p.  211;  Pusey, 
Jour.  Cutan.  Dis.,  1897,  p.  158— the  early  history  of  this  case  was  reported  by  Becker, 
Tri-State  Med.  Jour.,  May,  1893;  Bowen,  "Six  Cases  of  Bullous  Eruption  Following 
Vaccination,"  Jour.  Cutan.  Dis.,  1901,  p.  401  (in  children  between  the  ages  of  five  and 
ten,  and  appearing  within  from  one  to  four  weeks  after  vaccination,  and  lasting  tor 
months  and  years);  Stelwagon,  "Vaccinal  Eruptions,"  Jour.  Amer  Med.  Assoc.,  Nov. 
22,  1902;  Bowen,  Jour.  Cutan.  Dis.,  1904,  p.  265,  refers  to  several  other  cases. 

*  See  interesting  paper  by  Johnston,  "The  Evidence  of  the  Existence  of  an  Auto- 
toxic  Factor  in  the  Production  of  Bullous  Diseases,"  Brit.  Med.  Jour.,  Uct.  0,  i( 

6  Sequeira,  Brit.  Jour.  Derm.,  1911,  p.  295. 

8  "Dermatitis  Herpetiformis:  A  Personal  Experience  of  the  Disease,  Brit.  Jour. 
Derm.,  1897,  p.  97,  and  1899,  p.  282. 


368  INFLAMMA  TIONS 

Pathology.1 — Recent  studies  (Elliot,  Leredde  and  Perrin,  Unna, 
Gilchrist)  indicate  that  the  process,  inflammatory  in  character,  has 
its  beginning  in  the  upper  corium — in  the  papillary  layer,  or  in  the  deep 
epidermic  layers;  and  the  resulting  vesicle,  forming  beneath  the  epi- 
dermis, gradually  or  quickly  enlarges  and  works  upward,  the  epidermis 
being  secondarily  involved.  In  the  corium  are  noted  variable  edema, 
dilatation  of  the  vessels,  and  cell-masses  of  usually  lymphocytes,  occa- 
sionally of  plasma-cells.  Eosinophiles  are  found  both  in  the  corium  and 
epiderm,  and  are  present  usually  in  large  numbers  in  the  vesicles  and 
blebs,  and  also  in  the  blood  (Leredde,  Brown).  In  the  dilated  vessels 
are  to  be  seen,  in  addition  to  the  red  blood-corpuscles,  polynuclear  leuko- 


Fig.  88. — Dermatitis  herpetiformis,  vesicular  variety  (X  about  35):  Vv  and  F2, 
show  small  vesicles;  E,  epidermis  unchanged,  lifted  up  by  the  exudation;  S,  S,  sweat- 
gland  and  duct;  G,  sebaceous  gland.  The  contents  of  vesicles  consist  of  fibrin,  coagu- 
lated albumin,  polynuclear  leukocytes,  and,  at  the  bottom,  eosinophiles.  Glandular 
structures  not  involved.  Upper  half  of  corium  shows  acute  inflammatory  process, 
with  much  fibrin  (courtesy  of  Dr.  T.  C.  Gilchrist). 

cytes;  in  the  larger  vessels,  eosinophiles  in  scanty  number.  The  lesions 
contain  a  fibrinous  network,  in  the  meshes  of  which  are  found  polynu- 
clear leukocytes  in  large  numbers,  some  mononuclear  and  epithelial 
cells,  eosinophile  cells,  as  already  stated,  and  coagulated  albumin.  The 
pustules  are  probably  due  to  an  added  superficial  infection  from  without. 

1  Pathologic  anatomy:  Elliot,  New  York  Mcd.  Jour.,  1887,  vol.  i,  p.  449;  Leredde  et 
Perrin,  Annales,  1895,  pp.  281  and  452;  Gilchrist,  Johns  Hopkins  Hosp.  Reports,  1896, 
vol.  i,  p.  365. 

Regarding  eosinophilia:  Leredde  et  Perrin.  Annales,  pp.  281,  369,  and  452; 
Darier,  ibid.,  1896,  p.  842;  Leredde,  ibid.,  p.  846,  1899,  p.  355,  and  (also  anatomy), 
Gazette  des  Hopitaux,  March  26,  1898;  Funk,  Monatshefie,  1893,  vol.  xvii,  p.  266; 
Brown,  Jour.  Amer.  Med.  Assoc.,  Feb.  17,  1900;  Bushnell  and  Williams,  Brit.  Jour. 
Derm.,  1906,  p.  177  (diminished  phagocytic  power  of  the  eosinophile  cells). 


PLATE  XV. 


Dermatitis  herpetiformis  (?)  sometimes  met  with  in  children,  and  also  observed  devel- 
oping after  vaccination  ;  neck,  axillary,  genitocrural,  popliteal,  and  elbow-flexure  regions 
seem  favored  ;  vesicobullous  and  herpes  iris  type  ;  patient  aged  eleven  ;  two  years'  dura- 
tion, with  periods  of  comparative  quiescence. 


DERMATITIS  HERPETIFORMIS  369 

Leredde  strongly  believes  that  the  excretion  of  eosinophile  cells  by  the 
skin  to  be  an  essential  part  of  the  cutaneous  phenomena,  and  together 
with  the  eosinophile  cells  in  the  blood  are  characteristic  of  this  disease — 
a  view  shared,  in  part  at  least,  by  others  (Hallopeau,  Lafitte,  Danlos). 
It  is  now  known,  however,  that  eosinophile  cells  are  found  in  lesions  of 
other  bullous  diseases. 

Diagnosis. — At  various  periods  in  its  course  a  case  of  dermatitis 
herpetiformis  may  resemble  slightly  or  even  strikingly  erythema  multi- 
forme  and  pemphigus;  and  not  infrequently,  indeed,  the  clinical  picture 
may  be  for  a  time  closely  similar  or  even  the  same  as  one  of  these  dis- 
eases, and  without  knowledge  of  its  former  history  and  course  a  mistake 
could  be  readily  made.  Several  factors  need  to  be  kept  in  mind  in  the 
diagnosis  as  being  more  or  less  distinguishing:  Chronicity,  with  or  with- 
out remissions  or  short  or  long  intermissions;  multiformity,  tendency 
toward  grouping,  disposition  to  change  of  type,  itchiness,  with  sooner  or 
later  slight  or  marked  pigmentation. 

It  is  distinguished  from  erythema  multiforme  by  the  fact  that  this 
latter  is  an  acute  disease  running  a  course  of  ten  days  to  several  weeks, 
and  is  unaccompanied  by  intense  itching;  moreover,  its  distribution  is 
rarely  as  irregular  or  general  as  that  of  dermatitis  herpetiformis.  The 
vesicles  and  bullae — herpes  iris,  erythema  bullosum — which  are  occa- 
sionally seen  in  erythema  multiforme  have  their  origin  in  preexisting 
erythematous  lesions;  while  this  also  happens  in  dermatitis  herpetiformis, 
some  of  the  vesicles  and  bullae  will  be  found  to  arise  from  apparently 
healthy  skin.  In  doubtful  cases  an  observation  of  several  days  or,  at 
the  most,  a  few  weeks,  would  lead  to  a  correct  conclusion. 

Pemphigus  differs  from  the  bullous  type  of  dermatitis  herpetifor- 
mis in  that  the  lesions  of  the  former  are  usually  larger  and  show  no 
special  tendency  to  occur  in  groups  or  to  assume  irregular,  angular,  or 
multiform  shapes;  the  pemphigus  blebs,  moreover,  appear,  as  a  rule, 
from  sound  skin,  and  the  disease  lacks  the  small  vesicles  and  vesicular 
groups  and  occasional  small  pustules  and  pustular  groups  usually  found 
intermingled  in  the  bullous  eruption  of  dermatitis  herpetiformis.  In 
pemphigus  itching  is  wanting  or  slight,  whereas  in  dermatitis  herpeti- 
formis it  is  one  of  the  most  troublesome  symptoms.  The  reported  cases 
of  "pemphigus  pruriginosus"  are,  doubtless,  in  many  instances  at  least, 
examples  of  dermatitis  herpetiformis.  Pemphigus  with  itching  as  a 
symptom  may  be  distinguished  by  the  differential  points  already  given, 
especially  when  considered  in  connection  with  the  known  capriciousness 
of  type  in  dermatitis  herpetiformis.  The  constitutional  symptoms  of 
pemphigus  are  often  quite  marked— much  more  so,  as  a  rule,  than  ob- 
served in  dermatitis  herpetiformis. 

The  characters  of  dermatitis  herpetiformis  are  so  different  from 
urticaria  and  eczema  that  a  mistake  is  scarcely  possible.  In  urticaria 
the  lesions  are  all  wheals,  there  is  no  tendency  to  special  grouping, 
and  it  is  usually  acute  and  evanescent;  bullous  lesions  in  urticaria  are 
uncommon,  and  when  present,  spring  from  wheals  and  are  associated 
with  other  characteristic  wheals.  In  eczema  the  papules  and  vesicles 
are  much  smaller,  and  the  eruption  is  rarely  generally  distributed. 
34 


370  INFLAMMATIONS 

Prognosis. — As  to  relief,  much,  as  a  rule,  may  be  promised,  but 
as  to  cure  or  permanent  freedom  from  outbreaks  the  prognosis  cannot 
be  too  cautiously  guarded.  It  is  not  to  be  forgotten  that  dermatitis 
herpetiformis  is  a  particularly  persistent  and  chronic  disease,  capricious 
in  its  behavior  and  course,  and  rebellious  to  treatment.  Permanent 
recovery  is  to  be  considered  rather  exceptional;  there  is,  however,  a 
tendency  in  most  cases  to  become  less  active.  Those  showing  a  pre- 
vailing tendency  to  the  erythematous  form,  and  the  vesicular  expres- 
sion of  the  disease  occurring  in  connection  with  pregnancy  or  the  par- 
turient state  (herpes  gestationis)  are  the  more  favorable  varieties.  The 
disease  in  children  seems  much  less  rebellious,  and  recovery  is  not  so 
uncommon  as  in  adults.  The  pustular  and  bullous  types  are  sometimes 
of  a  serious  character.  A  fatal  ending  is  possible  in  the  grave  cases, 
especially  in  those  associated  with  septicemia.  It  must  be  conceded, 
however,  that  dermatitis  herpetiformis  usually  persists  for  years  without 
compromising  life,  and  that  in  many  of  the  patients  the  general  health, 
considering  the  violence  of  the  eruptive  phenomena,  remains  compara- 
tively undisturbed. 

Treatment. — Although  the  etiology  of  dermatitis  herpetiformis 
is  obscure,  it  is,  in  most  cases  at  least,  to  be  looked  upon  as  of  neurotic 
nature.  The  most  successful  treatment,  therefore,  is  one  that  keeps 
in  view  the  avoidance  or  correction  of  any  factor  detrimental  or  disturb- 
ing to  the  nervous  equilibrium,  and  which  also  aims  to  bring  about  a 
healthy  and  more  vigorous  nervous  tone.  The  mode  of  living,  the  diet, 
the  state  of  the  digestion,  and  the  condition  of  the  various  internal 
organs,  more  especially  the  liver  and  kidneys,  should  be  investigated. 
The  diet  should  be  generous,  but  plain  and  nutritious;  coffee  and  tea, 
except  in  very  moderate  quantity,  should  be  avoided,  likewise  all  indi- 
gestible foods.  Alcoholic  stimulants  are  usually  damaging.  Occa- 
sionally a  purely  milk  diet,  or  with  meat  once  daily,  has  a  favorable 
influence.  In  fact,  the  gastro-intestinal  tract  should  receive  particular 
attention,  as  the  toxic  material  which  may  be  responsible  for  the  malady, 
may  have  its  origin  here.  A  saline  purge  often  has  a  favorable  influence 
in  mitigating  the  severity  of  an  attack;  the  bowels  should  always  be 
kept  free.  Upon  the  whole,  constitutional  treatment  is  based  upon 
general  principles.  Irrespective,  however,  of  what  may  be  indicated 
by  suspected  etiologic  conditions,  three  remedies  need  special  mention — 
arsenic,  quinin,  and  strychnin  in  moderately  full  or  large  doses.  Arsenic, 
according  to  my  own  observation  and  those  of  others  (Jamieson,  Roberts, 
Mackenzie),1  stands  first  in  value;  in  small  doses,  it  is  often  valuable  as  a 
tonic,  but  in  some  instances,  especially  of  the  vesicular  and  bullous  types, 
pushed  to  the  point  of  tolerance,  it  will  be  found  of  distinct  service; 
after  it  fails  to  do  further  good,  it  can  be  stopped,  and  then  later  resumed. 
In  other  cases  it  seems  to  do  harm.  In  persons  of  depressed  general 
nutrition  cod-liver  oil  is  a  remedy  of  value.  Alkalies  and  diuretics  are 
sometimes  of  service.  Should  there  be  a  suspicion  of  hypothyroidism 
the  proper  remedy  (thyroid  gland  preparations)  should  be  tried — 

1  Morris  and  Whitfield,  Brit.  Jour.  Derm.,  1912,  p.  148  (case  demonstration  and 
discussion),  give  each  a  remarkable  instance  of  control  by  arsenic. 


PEMPHIGUS  371 

favorable  influence  from  its  use  in  such  instances  have  been  recorded 
(Button  and  Kanoky).  Phenacetin  (Morris,  Pringle)  or  acetanilid  will 
occasionally  favorably  influence  the  itching.  In  severe  cases  narcotics 
are  necessary  to  procure  sleep,  but  are  to  be  avoided  if  possible.  General 
galvanization  and  static  insulation  are  measures  which  may  be  of  service. 
In  persistent  cases  in  children  the  possibility  of  circumcision  having  a 
favorable  effect  should  be  considered. 

Regarding  the  external  treatment,  it  will  be  found  that,  as  a  rule, 
lotions  of  an  antipruritic  character  will  give  the  most  relief.  Blebs,  if 
present,  should  be  opened  and  evacuated.  In  some  cases  weak  alka- 
line and  bran  and  gelatin  baths  are  comforting.  Liquor  carbonis  deter- 
gens,  i  or  2  teaspoonfuls  to  a  small  teacupful  of  water,  will  often  be 
serviceable  for  controlling  the  pruritus;  if  well  borne,  and  if  the  weaker 
strengths  afford  no  relief,  this  preparation  may  be  used  in  stronger 
proportion,  often  up  to  the  pure  solution.  Ichthyol,  in  an  aqueous 
lotion,  from  2  to  10  per  cent,  in  strength,  is  also  of  value.  Resorcin, 
from  a  i  to  a  5  per  cent,  solution;  carbolic  acid,  from  i  to  3  drams  (4.-! 2.) 
to  the  pint  (500.)  of  water,  with  boric  acid  to  saturation;  liquor  picis 
alkalinus,  from  i  to  3  drams  (4.-! 2.)  to  the  pint  (500.)  of  water,  applied 
cautiously — are  all  of  value  in  some  cases  and  at  different  times  in  the 
same  case.  These  may  be  often  advantageously  supplemented  by 
bland  dusting-powders  or  by  the  mild  ointments,  such  as  that  of  zinc 
oxid,  cold  cream,  and  the  petroleum  ointments,  plain  or  carbolized  or 
with  from  i  to  10  grains  (0.065-0.65)  of  menthol  to  the  ounce  (32.). 
At  times  the  washes  are  not  well  borne;  then  the  ointments  already 
named  and  the  other  mild  ointments  used  in  eczema  may  be  employed 
alone  with  greater  benefit.  An  ointment  of  value  is  one  made  up  of 
from  i  to  2  drams  (4--8.)  of  liquor  carbonis  detergens  to  the  ounce  (32.) 
of  simple  cerate.  Sulphur  ointment  in  the  vesicular  and  vesicobullous 
and  pustular  varieties  of  the  disease,  rubbing  it  in  vigorously  so  as  to 
break  down  the  lesions,  is  sometimes  serviceable  (Duhring,  Mackenzie), 
but  it  is  a  strong  application,  and  must  be  tried  cautiously.  Lassar 
commends  tar  baths  and  tar-and-sulphur  ointment  as  of  considerable 
curative  value. 

PEMPHIGUS 

Synonyms— Fr.,  Pemphigus;  Ger.,  Pemphigus;  Blasenausschlag. 

Definition.— Pemphigus  is  an  acute  or  chronic  bullous  disease, 
characterized  by  the  formation  of  scanty  or  numerous  irregularly 
scattered,  variously  sized,  rounded  or  oval  blebs,  arising  from  appar- 
ently normal  or  moderately  reddened  skin,  and  which  may  or  may 
not  be  accompanied  by  mild  or  severe  constitutional  disturbance. 

Numerous  so-called  varieties  of  this  rare  and  as  yet  obscure  disease 
have  been  described,  based  chiefly  upon  the  duration,  age  of  the  patient, 
and  the  clinical  characters  and  behavior  of  the  eruption.  The  division 
is  in  many  respects  purely  arbitrary.  The  whole  subject  of  pemphigus 
is,  in  fact,  at  present  chaotic,  and  it  is  a  matter  of  difficulty  even  to  the 
trained  dermatologist  to  know  what  to  include  and  what  not  to  me  ude 
under  this  head.  Many  of  the  cases  formerly  considered  in  this  class, 


372  I  NFL  A  MM  A  TIONS 

and  still  so  considered  by  some  German  writers,  have  been  gathered 
together  to  form  the  group  constituting  the  dermatitis  herpetiformis  of 
Duhring.1 

The  presence  of  a  bleb  or  blebs  does  not,  however,  as  often  con- 
sidered by  many  physicians,  constitute  pemphigus,  as  such  lesions  are 
often  seen  as  an  accidental  or  unusual  manifestation  in  other  diseases, 
such,  for  example,  in  urticaria  (urticaria  bullosa),  erythema  multiforme 
(erythema  bullosum),  dermatitis  herpetiformis,  just  referred  to,  pom- 
pholyx,  dermatitis  venenata,  leprosy,  and  some  others.  On  the  con- 
trary, pemphigus  is  a  malady  in  which  the  lesions  consist,  primarily  at 
least,  of  distinct  watery  rounded  blebs,  of  more  or  less  general  distribu- 
tion, without  ring  or  other  peculiar  formation  or  special  tendency  to 
group,  and  appearing  irregularly  or  in  successive  crops,  and,  as  a  rule, 
running  a  chronic  course,  with  exacerbations.  The  subjective  symptoms 
usually  consist  of  tenderness,  soreness,  and  burning,  and  less  frequently 
itching. 

The  varieties  of  pemphigus  can  be  described  under  the  heads  of  pem- 
phigus acutus,  pemphigus  chronicus,  pemphigus  foliaceus,  and  pemphigus 
vegetans.  The  terms  "benignus,"  "malignus,"  "gangraenosus,"  "haemor- 
rhagicus,"  etc.,  sometimes  added  to  pemphigus,  are  self-explanatory. 

The  cases  described  under  the  headings  "Pemphigus  Contagiosus" 
Pemphigus  Neonatorum,  Pemphigus  Epidemicus,  etc.,  while  included, 
really  represent,  I  believe,  extensive  and  grave  types  of  impetigo  con- 
tagiosa. 

Symptoms. — Pemphigus  Acutus.2 — -Acute  pemphigus  includes  all 

1  Recent  papers  on  the  classification  of  bullous  diseases  by  Bowen  and  by  Bronson, 
with  discussion,  are  to  be  found  in  the  Trans.  Amer.  Derm.  Assoc.  for  1905,  and  Jour. 
Cutan.  Dis.,  1906,  pp.  110-217,  and  by  Corlett,  ibid.,  1906,  p.  464  (an  analysis  of  65 
bullous  cases);  Zeisler,  "Pemphigus,"  Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlix,  p.  270 
(with  report  of  cases).     Winfield,  "Pemphigus  and  Bullous  Dermatoses,"  Jour.  Cutan. 
Dis.,  1908,  p.  566  (with  bibliography);  Macleod,  "The  Present  State  of  Our  Knowledge 
of  Pemphigus,"  Practitioner,  1909,  No.  82,  p.  371;  Pernet,  "Pemphigus  and  Dermatitis 
Herpetiformis,"  Brit.  Jour.  Derm.,  Jan.,  1910,  reports  a  case  of  acute  septic  pem- 
phigus in  a  woman,  followed  after  convalescence  and  recovery  by  an  eruption  of  the 
type  of  dermatitis  herpetiformis;  Hartzell,  "Toxic  Dermatoses;  Dermatitis  Herpeti- 
formis, Pemphigus,  and  Some  Other  Bullous  Affections  of  Uncertain  Place,"  Jour. 
Cutan.  Dis..  1912,  p.  119;  Brocq,  Annales,  Jan.,  1912,  p.  i,  endeavors  to  simplify  and 
clarify  the  complicated  subject  of  the  classification  of  the  bullous  diseases. 

2  Some  literature  on  acute  pemphigus:  Pernet  and  Bulloch,  "Acute  Pemphigus:  A 
Contribution  to  the  Etiology  of  the  Bullous  Eruptions,"  Brit.  Jour.  Derm.,  1896,  pp. 
157  and  205.     This  admirable  paper  refers  to  the  various  acute  types,  especially  to  that 
in  adults  due  to  infection  from  animals  or  their  products.     The  subject  is  presented  in 
its  clinical,  etiologic,  bacteriologic,  and  histopathologic  aspects — with  numerous  litera- 
ture references.     The  reader  is  referred  to  this  paper  for  many  references  made  in  my 
own  text,  especially  as  to  bacteriologic  findings.     Hadley  and  Bulloch,  Lancet,  May  6, 
1899  (fatal  case  in  butcher,  starting  in  finger  injury);  Ravogli,  Cincinnati  Lancet- 
Clinic,  April  27,  1889,  p.  481;  Schamberg,  Annals  of  Gynecology  and  Pediatry,  Feb., 
1901,  p.  321  (fatal  case,  apparently  due  to  vaccination);  Whipham,  Lancet,  1896,  i,  p. 
1219  (2  cases;  arsenic  treatment,  i  death,  i  recovery;  with  some  bacteriologic  experi- 
ments by  S.  R.  Wells);  Robinson,  Manual  of  Dermatology,  p.  234;  Rose,  Montreal  Med. 
Jour.,  Jan.,  1899,  p.  50  (in  the  course  of  a  fatal  case  of  alcoholic  delirium) ;  Caie,  Brit.  Med. 
Jour.,  1903,  vol.  i,  p.  308,  a  case  of  acute  malignant  pemphigus,  ending  fatally  in  twelve 
days;  the  patient,  a  male  adult,  worked  among  cattle,  and  shortly  before  the  erup- 
tion had  pricked  his  hand  while  washing  sheep;   Howe,  "Cases  of  Bullous  Dermatitis 
Following  Vaccination,"  Jour.  Cutan.  Dis.,  1903,  p.  254  (with  several  case  illustrations; 
a  series  of  10  cases,  all,  except  i,  occurring  in  those  recently  vaccinated;  6  of  these  cases 
died);    Bowen,  "Acute   Infectious  Pemphigus  in  a  Butcher,  During  an  Epizootic  of 


PEMPHIGUS 


those  cases  in  which  the  course  is  more  or  less  limited,  and  the  termi- 
nation, within  several  weeks  or  a  few  months,  in  recovery  or  death. 
Its  occurrence  has  been  denied,  but  occasional  observations,  now  con- 
siderable in  number  (Damon,  Rayer,  Cazenave,  Neumann,  Allen, 
Payne,  Behrend,  Shillitoe,  Roach,  Van  Harlingen,  and  others),  leave 
no  doubt  as  to  its  existence.  It  is,  however,  rare,  and  seen  for  the  most 
part  in  children  of  early  age,  although  it  is  also  exceptionally  seen  in 
the  adult.  It  is  occasionally  observed  (Hardy)  in  young  girls  between 
the  period  of  puberty  and  full  sexual  maturity  with  menstrual  difficulties 
(so-called  pemphigus  virginum,  pemphigus  hystericus).  In  its  clear 
type  (blister  fever,  febris  bullosa,  pemphigus  febrilis)  the  eruption 
usually  comes  out  suddenly,  with  premonitory  symptoms  of  malaise, 
slight  or  severe  febrile  action,  chilliness  or  rigors,  and  other  evidence  of 


Fig.  89. — Pemphigus  in  a  negress  aged  thirty-one,  of  two  months'  duration,  showing 
the  fresh,  tense,  and  older  flaccid  blebs  on  upper  arm;  eruption  general.  Irregular 
febrile  disturbance,  but  otherwise  patient's  health  seemed  good. 

mild  or  grave  systemic  disturbance.  The  lesions  are  variously  sized 
from  that  of  a  pea  to  that  of  a  pigeon's  egg  or  larger,  are  generally  quite 
abundant,  and  irregularly  distributed  over  the  surface;  they  are  dis- 

Foot  and  Mouth  Disease,  with  a  Consideration  of  the  Possible  Relationship  of  the  Two 
Affections,"  Jour.  Cutan.  Dis.,  1904,  p.  253  (reviews  the  subject  of  acute  pemphigus, 
especially  as  to  its  possible  origin  from  animal  sources,  and  gives  a  resume  of  reported 
cases  with  references);  Saundby,  Lancet,  Oct.  i,  1904,  reports  a  case  of  acute  pem- 
phigus in  a  butcher's  apprentice;  Corlett's  case,  Jour.  Cutan.  Dis.,  1908,  p.  7,  with 
circulate  and  hemorrhagic  bullous  lesions,  apparently  due  to  streptococcic  infection 
and  ending  fatally,  seems  to  me  to  belong  here  rather  than  in  the  group  erythema  mul- 
tiforme  as  reported;  Grindon,  "Acute  Septic  Pemphigus,"  ibid.,  1900,  p.  439  (death; 
case  illustration;  patient  had  to  do  with  cattle  and  other  animals);  Pollitzer,  "A  Fatal 
Case  of  Bullous  Dermatitis,"  Jour.  Cutan.  Dis.,  1911,  p.  209 —  a  male,  aged  fifty-six, 
beginning  as  an  intensely  itchy  erythrodermia,  and  later  developing  pemphigoid  lesions, 
and,  soon  after,  profound  toxemia;  had  been  in  good  health  except  for  a  chronic  diffuse 
nephritis  which  had  apparently  given  no  trouble;  death  within  six  weeks;  post-mortem 
and  bacteriologic  findings  and  experimental  inoculations  negative. 


374 


INFLAMMA  TIONS 


tended  or  somewhat  flattened,  come  out  at  one  time  or  in  rapid  succession 
or  in  distinct  crops,  and,  as  a  rule,  arise  from  skin  showing  no  preliminary 
change;  sometimes,  however,  from  a  slightly  hyperemic  surface.  Some 
are  usually  surrounded  by  a  narrow  red  halo.  Generally  clear  at  first, 
they  often  become  milky  and  opaque,  sometimes  hemorrhagic,  and 
exceptionally  gangrenous.  In  other  instances  the  eruption  is  unaccom- 
panied by  pronounced  constitutional  involvement,  and  in  others  the 
febrile  action  and  other  systemic  symptoms  of  varied  nature  continue 
for  the  first  week  or  two,  until  subsidence  of  the  cutaneous  phenomena 
sets  in;  in  such  instances  complete  recovery  usually  takes  place  in  several 
weeks  to  one  or  two  months. 

In  some  of  the  febrile  cases  grave  symptoms  present  or  continue 
to  increase  in  severity,  the  throat  and  mouth  show  serious  involvement, 
the  blebs  become  flaccid  and  puriform,  and  exceptionally  the  under- 
lying surface,  gangrenous  (Lenhartz),  and  death  follows  in  one  to 
several  weeks.  In  some  instances  the  disease,  after  the  more  acute 
outbreaks  have  subsided,  gradually  becomes  less  active,  the  lesions 
are  less  numerous,  and  it  goes  into  the  chronic  form. 

The  blebs  disappear,  sometimes  partly  by  absorption,  with  desic- 
cation and  crusting,  or  sometimes  purely  by  desiccation  and  crusting, 
with  or  without  previous  accidental  or  spontaneous  rupture;  when 
the  crust  falls  off,  slight  temporary  redness  or  staining  is  noted,  but 
there  is  no  permanent  trace  left. 

The  acute  type  is  usually  observed  as  isolated  cases,  but  it  has,  or 
a  disease  simulating  it,  been  observed  (Colrat,  Kohler,  Bernstein,  and 
others)  to  occur  hi  epidemic  form  (pemphigus  epidemicus,  pemphigus 
contagiosus) ;  in  some  instances  with  but  slight  constitutional  symp- 
toms or  entirely  free  from  such,  and  in  others  moderately  active  and  oc- 
casionally severe.  These  doubtless  are  similar  to  the  contagious  or 
infectious  cases  observed  in  the  newborn — pemphigus  neonatorum 
— to  be  referred  to.  It  is  highly  probable  that  many  of  the  reported 
epidemic  and  contagious  cases  are  examples  of  impetigo  contagiosa 
and  bullous  varicella.  The  benign  pemphigus  contagiosus  described 
by  Manson  as  quite  common  in  the  tropics  is  probably  a  variety  of 
impetigo  contagiosa;  it  is  usually  diffused  in  children,  but  in  adults 
chiefly  about  the  axillary  and  genito-crural  regions,  and  in  the  latter 
sometimes  representing  doubtless  "dhobie  itch." 

Pemphigus   Acutus   Neonatorum1   (Pemphigus    neonatorum;    Pem- 

1  Literature  bearing  upon  pemphigus  neonatorum,  pemphigus  epidemicus,  and 
pemphigus  contagiosus:  Staub,  "Ueber  den  Pemphigus  der  neugeborenen  und  der 
Wocherinnen,"  Bericht  des  II.  Internal.  Dermatolog.  Congress,  1892,  p.  699;  Strelitz, 
"Bacteriologische  Untersuchungen  iiber  den  Pemphigus  neonatorum,"  Archiv  fur  Kin- 
derheilkunde,  1890,  vol.  xi,  p.  7;  and  1893,  vol.  xv,  p.  101;  Peter,  "Zur  Aetiologie  des 
Pemphigus  neonatorum,"  Berlin  klin.  Wochenschr.,  1896,  p.  124  (in  infant  suckled  by 
septicemic  mother);  Zechmeister,  "Ueber  Pemphigus  neonatorum,"  Miinchener  med. 
Wochenschr.,  1887,  p.  737 — abstract  in  Archiv,  1888,  p.  271  (in  76  births  under  charge 
of  one  midwife  28  cases  developed,  of  which  6  were  fatal);  Wichmann,  "Epidemic  von 
Pemphigus  Contagiosus,"  Tidsskrift  fiir  praklisk  Medicin,  1887,  No.  21 — abstract  in 
Archiv,  1888,  p.  423  (in  the  newborn;  23  cases,  of  which  3  died — all  the  children  born 
under  the  care  of  the  same  midwife);  Jiikovsky,  "Pemphigus  neonatorum,"  Vratch, 
No.  15,  1891,  p.  357 — abstract  in  Brit.  Jour.  Derm.,  1891,  p.  368  (12  infants,  of  which 
4  died — all  born  under  care  of  same  midwife);  Kilham,  "An  Epidemic  of  Pemphigus 


PEMPHIGUS  375 

phigus  neonatorum  contagiosus;  Pemphigus  epidemicus;  Pemphigus 
contagiosus). — The  cases  usually  included  under  this  subheading  of 
acute  pemphigus,  and  formerly  believed,  and  still  believed  by  a  few 
observers,  to  represent  a  distinct  pemphigus  type,  are  those  observed 
a  few  days  after  birth,  many  of  which  run  a  short,  mild  course,  others 
going  on  to  a  rapidly  fatal  termination.  Almost  all,  and  probably 
all,  these  cases,  as  Richter's  analytical  study  and  later  observations 

Neonatorum,"  Amer.  Jour,  of  Obstet.,  1889,  p.  1039  (12  cases,  all  mild;  bacteriologic 
examination  negative);  Homolle,  "Epidemic  of  Acute  Pemphigus  in  the  New-born," 
Gazette  Hebdom.,  Nov.  13,  1874 — abstract  in  Arch.  Derm.,  1875,  P-  *54  (among  79 
births  but  few  escaped;  the  disease  was  mild,  but  i  case  ending  fatally;  inocu- 
lation experiments  negative);  Corlett,  Indiana  Med.  Jour.,  Nov.,  1893,  p.  158; 
Moldenhauer,  "Ein  Beitrag  zur  Lehre  vom  Pemphigus  acutus,"  Archil)  fur  Gynakol., 
1874,  vol.  vi,  p.  369  (101  cases  observed  in  a  period  of  about  a  year — mild,  and  dis- 
tribution, character,  and  behavior  indicate  that  they  were  cases  of  impetigo  conta- 
giosa);  Klemm,  "Zur  Kenntniss  des  Pemphigus  contagiosus,"  Deutsches  Archiv  fur 
klin.  Medicin,  1871,  vol.  ix,  p.  199  (28  cases  are  reported,  and  a  study  of  which  leaves 
but  little  doubt  that  they  were  examples  of  impetigo  contagiosa);  Faber,  "Ueber  den 
acuten  contagiosen  Pemphigus,"  Monatshefte,  1890,  vol.  x,  p.  253  (an  analytic  paper 
of  reported  cases,  indicating  the  probability  that  many  were  impetigo  contagiosa); 
Greer,  "Puerperal  Septicemia  and  Pemphigus  Neonatorum,"  Brit.  Med.  Jour.,  1894, 
i,  p.  1241;  Holt,  "Pemphigus  Neonatorum"  (i  case  associated  with  general  infection 
with  staphylococcus  pyogenes;  death),  N.  Y.  Med.  Jour.,  1898,  i,  p.  175;  Solbrig, 
"Pemphigus  neonatorum,"  Zeitschrift  fur  Med.-Beamte,  1900,  vol.  xiii,  p.  41;  Kohler, 
"Ueber  die  Diagnose  und  Pathogenese  akuter  Blasenbildung  der  Haut  nebst  kasuis- 
tischem  Beitrag  zur  'Febris  bullosa' "  (small  epidemic  of  7  cases,  i  of  which  died), 
Deutsches  Archiv  fur  klin.  Medicin,  1899,  vol.  Ixii,  p.  579;  Bernstein,  "Ein  Beitrag 
zur  Kenntniss  des  Pemphigus  neonatorum  acutus"  (5  cases,  infants  and  adult;  some- 
what suggestive  of  impetigo  contagiosa,  although  the  reporter  excludes  this,  and  ex- 
perimental inoculations  were  negative),  Monatshefte,  1899,  vol.  xxviii,  p.  19;  Bloch, 
"Pemphigus  neonatorum,"  Archiv  fur  Kinderheilk.,  1900,  vol.  xxviii,  p.  61  (an  obser- 
vation of  20  cases,  some  fatal;  clinical,  anatomic,  and  bacteriologic  aspects  are  pre- 
sented); Knocker,  "Pemphigus  Neonatorum"  (2  cases,  mild  in  type;  had  been  de- 
livered and  looked  after  by  the  same  nurse),  Brit.  Jour.  Derm.,  1898,  p.  195;  Beck, 
"Aetiologie  des  Pemphigus  neonatorum"  (i  case — death;  cocci,  usually  paired,  found 
in  lesions  and  blood) — abstract  in  Monatshefte,  1899,  vol.  xxviii,  p.  410;  Windisch, 
"Pemphigus  Contagiosus  Tropicus,"  Jour.  Amer.  Med.  Assoc.,  1900,  vol.  xxxiv,  p.  77; 
Munro,  "Pemphigus  Contagiosus  (tropicus),"  Brit.  Med.  Jour.,  April  29,  1899,  p.  1021; 
Finlay,  "Pemphigus  Contagiosus  Tropicus,"  Austral.  Med.  Gaz.,  1898,  p.  114;  Brosin, 
"Pemphigusiibertragungen  im  Wirkungskreise  einzelner  Hebammen"  (2  epidemics;  in 
a  total  of  64  confinements  18  cases,  7  of  which  died),  Zeitschrift  fur  Geburtshulfe  und 
Gynakologie,  1899,  vol.  xl,  p.  418;  P.  Richter,  "Ueber  Pemphigus  neonatorum,"  Derma- 
tolog.  Zeitschr.,  1901,  vol.  viii,  Nos.  5  and  6,  reviews  most  thoroughly  the  whole  subject 
(over  100  pages,  with  20  pages  of  references);  he  concludes  that  the  dermatitis  exfolia- 
tiva  neonatorum  of  Ritter  is  a  variety,  and  that  pemphigus  neonatorum  also  bears  a 
relation  to  impetigo  contagiosa,  the  characters  of  the  newborn  skin  being  responsible 
for  the  clinical  differences;  it  is  due  to  the  presence  of  a  staphylococcus  of  a  doubtful 
nature,  with  a  group,  more  malignant,  infected  with  streptococci  or  mixed  staphylo- 
cocci  and  streptococci.  G.  J.  Maguire,  "Acute  Contagious  Pemphigus  in  the  New- 
born," Brit.  Jour.  Derm.,  1903,  p.  427  (indicative  of  its  identity  or  allied  nature  to 
bullous  impetigo  contagiosa);  Adamson,  "Pemphigus  Neonatorum  in  the  Light  of 
Recent  Research,"  ibid.,  p.  447  (conclusion  as  to  its  being  an  infantile  form  of  impetigo 
contagiosa);  Crary,  "A  Case  of  Acute  Septic  Pemphigus,"  Jour.  Cutan.  Dis.,  1906,  p. 
14  (with  review  and  bibliography);  Schwartz  (Geo.  T.  Elliot's  Service),  "An  Epidemic 
of  Pemphigus  Neonatorum,"  Bull,  of  Lying-in  Hosp.  of  New  York,  June,  1908  (with 
case  and  histologic  illustration;  there  were  27  cases  in  all,  22  of  the  27  developing  be- 
tween the  fourth  and  seventh  day;  7  died  and  most  of  these  died  on  the  fourth  to  tenth 
day  of  the  disease;  cultures  from  blebs,  before  and  after  death,  showed  only  a  staphy- 
lococcus; there  was  distinct  evidence  of  the  contagious  nature  of  the  disease;  the  mild 
cases,  running  a  benign  course,  would  have  been  looked  upon,  the  writer  states,  as 
impetigo  contagiosa;  Foerster,  "Pemphigus  Neonatorum,  or  Bullous  Impetigo  Con- 
tagiosa of  the  New-born,"  Jour.' Amer.  Med.  Assoc.,  1909,  vol.  liii,  p.  358  (review,  with 
literature  references). 


376 


INFLAMMA  TIONS 


by  others  indicate,  should  be  viewed  as  probably  a  type,  possibly  a 
variant  or  contaminated  type,  of  bullous  impetigo  contagiosa.1  Two 
forms  are  usually  distinguished,  the  grave  type,  which  sometimes  re- 
sembles pemphigus  foliaceus  and  Ritter's  disease,  and  a  mild  or  benign 
form.  The  mild  type,  of  which  a  number  of  instances  have  been  re- 
corded (Olshausen  and  Mekus,  Ravogli,  Corlett,  Kilham,  Padosa, 
Crocker,  Knocker,  and  others),  is  usually  entirely  free  from  systemic 


Fig.  oo. — Acute  pemphigus,  with  bleb  walls  largely  rubbed  off  or  collapsed; 
simulated  the  lesions  of  an  impetigo  contagiosa  in  the  earliest  part;  in  some  places 
patches  becoming  larger  by  a  spreading  undermining  serous  exudation;  lesions  were 
almost  all  more  or  less  flaccid  and  flat;  fatal  ending. 

disturbance,  is  of  acute  onset,  and  is  seen  in  the  newborn,  usually  in 
the  first  several  days  of  life.  The  lesions  are,  as  a  rule,  not  very  numer- 
ous, and  while  they  may  be  seated  upon  any  part,  are  observed  most 
frequently  or  abundantly  about  the  lower  trunk  and  thighs.  The 
eruption  may  however,  be  quite  extensive  and  of  general  distribution. 
A  favorable  termination  is  reached  in  the  course  of  a  few  weeks. 

1  It  is  not  improbable  that  even  dermatitis  exfoliativa  neonatorum  might  be  very 
properly  viewed  in  the  same  light. 


PEMPHIGUS  377 

On  the  other  hand,  cases  are  reported  (Tilbury  Fox,  Staub,  Peter, 
Greer,  Moldenhauer,  Klemm,  Brosin,  and  others)  of  severe  and  grave 
characters.  The  eruption  may  be  somewhat  sparse  or  abundant,  and 
there  is  accompanying  febrile  action  as  observed  in  ordinary  acute 
pemphigus  cases  already  described,  with  septic  symptoms;  or  there 
may  be  practically  absence  of  fever,  and  yet  the  cases  terminate  fatally 
(Brosin). 

Pemphigus  Chronicus. — Under  chronic  pemphigus  belong  most  of 
the  cases  usually  met  with,  and  to  which  the  name  of  pemphigus  vulgaris 
is  also  applicable.  It  is,  like  other  varieties,  rare,  and  especially 
in  this  country.  Its  chief  distinction  from  the  others  is  that  the  blebs 
continue  to  appear  incessantly,  the  skin  being,  as  a  rule,  never  free. 
On  the  other  hand,  there  may  be  shorter  or  longer  intervals  of  compara- 
tive or  complete  freedom.  The  lesions  appear  irregularly,  one  or  several 
at  a  time,  or  there  are  distinct  crop-like  exacerbations,  the  blebs  appear- 
ing in  numbers.  Probably  most  commonly  they  make  their  appearance 
in  numbers  for  several  days  or  more;  these  subside,  crust  over,  and  dis- 
appear, during  which  time  and  for  a  few  weeks  or  longer  scattered  lesions, 
in  scanty  number,  arise,  and  then  another  moderate  or  extensive  out- 
break manifests  itself,  and  so  the  malady  continues  indefinitely.  The 
mouth  and  throat  in  occasional  cases  are  also  noted  to  exhibit  the  erup- 
tion, and  exceptionally  the  disease  may  have  its  beginning  in  these  parts. 
In  rare  instances  the  conjunctivas  (pemphigus  conjunctiva?)  are  also 
invaded,  and  sometimes  accompanied  by  shrinking  of  the  parts  (von 
Graefe,  Morris  and  Roberts,  Fuchs,  and  others).1  The  blebs  are  usually 
well  distended,  pea-  to  small  egg-sized,  scattered,  or  often  close  together, 
several  occasionally  coalescing,  although  there  is  but  little  tendency 
to  grouping.  A  slight  admixture  of  blood  is  sometimes  noted,  and 
in  exceptional  cases  this  may  be  quite  decided  (pemphigus  haemorrhagi- 
cus).  An  individual  lesion,  as  in  the  other  varieties,  runs  its  course, 
and  crusts  over  in  several  days  to  two  weeks.  No  permanent  trace 
is  left  by  the  eruption,  but  on  areas  frequently  covered  with  recur- 
rent lesions  slight  pigmentation  may  show  itself.  In  the  mild  cases 
there  are  no  constitutional  symptoms;  in  others  chilliness  and  febrile 
action  preceding  or  accompanying  the  original  outbreak,  subsiding 
and  again  presenting  at  the  time  of  the  exacerbations;  in  still  others 
of  the  more  extensive  type  the  systemic  disturbance  is  more  or  less 
continuous.  The  subjective  symptoms  of  burning,  soreness,  and 
itching  (pemphigus  pruriginosus)  may  be  present  in  variable  degree; 
itching  is  rarely  troublesome  and  often  absent.  The  disease  may 
finally  end  in  recovery  or  terminate  fatally,  its  course  being  usually 
long  and  indeterminate. 

1  Morris  and  Roberts,  "Pemphigus  of  the  Skin  and  Mucous  Membrane  of  the 
Mouth,  Associated  with  'Essential  Shrinking'  and  Pemphigus  of  the  Conjunctivae, 
Brit.  Jour.  Derm.,  1889,  p.  176,  and  Monatshefle,  1889,  vol.  viii,  p.  437  (a  report  of  a 
case,  with  colored  plate,  and  a  tabulation  and  references  of  28  previously  reported 
cases);  Meneau,  Jour.  mal.  Cutan.,  Jan.,  1905,  gives  an  extensive  review  of  different 
forms  of  pemphigus  as  involving  the  mucous  membrane,  especially  of  the  conjunctiva, 
nose,  mouth,  throat,  and  larynx  (with  complete  bibliography);  Cocks,  Jour.  Amer. 
Med.  Assoc.,  Nov.  24,  1906,  p.  1736,  records  a  fatal  case  in  which  the  eruption  was 
limited  to  the  mucous  membranes. 


378  JNFLAMMA  TIONS 

Pemphigus  Foliaceus.1 — This  variety,  which  is  extremely  rare,  may 
assume  its  peculiar  features  from  the  start  or  it  may  develop  from  an 
acute  or  chronic  pemphigus  of  the  ordinary  character;  in  other  in- 
stances it  has  begun  as  a  superficial  generalized  cutaneous  edema 
(Quinquard),  as  a  scaly  greasy  surface  (Besnier),  as  a  dermatitis  her- 
petiformis  (Hallopeau  and  Fournier).  It  is  characterized  by  the 
formation  of  blebs  so  rapidly  and  so  quickly  repeated  that  the  dis- 
tended bulla  is  not  seen.  It  is  flat  and  but  slightly  raised,  and  is  scarcely 
dried  to  a  crust  before  another  flaccid  lesion  forms  beneath.  Or  the 
blebs  appear,  but  instead  of  being  distended  and  elevated,  are  flaccid 
and  flat,  become  purulent,  break  or  are  accidentally  ruptured,  and 
then  a  gradual  undermining  of  the  surrounding  epidermis  is  noted. 
The  eruption  is  usually  abundant  and  generally  distributed,  and  may, 

1  Literature  of  pemphigus  foliaceus:  Nikolsky,  "Contribution  a  la  question  du  pem- 
phigus foliace  de  Cazenave,"  These  de  doctoral,  Kieff,  1896  (refers  cases  of  Cazenave, 
Plieninger,  Bazin,  Guibout,  Meyer,  Munro  and  Swarts,  Sormani,  Besnier  (2  cases), 
Hallopeau  and  Fournier  (3  cases),  Petrini  (3  cases),  Regensburger,  and  Dumesnil  de 
Rochemont — 17  cases  in  all);  Lausac,  "Du  pemphigus  foliace  mixte  primitif,"  These  de 
doctoral,  Toulouse,  1898  (reports  i  case  and  refers  to  28  cases  previously  observed  by 
others — brief  abstract  of  his  own  case  and  conclusions  in  Annal-es,  1898,  p.  1040; 
Biddle,  "Pemphigus  foliaceous  or  Dermatitis  herpetiformis,"  Jour.  Cutan,  Dis.,  1897, 
p.  203;  Sherwell  (i  case,  with  photo),  Arch.  Derm.,  1877,  p.  97,  and  (same  case — recov- 
ery and  relapse),  Jour.  Cutan.  Dis.,  1889,  p.  453;  Graham  (i  case),  Canadian  Jour. 
Med.  Sci.,  June,  1879;  Hardaway  (i  case),  Jour.  Cutan.  Dis.,  1890,  p.  22;  Munro  and 
Swarts'  case  (ibid.,  1891,  pp.  332  and  423),  already  named  in  Nikolsky's  paper,  seems 
to  partake  of  the  nature  of  both  pemphigus  foliaceus  and  pemphigus  vegetans;  Klotz 
(i  case),  Amer.  Jour.  Med.  Sci.,  Dec.,  1891;  Nasarow  (i  case),  Dermatolog.  Zeitschr., 
1899,  vol.  vi,  p.  719;  Nazaroff  (i  case),  Roussky  Archive  Patologgi,  Feb.,  1900 — abstract 
in  Brit.  Jour.  Derm.,  1900,  p.  258;  Hellier  (i  case — infant  (pemphigus  neonatorum?), 
Brit.  Journ.  Derm.,  1899,  p.  18;  Savine  (i  case),  Jour,  de  med  mil.  russe,  July,  1897; 
abstract  in  Annales,  1898,  p.  597;  Hallopeau  et  Constensoux  (i  case  with  associated 
osteomalacia),  Annales,  1898,  p.  979;  Lindstroem  (3  cases),  ibid.,  1898,  p.  1026;  Leredde, 
"Etude  sur  le  pemphigus  foliace  de  Cazenave,"  ibid.,  1899,  p.  601  (a  study  of  path- 
ology and  pathologic  anatomy,  with  some  literature  references);  Fabry,  Archiv,  June, 
1904,  p.  183  (i  case,  beginning  with  redness  and  scaling,  showing  at  first  a  suggestive  re- 
semblance to  pityriasis  rosea  and  eczema  marginatum  developing  into  pemphigus 
foliaceus);  Brousse  and  Bruc,  Annales,  1905,  p.  853  (i  case;  began  with  an  erythematous 
eruption,  intense  general  itching,  followed  by  bleb  formation,  which  became  generalized, 
and  in  a  month  had  developed  into  the  exfoliative  type;  autopsy  report  and  i  clinical 
and  i  histologic  illustration);  R.  Cranston  Low,  Brit.  Jour.  Derm.,  1909,  pp.  101  and 
135  (2  cases,  both  women;  a  third  case,  with  symptoms  of  both  dermatitis  herpeti- 
formis and  pemphigus  foliaceus;  good  review  of  the  subject,  discussion  of  a  suggestive 
occasional  relationship  with  dermatitis  herpetiformis  and  full  bibliography;  several 
case  illustrations);  ibid.,  1911,  p.  i,  a  fourth  case,  woman  aged  fifty-two,  of  two  years' 
duration,  at  first  diagnosed  as  dermatitis  herpetiformis;  out  of  3  cases  only  i  (the 
last)  gave  a  culture  of  the  bacillus  pyocyaneus;  of  the  previous  cases,  case  i,  the  skin 
condition  still  remains  in  statu  quo;  the  case  3  has  remained  fairly  well,  but  has 
occasional  recurrences  of  an  eruption  of  the  nature  of  dermatitis  herpetiformis;  Scha- 
lek,  Jour.  Amer.  Med.  Assoc.,  July  2,  1910 — male,  aged  thirty-six;  C.  J.  White,  Boston 
Med.  andSurg.  Jour.,  May  4,  1911  (case  report — female  aged  seventy-three,  death  nine 
to  ten  months  after  original  outbreak);  Hazen,  "Pemphigus  Foliaceus,"  Jour.  Cutan. 
Dis.,  1910,  p.  118;  male,  Hebrew  aged  thirty;  had  begun  about  year  before  coming 
under  observation;  bacillus  pyocyaneus  was  demonstrated  in  circulating  blood,  urine, 
and  non-purulent  vesicles,  and  over  the  entire  cutaneous  surface;  staphylococcus  was 
a  secondary  invader;  and  ibid.,  1912,  p.  325,  second  case  in  negro  woman,  aged  fifty- 
one,  dying  about  five  months  after  its  first  appearance;  cultures  from  the  blood,  from 
the  skin  at  large,  and  from  the  outside  of  the  vesicles,  from  old  vesicles,  and  from 
ruptured  vesicles,  gave  the  staphylococcus  albus;  cultures  from  fresh,  unruptured 
vesicles  always  gave  bacillus  pyocyaneus  in  pure  culture;  autopsy;  cultures  were 
made  from  the  heart's  blood,  liver,  spleen,  and  kidneys,  and  all  gave  a  pure  growth 
of  the  bacillus  pyocyaneus;  histologic  illustrations  and  bibliography. 


PEMPHIGUS  279 

indeed,  involve  almost  the  entire  surface.  In  the  latter  instances  a  pic- 
ture is  presented  of  extremely  flaccid,  scarcely  elevated,  seropurulent 
or  purulent  variously  sized  blebs,  with  the  fluid  bulging  them  out  at  the 
most  dependent  portion;  ruptured  lesions  with  a  serous  or  seropurulent 
undermining  of  the  immediate  surrounding  epidermis;  thin  crusts  with 
rapidly  forming  exudation  beneath,  and  large  red,  raw,  oozing  sur- 
faces where  the  crusts  have  been  removed  or  rubbed  off,  and  where 
the  exudation  is  so  rapid  that  a  new  crust  cannot  form.  Exception- 
ally the  surface  remains,  temporarily  at  least,  almost  dry,  the  condi- 
tion resembling  dermatitis  exfoliativa.  Fissuring  occurs,  especially 
about  the  joints,  and  there  is  a  pervading  foul  odor  about  the  patient. 
In  extreme  cases  the  nails  and  hair  are  brittle  and  sometimes  shed, 
the  eyes  are  sore-looking,  the  conjunctivas  may  become  involved,  the 
mucous  membranes  share  in  the  disease,  and  with  increasing  gravity 
of  the  constitutional  symptoms,  and,  in  a  majority  of  the  cases,  the 
patient  finally  succumbs  from  exhaustion,  pyemia,  or  from  some  inter- 
current  disease.  Exceptionally  there  are  long  intervals  of  freedom 
(Sherwell).  The  malady  is  rare,  but  there  has  been  a  gradual  addition 
to  the  number  of  reported  cases  since  the  disease  was  first  described 
(Cazenave,  1850);  in  this  country  cases  have  been  recorded  by  Sherwell, 
Graham,  Hardaway,  Klotz,  Munro  and  Swarts,  Hazen,  C.  J.  White,  and 
a  few  others. 

Pemphigus  Vegetans.1— This  variety,  also  called  erythema  bullosum 

1  Literature  of  pemphigus  vegetans:   Crocker,  "Pemphigus  vegetans  (Neumann)," 
Brit.  Med.  Jour.,  March  16,  1889,  and  London  Med.-Chirur.  Soc'y  Trans.,  1889,  vol. 
Ixxii,  p.  233  (a  bibliography  of  cases  to  date  is  given);  Mapother  (i  case),  ibid,  (re- 
ferred to  in  the  discussion);  Miiller,  Monatshefte,  1890,  vol.  xi,  p.  427  (2  cases,  with 
2  plates  presenting  4  histologic  cuts;  a  brief  review  of  22  other  cases  from  literature, 
with  references,  are  given);  Hyde  (i  case),  Jour.  Cutan.  Dis.,  1891,  vol.  ix,  pp.  412 
and  459;  Lowe,  Lancet,  May  23,  1891;  Haslund,  Hospitalstidende,  1891  (quoted  by 
Crocker);  Herxheimer  (3  cases,  "Festschrift  der  Stadtischen  Krankenhauses  in  Frank- 
furt A.  M.,"  Archiii,  1896,  vol.  xxxvi,  p.  141 ;  Kobner  (2  cases),  Deutsches  Archivfur  klin. 
Medicin,  vol.  liii,  and  vol.  Ivii,  abstracts  in  Annales,  1894,  p.  890,  and  1897,  p.  816; 
Luithlen,  "Pemphigus  vulgaris  et  vegetans,"  Archiv,  1897,  vol.  xl,  p.  682;  Tommasoli, 
Archi-o,  1898,  vol.  xliv,  p.  325;  Neumann,  Wien.  klin.  Rundschau,  1900,  No.  i,  p.  i; 
Pini,  Giorn.  ital.,  1898,  p.  354  (chemical  experimental  researches) — brief  abstract  in 
Annales,  1899,  p.  505;  Phillipson,  et  Filed  (i  case),  Giorn.  ital.,  1896,  p.  354;  Ludwig 
(i  case),  Deutsch.  med.  Wochenschr.,  1897,  p.  267;  Mracek  (i  case),  abstract  in  Annales, 
1898,  p.  919;  Duhring  (i  case),  Cutaneous  Medicine,  part  ii,  p.  456;  Zumbusch,  "Ueber 
Zwei  Falle  von  Pemphigus  Vegetans  mit  Entwicklung  von  Tumoren,"  Archiv,  1904, 
vol.  Ixxiii,  p.  121  (mild  course  with  pedunculated  papillomatous  growths  in  i  case; 
large  areas  of  papillomatous  development  in  i  case  on  forearms,  leg,  and  soles  of  feet 
(Dermatitis  vegetans  (?));  Jamieson  and  Welsh,  Brit.  Jour.  Derm.,  1902,  p.  287,  and 
Dyce  Duckworth,  ibid.,  1903,  p.  26,  and  1904,  p.  245  (histologic  report  by  Little,  ibid., 
p.  138),  each  reports  an  extensive  case — both  fatal;  Hamburger  and  Rubel,  Johns  Hop- 
kins Hosp.  Bull.,  April,  1903,  p.  63,  report  a  fatal  case,  and  review  the  literature;  Zum- 
busch, Archiv,  1905,  vol.  xliii  (2  cases  with  development  of  tumors,  2  colored  plates); 
Ormsby  and  Bassoe  (an  acute  fatal  case  with  autopsy),  Jour.  Cutan.  Dis.,  1905,  p.  294; 
Ravogli,  ibid.,  1906,  p.  311;  Winfield,  ibid.,  1907,  pp.  17  and  71  (with  illustration),  re- 
ports a  fatal  case  with  autopsy,  and  gives  a  brief  analytic  review  of  reported  cases  with 
references;  Constantin,  Annales,  1907,  p.  641  (case  with  features  of  dermatitis  herpeti- 
formis  and  pemphigus  vegetans);  W.  Fox,  Brit.  Jour.  Derm.,  1908,  p.  181  (case  with 
illustration  of  vegetations  in  axillae  developing  upon  an  ordinary  pemphigus,  vegetating 
tendency  subsequently  disappearing,  the  malady  assuming  the  type  of  a  somewhat 
mild  pemphigus);  MacCormac,  ibid.,  p.  277  (vesicles  appearing  nine  days  after  child- 
bed, first  about  the  genitalia;  later,  vesicles  and  bullse  becoming  more  general,  the 
vegetating  tendency  about  axillae  and  lower  abdomen;  death  in  three  and  one-half 
months — references  as  to  bactiorologic  findings)  Fernet,  "Pemphigus  Vegetans  and 


380  INFLAMMATIONS 

vegetans  (Unna)  is  the  rarest  of  all,  and  was  first  described  (Neumann) 
in  1886;  since  then  other  cases  have  been  reported  (Crocker,  Hyde, 
Haslund,  Hutchinson,  Riehl,  Duhring,  and  others).  The  earliest 
manifestations  are  usually  to  be  seen  in  the  mouth,  throat,  or  lips,  and 
consist  of  whitish  or  reddish  plaques;  soon  the  ordinary  blebs  appear 
on  the  integument,  and  these  may  at  first  maintain  the  character  of 
ordinary  pemphigus,  but  after  a  while,  instead  of  going  through  the 
crusting  and  disappearance,  as  usually  noted,  vesicles  or  blebs  form 
around  a  crust ;  the  base  of  such  a  patch  becomes  inflamed,  often  edem- 
atous,  covered  with  a  viscid,  offensive  secretion,  and  finally  exhibits 
papillomatous  or  condyloma-like  vegetations.  Several  such  plaques 
become  confluent  and  form  large  areas.  This  peculiar  development  is 
seen  most  commonly  about  warm  and  moist  surfaces  in  close  contact, 
as  about  the  genital,  anal,  and  axillary  regions.  With  increasing 
constitutional  symptoms  which  are  usually  present  from  the  beginning, 
the  disease,  with  rare  exceptions,  finally  ends  fatally.  In  favorable 
cases  the  process  gradually  declines;  these  seem  to  be  chiefly  those 
in  which  the  eruption  was  scanty  and  mainly  about  the  mouth  (Hutch- 
inson) .  The  malady  is  sometimes  variable  in  its  course,  and  occasionally 
presents  here  and  there  distinct  blebs  in  which  the  vegetating  tendency 
is  not  displayed.  Exceptionally  there  is  observed  a  combination  of 
its  own  peculiar  manifestations  with  the  symptoms  of  pemphigus 
foliaceus.  There  is  usually  temperature  elevation,  somewhat  variable, 
it  is  true,  determined  by  the  extent  and  gravity  of  the  disease;  it  is 
usually  more  marked  at  periods  of  exacerbation  of  the  cutaneous 
phenomena.  On  the  other  hand,  the  body-heat  is  noted  at  times  to  be 
below  normal. 

Utiology. — Pemphigus  is,  fortunately,  extremely  rare,  and  much 
more  so  in  this  country  than  in  Europe.  It  is  met  with  in  both  sexes, 
with  probably  a  slight  preponderance  in  females;  it  is  more  frequent 
in  infants  and  children  than  in  adults.  The  causes  are  obscure.  It  is 
not  due  to  syphilis,  although  this  latter  does  give  rise  to  a  pemphigoid 
eruption,  but  one  entirely  different  in  its  character,  course,  and  behavior. 
It  is  not  hereditary;  the  cases  of  hereditary  tendency  to  bullous  develop- 
ment upon  the  slightest  local  irritation  belong  to  epidermolysis  bullosa 
(q.  i>.).  It  is  probable  that  the  several  so-called  varieties',  iare  due  to  dif- 
ferent causes,  or  at  the  least  the  ingrafting  of  an  accidental  factor  upon 
the  same  disease  process.  Acute  pemphigus  sometimes  has  its  origin 
in  a  septic  wound  (Fernet  and  Bulloch,  Hadley  and  Bulloch) ;  from,  in 
infants,  a  disease  of  the  navel  and  from  puerperal  processes  in  the  mother 
(Staub,  Peter,  Greer).  Pernet  and  Bulloch's  studies,  as  well  as  such 
cases  as  that  reported  by  Bowen,  point  strongly  toward  animals  or  their 

the  Bacillus  Pyocyaneus,"  Brit.  Med.  Jour.,  October  15,  1904  (i  case)  and  "A  Case  of 
Pemphigus  Vegetans,  ilnd.,  Sept.  24,  1910  (i  case);  Pollitzer,  "Pemphigus  Vegetans" 
(starting  as  a  condylomatous  patch  at  anus  in  male  aged  fifty-nine — death  in  about  six 
months),  Festschrift  zur  Vierzigjahrigen  Stiftungsfeier  der  Deutschen  Hospitals,  New 
York,  191 1,  p.  546;  abstract  in  Brit.  Jour.  Derm.,  1911,  p.  335;  Rutherford,  Brit.  Jour. 
Derm.,  1910,  p.  118  (i  case — acute,  death  in  seventeen  weeks);  Hartzell,  "A  Case  of 
Pemphigus  Vegetans,  with  Special  Reference  to  the  Cellular  Elements  Found  in  the 
Lesions,"  Jour.  Cutan.  Dis.,  1910,  p.  in.  Bottelli,  Giorn.  ital.,  full  abstract  in  Brit. 
Jour.  Derm.,  1911,  p.  371,  began  during  pregnancy;  bacteriology  negative;  death. 


PEMPHIGUS  381 

products  as  a  frequent  source;  this  may,  too,  explain  the  cases  following 
vaccination  occasionally,  as,  for  instance,  Howe's  cases.  Bowen  calls 
attention  to  the  similarity  of  some  cases  of  "foot  and  mouth  disease" 
in  cattle  to  acute  pemphigus  in  man.  Doubtless,  in  many  of  these 
acute  cases  just  referred  to,  the  actual  underlying  factor  is  a  strepto- 
coccic  infection.  The  bacillus  pyocyaneus  has  also  been  credited  with 
being  the  cause  in  some  cases.1  Johnston2  believes  we  have  evidence  of 
the  existence  of  an  autotoxic  factor  in  the  production  of  pemphigus  and 
other  bullous  diseases,  a  view  which,  it  seems  to  me,  has  much  in  its 
favor,  but  this  autotoxic  factor  may  be  of  varying  nature  and  origin. 
Other  factors  which  seem  to  be  of  moment  in  the  production  of  the  dis- 
ease are  chills  (Schwimmer,  Crocker),  nervous  influences,  such  as  periph- 
eral nerve  injuries  (Mitchell,  Morehouse  and  Keen,  Mougeot,  Leloir), 
diseases  of  central  nervous  system  (Charcot,  Balmer,  Leloir,  Kopp, 
Schwimmer,  Brissaud,  and  others),  degenerative  changes  in  the  periph- 
eral nerves  and  nerve-centers  (Dejerine,  Quinquaud,  Jarisch,  Mott  and 
Sangster,  and  others),  functional  nervous  disturbance,  and  hysteria- 
pemphigus  hystericus3  (Kaposi,  Hardy,  Jarisch,  Duhring,  and  others). 
Against  these  evidences  must,  however,  be  quoted  the  observation 
(Kaposi  and  Weiss)  that  in  9  fatal  cases,  in  only  i  was  there  structural 
nerve  alteration — diffuse  sclerosis  of  cord. 

That  the  derangement,  functional  or  organic,  of  the  nervous  system 
is  of  etiologic  importance  is  borne  out  by  the  cases  reported  by  the 
writers  just  referred  to,  and  by  the  experience  of  almost  all  others 
who  have  to  do  with  this  disease.  Whether  the  action  is  a  direct  one 
or  merely  contributory  to  a  successful  parasitic  invasion  or  infection  is 
an  unsolved  question.  At  all  events,  whatever  the  role  of  the  nervous 
system  may  be  in  the  chronic  variety,  there  can  scarcely  be  a  doubt 
that  an  important  etiologic  factor  in  many  of  the  acute  cases,  and 
especially  those  in  infants  and  young  children,  particularly  those  of 
epidemic  and  contagious  character,  is  to  be  found  in  micro-organisms. 
Such  findings  have  been  recorded  by  a  number  of  observers  (Alm- 
quist,  Escherich,  Peter,  Luithlen,  Gibier,  Demme,  Sahli,  Claessen, 
Whipham,  Holt,  Beck,4  and  others),  but  there  has  not  been  sufficient 

1  Petges  and  Bichelonne,  "Septicemie  a  bacille  pyocanique  et  pemphigus  bulleux 
chronique  vrai,"  Annales,  1909,  p.  417,  report  a  case,  review  the  subject,  with  refer- 
ences, and  conclude  that  the  bacillus  pyocaneus  can  play  a  r61e  both  in  chronic  bullous 
pemphigus  and  pemphigus  vegetans;  Hazen  (loc.  tit.)  found  this  organism  in  two  cases 
of  pemphigus  foliaceus  and  believes  it  pathogenic  in  some  cases. 

2  Johnston,  Brit.  Med.  Jour.,  Oct.  6,  1906. 

3  C.  J.  White,  "Recurrent,  Progressive,  Bullous  Dermatitis  in  a  Hysterical  Subject," 
Jour.  Cutan.  Dis.,  1903,  p.  415,  reports  a  curious  case  of  bullous  lesions,  the  outbreak 
beginning  usually  on  an  extremity,  and  then  extending  upward,  with  periods  of  freedom, 
and  later  involvement  of  other  parts  (4  other  somewhat  similar  cases  in  literature  are 
briefly  described,  with  references  to  these  and  other  papers  on  allied  subjects).     Coffin, 
Boston  Med.  and  Surg.  Jour.,  April  27,  1911,  p.  612,  gives  details  of  a  case — patient, 
woman  aged  fifty-seven — in  which  oral  cavity,  epiglottis,  and  larynx  were  involved  for 
four  years  without  accompanying  cutaneous  manifestations:   two  years' after  the  onset 
the  eyes  became  involved;  and  two  years  later  the  skin  became  involved  for  the  first 
time,  and  one  year  before  her  death  (five  years  after  beginning),  blebs  appeared  over 
entire  body;  death  from  sepsis  starting  in  a  lesion  on  the  foot. 

4  Lipschiitz,  Archiv,  1912,  cxi,  No.  3,  p.  675 — abstract  in  Jour.  Cutan.  Dis.,  March, 
1913,  (elaborate  study  based  on  n  cases  of  chronic  pemphigus)  has  found  two  distinct 
parasites  in  the  serum  contents  of  the  bullae;  one  he  names  the  "cystoplasma  oviforme," 


382  INFLAMMA  TIONS 

uniformity  to  warrant  positive  conclusions,  although  the  majority  of 
observers  found,  in  pemphigus  neonatorum,1  staphylococcus  aureus 
and  albus;  and  some  were  able  to  produce  the  disease  by  inoculation 
from  lesions  (Moldenhauer,  Koch,  Vidal),  and  also  by  inoculation  from 
cultures  (Almquist,  Strelitz).  A  diplococcus  has  been  found  by  several 
observers  in  acute  pemphigus  (Demme,  Claessen,  Bulloch,  Whipham, 
Beck).  Investigations  by  others  in  both  these  directions  have,  how- 
ever, not  met  with  the  same  positive  results.  The  acute  cases  resulting 
from  septic  infection  already  referred  to  point  likewise  to  micro-organ- 
isms as  a  cause.  The  microbic  view  is  also  supported  by  the  series  of 
cases  of  pemphigus  neonatorum  occurring  in  infants  cared  for  by  the 
same  widwife,  an  observation  repeatedly  made  (Corlett,  Knocker,  and 
several  others).  It  is  probable  that  most  of  these  are  examples  of 
bullous  impetigo  contagiosa,  as  instances  of  transference  to  older  mem- 
bers of  the  family,  etc.,  have  occurred,  and  in  whom  the  lesions  are 
essentially  those  of  this  latter  disease,  a  view  which  is  held  by  most 
observers  (Pontoppidan,  Faber,  Crocker,  Duhring,  and  many  others). 
Another  view  of  the  etiology  of  pemphigus  formerly  held  was  that 
the  malady  is  due  to  defective  kidney  elimination,  and  occasional  acute 
cases  are  noted  to  follow  or  be  associated  with  organic  kidney  disease. 
Urine  examinations  in  most  instances,  however,  disclose  nothing.  As 
in  other  bullous  diseases,  eosinophilia  has  been  noted  (Leredde),  and  a 
diminution  of  the  red  blood-corpuscles  observed  (Hallopeau  and  Leredde, 
Nikolski). 

Pemphigus,  especially  the  acute  form,  has  also  been  observed  to 
follow  rheumatic  fever,  the  exanthemata,  diphtheria,  and  other  acute 
systemic  disorders. 

Pemphigus  vegetans2  seems,  as  noted  by  Hutchinson,  Danlos,  Brocq, 
and  others,  much  more  common  with  those  who  live  in  the  country — 
2  cases  that  came  under  my  observation  were  from  country  districts. 

Pathology. — In  connection  with  pemphigus  lesions  on  the  skin 
organic  changes  have  been  noted,  as  already  remarked,  in  other  struc- 
tures, more  especially  the  nervous  system  in  its  various  parts,  centrally 
to  peripherally,3  the  liver  and  kidneys  have  also  exhibited  disease  in 

measuring  1.5  to  2.7  micra,  with  an  eccentric  nucleus,  extending  through  the  margin 
or  just  bordering  the  periphery;  in  the  same  case  it  may  be  absent  at  times  and  times 
when  present  in  great  numbers;  the  other  organism,  he  names  "anaplasma  liberum," 
is  considerably  smaller,  has  practically  no  cytoplasm,  being  entirely  made  up  of 
chromatin  or  nuclear  substance.  The  exact  relationship  of  the  two  is  not  clear.  He 
found  the  same  present  in  cases  which  pass  as  dermatitis  herpetiformis. 

1  Both  Whitfield  (Brit.  Jour.  Derm.,  1903,  p.  221)  and  Macleod  (Brit.  Med.  Jour., 
1903,  p.  1278)  obtained  pure  cultures  of  a  streptococcus. 

2  Stanziale,  Annales,  1904,  p.  15,  found  in  a  case  of  pemphigus  vegetans  a  diplo- 
bacillus  (probably  identical  with  the  small  diplococcus  of  Waelsch),  and  a  pseudo- 
diphtheritic  bacillus.     The  latter,  he  thought,  played  a  r61e  in  the  production  of  the 
vegetating  lesions.     Hamburger  and  Rubel,  loc.  cit.,  also  isolated:  a  pseudodiphtheritic 
bacillus. 

3  Jamieson  and  Welsh,  loc.  cit.,  found  in  a  well-marked  case  of  pemphigus  vegetans 
distinct  degenerative  changes  of  a  special  character  in  the  nerve-cells  of  the  spinal  cord, 
and  to  a  less  pronounced  extent  of  the  sympathetic  ganglia,  and  the  cerebral  cortex;  con- 
sisting "of  an  evidently  slowly  progressive  rarefaction  of  the  chromophile  bodies  of  the 
protoplasm,  more  especially  in  the  perinuclear  zone,  formation  of  minute  vacuoles  in 
the  altered  portion  of  the  protoplasm,  swelling  of  the  cell-body,  disintegration  of  the 
nucleus,  and,  finally,  destruction  of  the  whole  element." 


PEMPHIGUS  383 

some  cases.  To  a  great  extent,  or  at  least  in  many  instances,  the 
cutaneous  manifestations  must  be  considered  but  a  part  of  a  systemic 
process  or  infection.  This  belief  is  supported  by  the  findings  of  micro- 
organisms referred  to  in  etiology. 

Pathologic  anatomy1  discloses  (Robinson,  Crocker,  Luithlen,  Unna, 
Gilchrist,  Jarisch,  and  others)  that  the  local  changes  in  the  cutaneous 
lesions  are  slightly  varied,  dependent,  doubtless,  upon  the  degree  of 
inflammatory  action  and  the  stage  of  formation,  although  the  bleb  is 
more  superficial  than  obtains  in  herpes.  The  roof-wall  is  the  upper 
horny  layer,  and  the  base  the  rete;  but  in  some  instances  the  inside  of 
the  roof  shows  a  layer  of  rete  cells,  and  in  others  the  corium  is  the  floor 
of  the  lesion.  The  bleb  is  doubtless  due  to  a  sudden  effusion  from  the 
vessels  of  the  corium,  probably  following  paralysis  and  dilatation  of  the 
vessels.2  In  the  early  stage  of  its  formation,  in  most  lesions,  inflamma- 
tory signs  are  slight;  in  others  they  are  present,  usually  but  to  a  moderate 
degree.  The  papillae  are  edematous;  dilatation  of  the  vessels,  emigration 
of  polynuclear  leukocytes,  and  a  variable  amount  of  serous  infiltration 
of  the  tissues  are  noted.  In  pemphigus  vegetans  are  found  (Neumann, 
Riehl,  Kaposi,  Unna3)  marked  hypertrophy  of  the  papillae  and  pro- 
nounced proliferation  of  the  rete,  with  outgrowth  of  the  same;  enlarge- 
ment of  the  superficial  blood-vessels  and  edema  of  the  upper  layers  of 
the  corium. 

The  contents  of  the  lesions  are  neutral  or  alkaline  in  reaction  and 
composed  of  serum,  to  which  are  added  later  pus-cells,  epithelial  cells, 
and  fat;  ammonia  has  been  found  in  it,  as  well  as  in  the  urine;  phos- 
phorus has  also  been  found  and  thought  to  be  due  to  nerve  dis- 
integration. An  increase  of  eosinophile  cells  has,  as  already  stated, 
in  some  instances  been  noted  both  in  the  bullae  and  in  the  blood, 
but  as  yet  no  significance  can  be  assigned  to  this  increase,  as  it  is 
observed  in  vesicles  and  bullae  of  other  maladies  and  even  in  those  of 
artificial  origin.4 

1  Jarisch,  "Zur  Anatomic  und  Pathogenese  der  Pemphigusblasen,"  Archiv,  1898, 
vol.  xliii,  p.  341;  Robinson,  section,  drawing,  and  description  in  Duhring's  Cutaneous 
Medicine,  part  ii;  Gilchrist,  ibid.;  Kromayer,  Dermatologische  Zeitschnft,  1897,  vol. 
iv;  Kreibich,  Archiv,  1899,  vol.  1,  pp.  299,  375;  Luithlen  (Pemphigus  vulg.  et  veg.), 
Archiv,  1897,  vol.  xl,  p.  682,  and  (Pemphigus  neonatorum),  Wien.  kiln.  Wochenschr., 
1899,  p.  69. 

2  According  to  Weidenfeld's  investigations  ("Beitrage  zur  Klinik  und  Pathogenese 
des  Pemphigus,"  Vienna,  1904,  a  monograph  based  on  18  cases:  9  pemphigus  vulgaris, 
4  pemphigus  serpiginosus,  5  pemphigus  foliaceus,  and  i  pemphigus  vegetans),  he  found 
that  in  some  cases  of  pemphigus,  pressure  would  always  provoke  a  bleb,  in  other  cases 
pressure  had  absolutely  no  influence,  while  in  a  third  group  it  was  variable — sometimes 
pressure  producing  a  bleb  and  sometimes  not.     In  the  stages  of  improvement  none  could 
be  provoked,  but  as  soon  as  the  general  condition  (eruption,  etc.)  showed  increase  and 
aggravation,  blebs  could  again  be  provoked  by  pressure.     The  author  explains  this  upon 
the  assumption  of  a  variation  or  disappearance  and  reappearance  of  some  noxious  mate- 
rial having  a  damaging  influence  on  the  circulatory  system. 

3  Hartzell  (loc.  cit.)  found  in  a  flaccid  bleb  from  a  case  of  pemphigus  vegetans  in 
addition  to  eosinophiles,  "a  moderate  number  of  large  round  cells  quite  uniform  in  size 
and  appearance,  lying  here  and  there  among  the  other  cells,  stained  with  eosin,  con- 
taining a  large  cavity  with  a  limiting   membrane  more  deeply  stained  than  the  ring- 
like  body  of  the  cell."     They  resembled  the  "ballooned"  epithelium  found  in  zoster, 
etc.,  although  the  writer  inclined  to  believe  them  quite  distinct. 

4  Hartzell  found  the  eosinophiles  extremely  numerous  in  a  bleb  of  pemphigus  vege- 
tans and  scanty  in  number  in  a  bleb  from  pemphigus  vulgaris. 


INFLAMMA  TIONS 


Diagnosis. — The  disease  is  to  be  distinguished  from  erythema 
bullosum,  urticaria  bullosa,  impetigo  contagiosa,  dermatitis  herpeti- 
formis,  and  the  bullous  syphiloderm. 

In  erythema  bullosum  the  blebs  are  a  part  of  an  eruption  (ery- 
thema multiforme)  in  which  other  characteristic  features  are  usually 
present;  even  when  all  the  lesions  are  bullous  there  is  likely  to  be  a 
circinate  or  ring-like  configuration  with  some,  and  the  eruption  is  gen- 
erally limited  to,  or  more  abundant  on,  certain  regions,  as  the  hands 
and  forearms — erythema  bullosum  never  has  a  general  distribution. 
Moreover,  the  blebs  frequently  spring  from  erythematous  or  inflam- 
matory skin,  and  the  disease  runs  a  rapid  course  without,  as  a  rule, 
any  persistent  or  marked  systemic  symptoms. 


Fig.  91. — Pemphigus — a  beginning  bleb  (a)  between  corium  and  the  epidermis, 
the  bared  papillie  (6)  forming  the  base;  acute  inflammatory  changes  in  the  papillary 
layer  of  the  corium,  with  marked  serous  exudation,  particularly  about  the  vessels; 
reticular  part  of  the  corium  and  the  sweat-glands  (s3,  s4,  s5)  are  practically  normal, 
except  where  the  sweat-ducts  (sl,  s2)  are  involved  in  the  bleb-formation:  d,  corneous 
layer;  e,  rete;  v,  v,  blood-vessels;  c,  cell  masses  at  base;/,  about  the  natural  size  of  bleb 
examined  (courtesy  of  Dr.  T.  Caspar  Gilchrist). 

The  bullous  syphiloderm  is  usually  observed  in  infants  in  the  first 
few  days  or  weeks  of  life;  and  the  lesions  are  often  seen  on  the  palms 
and  soles,  parts  not  commonly  involved  in  pemphigus.  Moreover, 
the  syphilitic  blebs  soon  become  puriform,  form  thick  crusts,  and 
under  which,  as  a  rule,  ulceration  is  noted.  In  syphilis  of  this  type 
other  characteristic  symptoms  are  always  to  be  found.  Pemphigus 
vegetans  bears  strong  resemblance  to  the  vegetating  syphiloderm;  in 
this  latter,  however,  the  disease  remains  more  or  less  limited  to  the 
genital  region  and  around  the  anus,  with  but  little  disposition  to  spread 
extensively,  as  is  observed  in  pemphigus.  Moreover,  in  syphilis  a 
positive  destructive  tendency  is  sometimes  noted,  and  there  is  absence 


PEMPHIGUS  385 

of  any  tendency  to  bleb-formation,  usually  seen  at  some  stage  of  pem- 
phigus vegetans.  The  clinical  history,  the  presence  or  absence  of  other 
syphilitic  lesions  or  symptoms,  examination  for  spirochaetae,  and  the 
Wassermann  test  must  sometimes  be  utilized.  In  pemphigus,  too, 
slight  or  severe  constitutional  involvement  is  usually  noted.  Pem- 
phigus foliaceus  and  dermatitis  exfoliativa  are  sometimes  confounded, 
but  the  dry  character  in  the  latter  and  the  absence  of  mouth  involve- 
ment and  any  tendency  to  bleb-formation  are  different  from  what  are 
observed  in  pemphigus. 

Eczema  rubrum  and  pemphigus  foliaceus  have,  in  a  general  way, 
some  resemblance,  but  the  former  is  never  universal,  and,  indeed, 
rarely  extensive;  the  crusting  of  the  former  is  usually  less  pronounced, 
the  crusts  being  in  small  flakes,  whereas  in  pemphigus  they  are  often 
of  considerable  size ;  moreover,  blebs  are  not  seen  in  eczema,  and  the  char- 
acters of  the  general  symptoms  observed  in  pemphigus  are  wanting. 

It  is  scarcely  possible  to  confound  the  blebs  occasionally  noted  in 
scabies  with  pemphigus;  in  the  former  there  is  never  present  more  than 
a  scant  number,  and  the  other  eruptive  lesions,  together  with  the  dis- 
tribution and  history,  are  entirely  different  from  the  picture  of  pemphi- 
gus. The  differentiation  from  bullous  urticaria,  impetigo  contagiosa, 
and  dermatitis  herpetiformis  will  be  found  discussed  under  those  diseases. 

Prognosis.— Too  much  caution  cannot  be  exercised  in  express- 
ing a  positive  opinion  as  to  the  final  outcome.  As  to  acute  pemphi- 
gus, the  character  of  the  outbreak,  whether  attended  by  active  con- 
stitutional symptoms,  the  behavior  of  the  lesions  (whether  serous, 
purulent,  hemorrhagic,  or  gangrenous),  the  extent  of  the  eruption, 
the  previous  and  present  health  of  the  patient — all  have  a  bearing. 
Those  cases  in  which  more  or  less  grave  systemic  disturbance  presents, 
and  those,  usually  the  same  class,  in  which  the  lesions  become  rapidly 
purulent  or  are  hemorrhagic  or  gangrenous,  are  almost  always  fatal. 
Involvement  of  the  mucous  surfaces  is  of  unfavorable  significance.1 
Even  slight  systemic  disturbance,  especially  chills,  has  a  serious  import. 
The  vegetating  and  foliaceous  varieties  rarely  recover,  but  they  may  be 
of  months'  or  years'  duration.  The  septic  types,  arising  from  a  wound, 
are  grave.  Almost  all  cases  unattended  by  temperature  elevation  or 
other  constitutional  symptoms  get  well,  although  the  possibility  of  chang- 
ing to  a  severe  type  is  to  be  kept  in  mind.  In  short,  the  prognosis  for 
the  milder  cases  is  usually  favorable;  for  the  extensive  and  grave  erup- 
tions, serious.  The  prospect  in  children  is  much  better  than  in  adults. 

In  chronic  cases  the  same  features  bear  upon  the  ultimate  prog- 
nosis: persistence  and  chronicity  are  the  rule,  and  relapses  are  not  un- 
common. Death  usually  takes  place  from  general  septic  infection; 
from  gradual  marasmus,  sometimes  with  diarrhea;  and  occasionally 
from  suddeh  collapse.2 

Treatment.— The    treatment   includes  both  constitutional  and 

1  According  to  Weidenfeld,  "Beitrage  zur  Klinik  und  Pathogenese  des  Pemphigus," 
Vienna,  1904,  those  cases  of  pemphigus  in  which  the  malady  begins  m  th 

the  gravest. 

2  Klotz,  Jour.  Cutan.  Dis.,  1909,  p.  242,  reports  such  a  case. 

25 


386  INFLAMMATIONS 

local  remedies.  The  systemic  treatment,  which  is  of  essential  impor- 
tance in  the  grave  acute  and  in  the  chronic  varieties,  is,  upon  the  whole, 
to  be  based  upon  general  principles,  any  possible  etiologic  factor  being 
corrected,  modified,  or  removed,  the  general  health  built  up,  and  the 
digestive  tract  looked  after.  In  fact,  a  careful  study  of  the  whole 
economy  should  be  made.  The  patient  should  have  the  benefit  of  good 
hygienic  conditions.  There  are,  however,  certain  remedies  which  have 
acquired  deservedly  more  or  less  reputation  of  exerting  a  specific  influ- 
ence. First  in  importance  is  arsenic  (Hutchinson,  Morris,  and  others), 
given  in  safe  but  increasing  doses  up  to  the  point  of  tolerance.  The 
drug  has  in  some  cases  a  controlling  influence,  and  it  is  sometimes  cura- 
tive; its  use  should  be  persisted  in,  as  it  is  usually  after  long  administra- 
tion that  its  beneficial  effects  are  to  be  expected;  it  should  also  be  con- 
tinued in  small  doses  for  some  time  after  the  disease  has  disappeared.1 
Sodium  cacodylate  by  hypodermic  injection  is  sometimes  valuable. 
Strychnin  and  large  doses  of  quinin  are  likewise  useful  in  some  instances. 
These  three  remedies,  arsenic,  quinin,  and  strychnin,  probably  the  most 
valuable  in  this  malady,  can  advantageously  be  prescribed  conjointly. 
Iron  in  full  doses,  cod-liver  oil,  and  linseed  meal  (Sherwell)  are  also  of 
service  in  some  cases.  Opium,  especially  in  the  vegetating  form  (Hutch- 
inson), pilocarpin,  and  atropin  (Crocker),  have  exceptionally  proved  of 
advantage.  It  is  a  good  field  for  the  trial  of  vaccines.  Change  of 
scene  and  climate  is  of  distinct  value  in  some  instances.  The  dietary 
should  be  generous,  but  of  a  plain  and  substantial  character. 

Externally  applications  of  a  soothing  nature  are  the  most  grateful. 
It  is  a  good  rule  to  open  and  evacuate  the  blebs  as  soon  as  they  form, 
immediately  applying  one  of  the  local  remedies.  The  various  lotions 
employed  in  the  acute  type  of  eczema,  especially  those  containing  sedi- 
ments, are  valuable,  and  should  be  applied  freely  by  dabbing  on  or  by 
compresses;  or,  instead  of  lotions,  the  several  dusting-powders  named, 
particularly  those  containing  boric  acid.  In  painful  and  extensive  cases 
linimentum  calcis  is  grateful.  Engman  and  C.  J.  White2  commend 
the  free  and  very  liberal  use  of  drying  powder,  the  former  using  corn- 
starch  powder  and  the  latter  borated  talc;  the  patient  is  actually  to  live 
in  the  powder.  Sometimes  ointments,  such  as  the  zinc  oxid  ointment, 
an  ointment  containing  i  dram  (4.)  of  calamin  to  the  ounce  (32.),  a  mild 
salicylic  acid  ointment,  from  10  to  20  grains  (0.65-1.3)  to  the  ounce  (32.), 
and  salicylated  paste  are  comforting.  In  cases  in  which  the  disease  is 
more  or  less  general,  bran  baths,  starch  baths,  gelatin  baths,  and  occa- 
sionally an  alkaline  bath,  followed  by  the  application  of  an  ointment, 
will  prove  acceptable.  In  the  most  severe  types  the  continuous  bath 

1  Pollitzer,  Festschrift  des  Deutschen  Hospitals,  1911,  p.  546,  reports   an  apparent 
cure  of  a  case  of  chronic  pemphigus  with  severe  involvement  of  the  mucous  membranes 
with  large  doses  of  arsenic;    Sutton,  Boston  Med.  and  Surg.  Jour.,  March   9,  1911, 
reports  a  rapidly  favorable  result  in  a  single  case  from  a  dose  of  salvarsan.      In  a  case 
at    Philadelphia  Hospital,  with  slight  tendency  to  vegetating  type,  first  under  Dr. 
Hartzell's  care  and  subsequently  mine,  rapid  temporary  improvement  was  noted  from 
a  dose  of  salvarsan,  but  later  to  another  dose  there  was  no  response,  the  patient  sub- 
sequently dying  from  the  disease. 

2  C.  J.  White,  "The  Dry  Treatment  of  Certain  Dermatoses,"  Jour.  Cutan.  Dis., 
Dec.,  1912,  p.  705. 


DERMATITIS    VEGETANS  38? 

(Hebra)  is  to  be  employed.  In  cases  in  which  itching  is  a  more  or  less 
prominent  symptom  carbolic  acid  may  be  added  to  the  lotions  or  oint- 
ments employed;  or  the  other  applications  employed  to  relieve  itching, 
as  mentioned  in  the  treatment  of  eczema,  may  be  resorted  to.  In  pem- 
phigus occurring  in  infants  and  young  persons  the  same  general  plan 
of  treatment  is  to  be  followed. 


DERMATITIS  VEGETANS 

A  malady  variously  thought  to  be  a  modification,  or  subvariety, 
of  pemphigus  vegetans  as  usually  encountered,  or  as  an  entirely  distinct 
disease  is  that  described  first  by  Hallopeau,1  as  pyodermatitis  vegetans 
(pyodermite  vegetante),  and  subsequently  by  Hartzell,2  Jamieson, 
Fordyce,  and  Gottheil  under  the  name  of  "dermatitis  vegetans."  Later 
Wende3  and  Degroat  reported  2  cases  in  children,  and  briefly  reviewed 
5  others  (2  adults,  3  children)  previously  recorded,  in  which  the  same 
peculiar  vegetations  developed  upon  an  eczematous  basis. 

The  cases  of  Hallopeau,  Hartzell,  and  Jamieson  in  many  respects 
showed  close  clinical  similarity  to  pemphigus  vegetans  (just  described), 
but  the  serious  constitutional  element  was  lacking,  and  the  first  eruptive 
features  were,  predominantly  at  least,  those  of  vesicles,  vesicopustules, 
and  pustules,  and  not  infrequently  grouped  as  in  dermatitis  herpetifor- 
mis.  The  vegetating  plaques  were  amenable  to  antiseptic  applications, 
leaving  behind  some  pigmentation,  which  finally  completely,  or  almost 
completely,  disappeared.  Hallopeau  long  maintained  the  individuality 
of  the  disease  and  its  non-identity  with  either  pemphigus  vegetans  or 
dermatitis  herpetiformis;  its  relationship  to  the  latter  being  asserted  in 
a  report  by  Wickham,4  of  a  case  presenting  similar  vegetating  forma- 
tions, under  the  name  of  "Un  cas  rare  de  dermatite  herpetiforme  de 
Duhring;  variete  pustuleuse  et  vegetante,"  and  this  belief  supported 
in  the  discussion  by  Vidal,  Besnier,  and  Brocq.  Although  this  case 
may  be  probably  accepted  as  an  example  of  dermatitis  vegetans,  it 
showed,  as  Hartzell  states,  "that  his  own  case  and  those  of  Hallopeau 
and  Wickham,  in  which  there  were  no  blebs,  but  the  eruption  distinctly 

1  Hallopeau,  Arckiv,  1898,  vol.  xliii,  p.  289,  and  vol.  xlv,  p.  323,   and  Annales, 
1898,  vol.  ix,  p.  969,  and  also  in  his  treatise  (Hallopeau  and  Leredde),  Dermatologie, 
190x3,  under  "Pemphigus  Vegetans,  or  Maladie  de  Neumann";  Fernet,  "Dermatitis 
Pustulosa  Vegetans  Recurrens,"  Jour.  Cutan.  Dis.,  1912,  p.  517,  records  a  remarkable 
case  (woman  aged  twenty-six),  approaching  more  closely  to  Hallopeau's   case  than 
to  others,  but  getting  well  and  then  recurring. 

2  Hartzell,  Jour.  Cutan.  Dis.,  1901,  p.  465  (with  illustration  of  genital  region  and 
histologic  cut);  Jamieson,  Brit.  Jour.  Derm.,  1902,  p.  407  (with  illustration  of  hand  and 
histologic  cuts);  Fordyce  and  Gottheil,  Jour.  Cutan.  Dis.,  1906,  p.  543  (with  case  and 
histologic  illustrations,  review,  and  bibliography). 

3  Wende  and  DeGroat,  "Vegetating  Dermatitis  Developing  During  the  Course  of 
Infantile  Eczema,"  (2  cases),  Jour.  Cutan.  Dis.,  1902,  p.  58  (with  illustration  of  face 
and  histologic  cuts),  and  ibid.,  1911,  p.  743,4  cases  with  case  illustrations;  review,  and 
bibliography;  Corlett,  Brit.  Med.  Jour.,  Oct.  6,  1906,  has  reported  a  somewhat  similar 
case,  but  developing  as  a  bromid-like  papulopustular  eruption. 

4  Wickham,  Annales,  1801,  p.  1005;  King  Smith,  "A  Case  of   Dermatitis  Vege- 
tans," Jour.  Cutan.  Dis.,  1910,  p.  605  (with  a  good  illustration);  rather  unusual  case; 
in  some  respects  similar  to  Wickham's;  early  condition  suggestive  of  dermatitis  her- 
petiformis and  some  phases  of  pemphigus;  nails  of  hand  and  feet  fell  off. 


INFLAMMA  TIONS 


pustular,  or  vesicopustular,  with  a  marked  tendency  to  occur  in  groups, 
and,  in  some  instances  preceded  by  erythematous  patches,  to  be  much 
more  closely  allied  to  dermatitis  herpetiformis  than  to  pemphigus"- 
an  opinion  which  Fordyce  and  Gottheil  believe  is  also  supported  by  their 
case.  That  there  are  cases,  however,  in  which  such  features,  as  well  as 
erythematous  rings  and  gyrate  patterns  are  conjoined  with  bleb-forma- 
tion, is  shown  by  the  example  recorded  by  Ormerod,1  concerning  which 
there  was  some  difference  of  opinion  as  to  its  proper  place — pemphigus 
vegetans  or  dermatitis  vegetans,  Crocker  viewing  it  as  the  latter.  It  is 
to  be  said  that  Hallopeau,  receding  from  his  earlier  stand,  has  recently 
placed  the  malady  as  a  variety  of  pemphigus  vegetans.  Jamieson 
strongly  maintains  its  individuality.  The  cases  reviewed  and  reported 


Fig.  92. — Dermatitis  vegetans  (courtesy  of  Dr.  M.  B.  Hartzell). 

by  Wende  and  Degroat  go  to  show  that  somewhat  similar  vegetations, 
probably  from  some  added  infective  agent,  can  also  arise  on  the  vesicular, 
pustular,  or  oozing  surface  of  such  a  mild  disease  as  eczema,  and  seem  to 
point  to  the  possibility  that  this  peculiar  vegetative  tendency  is  not  nec- 
essarily characteristic  of  any  particular  malady,  but  may  be  simply  an 
accidental  or  added  feature  to  the  several  diseases  named.  Pusey,2 
whose  2  cases  of  'Vegetating  dermatoses"  are  closely  similar  to  those  of 
Hallopeau,  Wickham,  Hartzell,  Jamieson,  and  Fordyce  and  Gottheil, 

1  Ormerod,  Brit.  Jour.  Derm.,  1903,  p.  26  (case  demonstration). 

2  Pusey,  Jour.  Cutan.  Dis.,  1906,  p.  555  (with  case  illustrations);  Perrin's  3  cases 
(Annales,  "Dermite  vegetante  en  placards  chez  les  nourrissens  seborrhoeiques,"  1900, 
P-  I055)  have  some  features  in  common  with  both  the  Wende  and  Pusey  cases. 


EP1DERMOLYSIS  BULLOSA 

and  yet  apparently  arising  upon  an  eczematous  basis,  also  takes  this 
view  of  the  malady.  In  a  few  of  the  reported  cases  in  children,  some- 
times beginning  as  a  papulopustule  or  pustule,  the  suggestion  of  a 


Fig.  93. — Dermatitis  vegetans  (courtesy  of  Dr.  Grover  W.  Wende). 

bromid  eruption  is  strong,  but  this  seems  to  have  been  carefully 
eliminated.  As  already  intimated,  cleanliness  and  antiseptic  applica- 
tions are  usually  efficacious  in  its  treatment. 


EPIDERMOLYSIS  BULLOSA 

Synonyms. — Epidermolysis  bullosa  hereditaria;  Acantholysis  bullosa. 

This  is  a  rare  affection,  described  (Goldschneider,  Kobner,  Blumer, 
Valentine,  Elliot,  .Hallopeau,  Beatty,  Bowen,  and  others)  in  recent 
years,  characterized  by  the  formation  of  vesicles  and  blebs  on  any 
part  subjected  to  slight  rubbing,  knocks,  or  irritation.  It  is  usually 
hereditary,1  the  same  condition,  as  a  rule,  having  existed  in  one  or 

1  Bettman,  Dermatolog.  Zcitschr.,  1903,  vol.  x,  p.  561,  abstract  in  Brit.  Jour.  Derm., 
1904,  p.  198,  gives  a  striking  example  of  hereditary  transmission.  His  cases  were  a 
father  and  two  daughters,  with  this  family  history:  First  known  case  was  a  daughter  (i 
of  13  children);  of  her  10  children,  2  were  affected;  i  of  these  affected  was  married, 
and  of  her  14  children,  2  were  affected;  of  these  i  (female)  had  5  children,  of  whom  4 
were  affected;  the  other  of  the  two  (a  male)  had  2  children,  both  of  whom  were  affected. 
Valentin,  Archiv,  1906,  vol.  Ixxviii,  p.  87,  also  records  a  somewhat  similar  instance  of 
heredity;  also  Engman  and  Mook,  Jour.  Cutan.  Dis.,  1906,  p.  55  (in  i  of  their  4  cases); 
McMurray  and  L.  Johnston,  Australasian  Med.  Gaz.,  Jan.  25,  1913,  p.  74 — 2  cases 
father  and  son,  beginning  in  both  in  the  first  year  of  life. 


390 


Fig.  94. — Epidermolysis  bullosa,  showing  blebs,  mostly  broken,  on  those  parts 
most  subject  to  pressure  and  slight  traumatism,  as  about  the  ankle,  tibial  surface, 
knees,  and  dorsal  surface  of  the  fingers  (courtesy  of  Dr.  J.  C.  Johnston). 


Fig.  95. — Epidermolysis  bullosa,  with  atrophy  of  finger-ends  and  loss  of  nails, 
and  thinning  of  skin  from  constant  vesicle  and  bleb  formation — case  referred  to  in  the 
text — upper  part  of  back  of  same  patient  is  shown  in  other  cut. 

more  previous  generations.     It  generally  makes  its  first  appearance  in 
early  infancy  or  childhood,  and  the  tendency  persists  indefinitely. 

The  lesions  consist  of  small  and  large  bullae,  exceptionally  partly 


EPIDERMOLYSIS  BULL  OS  A 


391 


hemorrhagic,  arising  especially  on  parts  of  the  surface  subjected  to 
friction  from  the  wearing  apparel,  collar,  wristband,  etc.,  as  on  various 
parts  of  the  body;  or  from  slight  knocks  or  pressure,  as  on  the  hands 
from  the  use  of  implements,  over  the  joints,  etc.  They  are  also  observed 
in  the  mouth  in  some  cases.  The  skin  remains  free  if  not  subjected 
to  such  influences.  In  some  instances  the  susceptibility  is  less  marked 
than  in  others.  As  a  rule,  the  blebs  disappear  without  trace;  excep- 
tionally some  pigmentation  and  slight  scarring  result.  In  a  case  under 
my  observation  the  neck  and  upper  back,  wrists,  and  hands  exhibited 
almost  continuous  bleb-formation,  the  hand  lesions  resulting  from 
work  (drawing  and  designing).  This  tendency  was  especially  noted 


Fig.  96. — Epidermolysis  bullosa — blebs  collapsed  or  rubbed  off.  Condition  most 
marked  here,  on  knees  and  lower  parts  of  legs,  and  forearms  and  hand — case  referred 
to  in  the  text. 

at  the  finger-ends,  and  finally  led  to  some  atrophy  and  nail-loss.  The 
patient  is  now  thirty,  and  the  condition  has  existed  since  birth,  although 
the  tendency  is  gradually  lessening.  In  some  instances  a  similar 
atrophy  of  the  finger-ends,  associated  with  alopecia  (G.  W.  Wende  and 
others)1  has  also  been  observed. 

1  G.  W.  Wende  (i  case),  Jour.  Cutan.  Dis.,  1902,  p.  537  (with  references  and  illus- 
trations), and  (i  case),  ibid.,  1904,  P-  14  (with  illustration);  Fernet,  Brit.  Jo*r.  Derm 
1904,  p.  225  (nails,  both  of  fingers  and  toes,  were  non-existent);   Colcott  *ox,  &ru. 
Jour.  Derm.,  1905,  p.  223  (case,  with  progressive  deformations);  Sichel,  tto&.tp.& 
(case  presentation;  with  deformations  and  cicatricial  alopecia) ;  Savill,  ibid.,  p.  40°  (.<*** 
presentations;  2  brothers);  Petrini-Galatz,  Anndes,  1906,  p.  766  (2  cases  congenital 
and  dystrophic;  histologic;  with  many  references);  Williams,  Brit  Jour.  Derm.,  Jan 
1907,  p.  10  (evidences  of  antenatal  development);  Allworthy,  Brit.  Jour.  Derm.,  19  o, 
P-  373  (with  good  illustrations;  congenital;  dystrophy  of  thumb  and  great  toe-nails). 


392 


INFLAMMA  TIONS 


The  general  health  is  not  involved.  In  some  cases  there  is  an  asso- 
ciation of  milium-like  cysts  (Augagneur,  Beatty,  Bowen,  Bukovsky).1 

The  nature  of  the  disease  is  obscure.  The  mild  traumatism,  if  it 
can  be  so  called,  excites  rapid  exudation  from  the  dermal  vessels  into 
the  rete,  separating  this  latter,  and  giving  rise  to  blebs.  Elliot's  investi- 
gations lead  to  the  conclusion  that  epidermolysis  bullosa  is  not 
a  disease  in  the  strict  sense  of  the  term,  but  a  cutaneous  condition; 
the  individual  is  born  with  a  congenital  irritability  of  the  vascular  supply 
of  the  skin,  which  responds  to  every  irritation,  and  in  consequence 
the  basal  portion  of  the  rete  is  kept  bathed  in  a  more  or  less  serous 
transudation,  inducing  degenerative  changes;  greater  or  repeated 


Fig.  97. — Epidermolysis  bullosa:  section  of  a  portion  of  a  bulla,  showing  the  degen- 
eration of  the  basic  portion  of  the  rete  (courtesy  of  Dr.  Geo.  T.  Elliot;  photomicrograph 
by  Dr.  J.  A.  Fordyce). 

irritation    causes   greater    exudation,    detaching    the    loosely   fastened 
rete,  and  the  bleb  is  thus  formed.      Engman  and  Mook2  found  the 

1  For  complete  clinical  survey  and  resume  of  the  disease  see  Wallace  Beatty's  paper, 
Brit.  Jour.  Derm.,  1897,  p.  301;  Bowen's  paper,  Jour.  Cutan.  Dis.,  1898,  p.  254,  and 
for  the  histopathologic  aspects,  Elliot's  paper,  Trans.  Amer.  Derm.  Assoc.for  i8gg;  H. 
L.  Smith,  Maryland  Med.  Jour.,  April,  1901,  reports  a  case  in  a  negro,  with  notes  on 
the  blood  and  vesicle  cells  by  T.  R.  Brown,  who  found  both  local  and  general  eosino- 
philia.     This  paper  also  gives  a  summary  of  the  literature.     Bukovsky's  (Archiv,  1903, 
vol.  Ixvii,  p.  163)  investigation  of  these  bodies  showed  (as  also  demonstrated  by  others) 
a  histologic  connection  with  the  sweat-ducts — retentive  cysts  of  the  ducts,  their  outlets 
becoming  blocked  by  the  healing  of  the  bullae.     Engman  and  Mook's  investigations 
confirm  this;  their  paper  (loc.  tit.)  reviews  the  disease,  and  gives  full  bibliography. 

2  Engman  and  Mook,  1906,  loc.  cit.,  and  Trans.  Amer.  Derm.  Assoc.for  IQOQ,  p.  151, 
Jour.  Cutan.  Dis.,  1910,  p.  275,  and  Interstate  Med.  Jour.,  July,  1911,  p.  499 — constantly 
found  elastic  tissue  absent  or  practically  so.     Kanoky  and  Sutton's  investigations, 
Jour.  Amer.  Med.  Assoc.,  April  2,  1910,  p.  1137,  confirm  the  Engman-Mook  findings. 
Review,  summary  and  references  will  be  found  in  these  several  papers. 


DERMATITIS  REPENS 


393 


elastic  tissue  almost  completely  absent,  and  attribute  the  disease  to 
this  factor. 

Treatment  has  no  influence  in  modifying  or  lessening  this  tendency; 
puncturing  the  lesions  when  small  curtails  their  growth  (Airworthy). 
As  much  as  possible  pressure  and  friction  should  be  guarded  against; 
soothing  and  protective  applications  should  be  made  to  the  excoriated 
surfaces. 

DERMATITIS  REPENS1 

Synonyms. — Acrodermatite  suppurative  continue  (Hallopeau);  Acrodermatitis 
perstans. 

Definition. — Dermatitis  repens  is  a  spreading  dermatitis  starting 
from  an  injury,  extending  by  a  serous  undermining  of  the  epiderm, 
and  usually  occurring  upon  the  upper  extremities. 

Symptoms. — The  disease,  first  described  by  Crocker,  may  begin 
shortly  after  an  injury,  or  immediately  after  a  surgical  operation,  or 
even  after  complete  healing  has  taken  place.  It  begins,  as  a  rule, 
by  redness  and  serous  exudation ;  the  skin  breaks  at  this  point,  and  the 
exudation  continues  to  be  produced  at  the  periphery  and  gradually 
undermines  the  epidermis,  in  this  manner  extending  and  covering  con- 
siderable area.  Or  the  disease  appears  first  by  the  development  of  one, 
several,  or  more  vesicles  or  small  blebs,  which  become  confluent,  and 
followed  by  gradual  peripheral  undermining.  Exceptionally  the  first 
lesions  are  papular.  When  established,  a  picture  is  presented  of  a  red, 
raw-looking,  usually  oozing  surface,  with  an  elevated,  confluent,  spread- 
ing, vesicular  wall,  which  invades  the  adjoining  skin,  and  presents  toward 
the  red,  weeping  surface  which  has  just  been  passed  over  a  raised,  irregular 
rim  of  partially  detached  or  loosened  epidermis.  As  the  disease  spreads 
the  oldest  part  becomes  dry  and  heals,  the  epidermal  covering  being  thin 
and  atrophic  in  appearance.  Occasionally  the  traversed  part,  while 
red,  soon  becomes  dry;  and  then  there  presents  the  spreading  peripheral 
serous  wall  with  the  ragged  epidermic  edge,  under  this  latter  a  red 

1  Literature:  Crocker,  Diseases  of  the  Skin,  London,  1888,  p.  128,  and  Trans.  Inter- 
nal. Cong.  Derm,  and  Syph.,  in  Vienna,  1892;  Garden,  in  Crocker's  paper  in  the  Trans- 
actions; Nepveu,  Brit.  Med.  Jour.,  1886,  ii,  p.  1194  (Paris  correspondence);  Stowers, 
Brit.  Jour.  Derm.,  1896,  p.  i;  Freche  ("Eruption  trophoneurotique  des  extremite's  rap- 
pelant  la  dermatitis  repens"),  Annales,  1897,  p.  491;  Hardaway,  American  Text-book 
of  Genito-urinary  Diseases,  Syphilis,  and  Diseases  of  the  Skin,  p.  877,  briefly  refers  to  a 
case;  Hyde  and  Montgomery,  Diseases  of  the  Skin,  seventh  edit.,  p.  434,  briefly  refers  to 
3  cases  in  speaking  of  treatment;  Hallopeau,  Annales,  1897,  pp.  473  and  I277,  under 
the  name  of  "  Acrodermatites  continues,"  gives  notes  of  a  few  cases  with  some  points 
in  common  with  dermatitis  repens,  but  which  he  considers  entirely  distinct  from  the 
latter — he  also  considers  the  cases  by  Stowers  and  by  Freche  as  similar  to  his  own,  and 
not  identical  with  the  disease  as  described  by  Crocker;  Audry,  "Les  phlycte'noses  r6cidi- 
vantes  des  extremite's,"  ibid.,  1901,  p.  913  (2  cases,  with  a  re'sume'  of  previously  pub- 
lished cases);  Hartzell,  "Dermatitis  Repens,"  Jour.  Amer.  Med.  Assoc.,  Dec.  20,  1902 
p.  1581  (i  case,  with  a  review  of  recorded  cases);  Sutton,  "A  Comparative  Study  of 
Dermatitis  Repens  and  Acrodermatitis  Perstans,"  Jour.  Cutan.  Dis.,  1911,  p.  325, 
with  review  of  the  Radcliffe-Crocker  cases  and  of  the  features  of  the  Hallopeau  cases 
(acrodermatite  suppurative  continu6),  report  of  2  new  cases  resembling  former,  and  i 
new  case  resembling  latter,  with  histology  and  bacteriologic  findings— with  positive 
conclusions  as  to  their  clinical  and  pathologic  identity;  animal  experimentation  prac- 
tically negative;  the  organism  probably  some  particular  strain  of  the  Staphylococcus 
pyogenes  aureus  or  albus. 


394  INFLAMMA  TIONS 

oozing  surface,  and  beyond,  on  the  old  part,  a  dry  or  but  slightly  moist, 
red  surface.  In  some  instances  the  border  portion  may  show  some 
crust-formation.  Exceptionally  the  malady  may  spread  with  a  super- 
ficial elevated  vesicular  wall,  and,  as  it  extends,  the  older  part  collapses 
and  dries,  resulting  in  a  somewhat  scaly  surface. 

The  disease  may  invade  a  considerable  area;  it  may  start  at  a  finger 
and  traverse  the  entire  arm,  and  even  extend  on  to  the  trunk.  Mod- 
erate cases  may  not  involve  more  than  a  greater  part  of  the  hand  and 
the  lower  part  of  the  forearm.  In  fact,  it  may  not  extend  beyond  a  small 
area — as,  for  instance,  over  a  finger  or  a  finger  and  small  part  of  the 
hand.  It  is  generally  slow  in  its  progress,  but  exceptionally,  as  in  the 
case  pictured,  quite  rapid,  covering  the  surface  shown  in  a  period  of  about 


Fig.  98. — Dermatitis' repens  in  a  middle-aged  woman,  of  about  a  week's  duration, 
beginning  at  a  cut  shown  on  the  thumb,  and  followed  by  progressive  serous  epidermic 
undermining  extending  down  the  fingers,  across  the  hand,  and  up  the  wrist. 

one  week.  There  seems  but  little,  if  any,  tendency  to  spontaneous  cure. 
It  is  usually  seen  starting  on  the  finger  or  some  part  of  the  hand,  and 
rarely  elsewhere. 

A  closely  similar  and,  doubtless,  allied  condition  is  acrodermatitis 
perstans  (acrodermatites  continues  of  the  French),  in  which  the  erup- 
tion is  more  of  a  vesicular  and  pustular  nature,  the  first  lesions  being 
vesicles  or  pustules.  Beginning  usually  on  one  finger,  it  may  remain 
localized  for  some  time,  gradually,  by  the  development  of  fresh  foci, 
involving  other  fingers,  the  nail  regions,  and  parts  of  the  hand.  Other 
regions  of  the  body  may  show  a  secondary  erythematosquamous 
eruption. 

Etiology. — An  injury,  usually  slight  in  character,  such  as  a  cut 


THE  IMPETIGOS 


395 


or  a  burn,  appears  to  be  the  starting-point  of  the  disease,  probably 
from  a  peripheral  neuritis.  It  would  seem  to  me  that  the  malady  is  due 
to  parasitic  invasion,  the  break  of  continuity  affording  opportunity 
for  inoculation.  Or  a  peripheral  neuritis  may  be  the  causative  agent. 
It  is  possible  that  both  factors  may,  as  Crocker  states,  be  etiologic,  the 
neuritis  primary,  and  parasitic  invasion  secondary. 

Diagnosis. — The  disease  somewhat  resembles  eczema  rubrum; 
but  its  origin  from  an  injury,  method  of  spread,  the  elevated  vesicular 
or  bullous  spreading  wall,  usually  with  the  loosened  or  projecting  rim 
of  epidermis,  and  the  red,  oozing,  and  sometimes  atrophic-looking  surface 
will  prevent  any  confusion.  Those  cases  beginning  in  a  group  of  several 
vesicles  or  bullae  may  at  first  slightly  suggest  pompholyx. 

Treatment.— The  undermined  and  loose  skin  should  be  first 
cut  away.  The  few  cases  which  have  been  under  my  own  care  were 
cured  by  applications  of  a  saturated  solution  of  boric  acid  containing 
2  or  5  grains  (0.13-033)  of  resorcin  to  the  ounce  (32.);  bathing  the  parts 
with  this  morning  and  night,  and  while  the  surface  is  still  wet  with  it, 
covering  over  thickly  with  powdered  boric  acid,  and  enveloping  in  a  loose, 
light  dressing.  Should  there  be  considerable  oozing,  sufficient  to  lead 
to  adherence  of  the  enveloping  dressing,  then  the  under  part  of  this  latter, 
in  contact  with  the  powder,  can  be  slightly  greased  with  petrolatum. 
Once  daily  the  affected  area  should  be  gently  washed  clean  with  warm 
water. 

Crocker  cured  one  case  by  keeping  the  part  constantly  wrapped 
up  with  linen  cloths  wet  with  lead  lactate  lotion;  one  with  painting 
on  a  10  per  cent,  permanganate  of  potassium  solution  three  times  daily 
until  a  crust  is  formed.  Hardaway  had  success  with  an  ointment  of  a 
dram  (4.)  of  aristol  to  an  ounce  (32.)  of  unguentum  vaselini  plumbicum. 
Applications  of  a  saturated  solution  of  pyoktanin  blue  and  a  solution  of 
sodium  hyposulphite  have  also  been  commended. 

Hartzell  found  applications  of  formalin — i  dram  to  an  ounce  of  glyc- 
erin (4.  :  32.) — to  the  spreading  edges,  followed  by  Brooke's  paste  (see 
treatment  of  cutaneous  tuberculosis),  efficacious. 

Hallopeau  and  Gastou1  had  results  in  i  case  (acrodermatite  sup- 
purative  continue),  which  promised  complete  success,  from  x-ray  treat- 
ment. 

THE  IMPETIGOS 

In  olden  times  the  term  impetigo,  as  well  as  impetigo  simplex, 
impetigo  sparsa  (Willan,  Bateman,  Wilson,  Hillairet),  was  applied  to 
various  pustular  inflammations  of  the  skin.  From  this  ill-defined 
classification  many  authors  gradually  accepted  two  divisions  of  this 
group:  one  under  the  name  of  impetigo  or  impetigo  simplex,  and  the 
other  under  the  name  of  impetigo  contagiosa  (Tilbury  Fox2);  under 
the  former  were  included  most  accidental  pustular  lesions  seen  in 
connection  with  parasitic  diseases,  especially  pediculosis,  and  those 

1  Hallopeau  and  Gastou,  Annales,  1904,  p.  1021. 

2  Tilbury  Fox,  Brit.  Med.  Jour.,  1864,  pp.  467.  495,  553,  and  607;  and  Jour.  Lulan. 
Med.,  Oct.,  1869,  p.  231;  Treatise  on  Diseases  of  the  Skin,  third  edit.,  p.  227. 


396  INFLAMMA  TIONS 

occasionally  occurring  in  connection  with  eczema  and  other  inflammatory 
dermatoses,  and  this  variety  was  for  a  long  while  thought  to  be  non- 
contagious.  While  most  authors  considered  this  type  more  of  an  acci- 
dental lesion  than  a  distinct  morbid  entity,  others,  and  in  our  own  country 
notably,  Duhring1  and  Robinson2  contended  that  there  was  a  special 
disease  of  which  the  rounded,  semiglobular  pustule,  practically  non- 
contagious,  and  occurring  in  children,  and  presenting  a  variable  number 
of  lesions,  did  exist.  Under  the  other  heading — impetigo  contagiosa — 
authors  have  been  accustomed  to  place  those  cases  of  vesicular  and  sero- 
purulent  and  purulent  lesions  seen  chiefly  upon  the  face  of  children, 
usually  running  a  definite  limited  course,  and  which  clinical  observation 
had  pointed  out  had  very  decided  contagious  properties.  Later,  chiefly 
since  the  experiments  of  Bockhart,3  all  these  various  pustular  lesions 
have  been  thought  to  represent  the  same  morbid  process  resulting  from 
inoculation  by  pyogenic  cocci.  This  acceptation  would  attribute 
the  somewhat  varied  clinical  pictures  to  the  fact  of  different  environ- 
ment, different  "soil,"  and  different  virulence  of  the  infecting  germ. 
For  clinical  purposes  and  for  treatment  this  view,  while  in  the  light 
of  more  recent  research  not  wholly  scientifically  exact  as  to  the  patho- 
genic organisms,  appeared  to  be  the  most  satisfactory.  Since  this 
view  became  the  prevailing  one,  however,  clinical  and  experimental 
studies  by  Unna,4  Sabouraud,5  and  others6  seem  to  show  various 
types  of  impetigo  due  to  different  micro-organisms.  Unna  would 
have  us  believe  that  there  are,  in  reality,  several  distinct  diseases: 
impetigo  vulgaris  (impetigo  contagiosa  of  Tilbury  Fox  and  others), 
impetigo  staphylogenes  (impetigo  of  Bockhart  and  Duhring),  and 
impetigo  circinata  and  impetigo  streptogenes.  Sabouraud's  clean- 
cut  investigations  led  him  to  conclude  that  there  are  two  separate 
maladies,  one  due  to  the  streptococcus  and  the  other  to  the  staphyl- 
ococcus,  the  former  causing  the  impetigo  contagiosa  of  Tilbury  Fox 
and  others,  and  the  latter  the  impetigo  of  Bockhart.  It  will  be  seen 
that  while  the  question  of  impetigo  is  still  in  an  unsettled  condition, 
much  has  been  done,  and  is  being  done,  to  add  to  its  elucidation. 

The  facts  as  now  known  seem  to  indicate  that  there  are  several 
types  of  impetigo,  sometimes  doubtless  mixed  in  character,  the  slightly 
varied  clinical  differences  of  which,  for  practical  purposes,  may  be 

1  Duhring,  Diseases  of  the  Skin,  third  edit.,  p.  293;  part  ii,  Cutaneous  Medicine, 
p.  422. 

2  Robinson,  Manual  of  Dermatology,  p.  280. 

3  Bockhart,  Monatshefte,  1887,  p.  450. 

4  Unna  and  Schwenter-Trachsler,  "Impetigo  Vulgaris,"  Monatshefte,  vol.  xxviii, 
pp.  229,  281,  333,  and  385  (an  elaborate  and  experimental  paper  reviewing  the  whole 
subject  and  literature  of  impetigo). 

6  Sabouraud,  "Etude  clinique  et  bacteriologique  de  1'impetigo,"  Annales,  1900, 
pp.  62  and  320  (a  complete  and  elaborate  investigation  of  the  subject,  with  important 
literature  references  and  a  number  of  cuts). 

6  Other  important  recent  literature:  Wickham,  Union  medicale,  Feb.,  1892,  Nos. 
16  to  23,  and  Brit.  Jour.  Derm.,  1892,  p.  202;  Balzer  and  Griffon  (bacteriologic;  strep- 
tococci found  in  every  instance),  La  Presse  med.,  1897,  No.  89;  Dubreuilh,  "De  la 
nature  de  I'impetigo  et  de  1'eczema  impetigineux,"  Annales,  1890,  p.  289.  Also  valu- 
able papers  bearing  upon  the  role  of  pus-producing  organisms  in  skin  diseases  in  Trans. 
Amer.  Derm.  Assoc.  for  i8gg,  by  Elliot  (p.  75)  and  Gilchrist  (p.  87)  and  (of  staphylo- 
coccus)  C.  J.  White,  Med.  Com.  Mass.  Med.  Soc.,  1899,  p.  157. 


IMPETIGO    CONTAGIOSA 


397 


ignored,  inasmuch  as  for  all  the  treatment  is  always  the  same.  All 
forms  are  contagious,  the  impetigo  of  Bockhart  being  the  least  so.  As 
Tilbury  Fox's  impetigo  contagiosa  is  that  most  commonly  observed, 
they  will  be  here  considered  under  that  heading. 

IMPETIGO  CONTAGIOSA 

Synonyms  and  Varieties. — Porrigo  contagiosa;  Impetigo  parasitica;  Impetigo 
vulgaris  (Unna);  Impetigo  simplex;  Impetigo  sparsa;  Impetigo  streptogenes;  Impetigo 
staphylogenes;  Impetigo  circinata;  Impetigo  figurata. 

Definition. — Impetigo  contagiosa  is  an  acute,  contagious,  inflam- 
matory disease,  characterized  by  the  formation  of  discrete,  superficial, 
flattened,  rounded,  or  oval  vesicles  or  blebs,  often  becoming  seropurulent, 
and  drying  to  thin  yellowish  crusts. 

Exceptionally  the  beginning  lesions  are  small  pustules,  and  which 
may  dry  to  thicker  crusts.  And  occasional  types  of  a  circinate  or  even 
serpiginous  configuration  are  noted. 

Symptoms. — In  a  typical  case  of  impetigo  contagiosa  of  the 
common  form  of  the  disease  several  vesicopapules,  vesicles,  or  ves- 
icopustules  make  their  appear- 
ance simultaneously  or  in  rapid 
succession  upon  the  face,  face 
and  scalp,  or  face  and  fingers, 
or  upon  all  these  various  parts. 
At  first  small,  they  tend  to  in- 
crease in  size,  becoming  de- 
cidedly flattened,  with,  in  some 
cases,  in  some  of  the  lesions,  a 
slight  relative  depression  of  the 
central  part,  as  compared  to 
the  extending  peripheral  por- 
tion ;  there  may  even  be  distinct 
umbilication.  They  are  super- 
ficial, and,  as  a  rule,  are  without 
conspicuous  areola  and  without 
distinctly  inflammatory  base. 
They  attain  the  diameter  of  a 
pea  or  a  dime,  and  when  close 
together,  as  often  noted  when 
about  the  mouth  and  chin, 
coalesce  and  form  one  or  more 
large,  irregular  patches.  The 
contents  at  first  are  often  purely  serous,  later  becoming  milky  or 
seropurulent  or  even  purulent.  If  a  vesicopustule  or  bleb  is  broken, 
a  reddish,  moist,  abraded-looking  surface  is  exposed,  secreting  a  thin 
watery  or  puriform  liquid,  and  looking  not  unlike  a  superficial  burn  or 
abrasion.  Several  days  after  the  appearance  of  the  lesions  they  begin 
to  dry  to  thin,  granular,  yellow  or  yellowish,  wafer-like  crusts,  which 
are  but  slightly  adherent,  and  later  on,  when  the  edges  have  com- 
menced to  loosen,  have  the  appearance  of  being  imperfectly  pasted 


Fig.  99. — Impetigo  contagiosa  in  a  girl  of 
ten  years,  of  one  week's  duration,  crusting 
stage  already  reached;  on  chin  and  nose 
lesions  have  coalesced. 


3  98  INFLAMMA  TIONS 

on.  A  not  unusual  site  for  a  vesicopustule  is  around  a  finger-nail, 
where  it  is  somewhat  suggestive  of  a  superficial  paronychia.  Excoria- 
tions, scratch-marks,  or  abrasions,  if  present,  soon  become,  through 
auto-inoculation,  the  seat  of  characteristic  lesions.  Fresh  lesions  may 
appear  singly  or  in  crops  from  day  to  day,  but  finally,  in  the  course  of 
several  days  or  a  week,  new  ones  cease  to  form  and  the  malady  gradually 
ends.  The  crusts  soon  drop  off,  leaving  behind  reddish  spots  which 
rapidly  fade  away.  Itching  may  or  may  not  be  present.  The  whole 
course  of  the  disease,  as  a  rule,  occupies  ten  days  to  a  few  weeks. 

Occasionally,  in  addition  to  the  eruption  upon  the  skin,  the  conjunc- 
tival,  nasal,  or  oral  mucous  membranes  may  show  lesions;  and  excep- 
tionally the  greater  part  of  the  eruption  may  be  about  and  in  the 
nasal  orifices  and  about  the  lips,  and  even  within  the  mouth.1  As  a 
rule,  there  is  no  constitutional  disturbance,  but  when  the  eruption  is 
extensive,  as  it  is  more  apt  to  be  in  the  epidemic  form  of  the  disease, 
it  is  preceded  by  light  febrile  action  and  malaise. 


Fig.  100. — Impetigo  contagiosa,  with  small  lesions,  in  a  girl  of  fourteen  years,  and  of 

six  days'  duration. 

All  observers  have  recognized  the  existence  of  anomalous  types.2 
In  some  of  these  the  eruption  consists  of  but  two,  three,  or  several 
ill-defined  lesions  about  the  nose  and  mouth,  with  possibly  one  or  two 
upon  the  fingers.  In  others,  again,  the  eruption  is  more  or  less  scattered 

1  D.  W.  Montgomery,  "The  Determination  of  Impetigo  Contagiosa  to  the  Mucous 
Membranes,"  Jour.  Cutan.  Dis.,  1910,  p.  445;   Gushing,  "Stomatitis   in   Impetigo 
Contagiosa,"  Arch.  Pediat.,  June,  1904  (with  literature  references);  Cornby,  La  France 
Medicate,  Dec.  24,  1887  (cited  by  Gushing)  records  instances  of  vulvovaginal  involve- 
ment. 

2  Foster,  "Herpes  Contagiosus  Varioliformis,"  Arch.  Derm.,  1875,  p.  97;  Corlett, 
"Impetigo:   Its  Clinical  Forms  and  Present  Status,  Including  Ecthyma  and  the  so- 
called  Pemphigus  Contagiosus,"  Cleveland   Jour.  Med.,  1898,  vol.  iii,  p.  513;  Allen 
(general — bullous),   Trans.   Amer.   Derm.  Assoc.  for  1896;  Elliot  (general — bullous), 
Jour.  Cutan.  Dis.,  1894,  p.  194;  Anthony  (various  forms),  ibid.,  1898,  p.  218;  Stel- 
wagon  (various  forms),  Phila.  Med.  Times,  Sept.  22,  1883;  Engman,  "Impetigo  Con- 
tagiosa and  Its  Bacteriology,"  Jour.  Cutan.  Dis.,  1901,  p.  180  (with  review  and  bibli- 
ography); Grindon  (bullous),  ibid.,  p.  188. 


IMPETIGO   CONTAGIOSA  399 

over  face,  hands,  limbs,  and  to  a  less  extent  upon  the  trunk.  In  some 
instances,  of  more  or  less  general  distribution,  the  lesions,  instead  of 
being  flat,  consist  of  pea-  to  nut-sized  blebs,  flaccid  or  tense;  and  when 
occurring  in  an  epidemic  manner  among  infants  and  young  children  the 
malady  simulates,  according  to  the  predominant  size  of  the  lesions, 
varicella  or  pemphigus  (impetigo  contagiosa  bullosa).  Most,  and  proba- 
bly all,  of  the  reported  cases  of  contagious  pemphigus  and  acute  pem- 
phigus in  infants  and  children  are  examples  of  this  variety  (impetigo 
strep togenes ?);  and  exceptionally  such  cases  assume  a  serious  aspect. 

In  occasional  cases  they  may  present  segmental  or  ring-like  or  ser- 
piginous  configuration  (impetigo  circinata,  impetigo  figurata).1  In  rare 
instances,  instead  of  vesicles  or  blebs,  many  of  the  lesions  are  pustular, 
and  especially  those  upon  the  legs,  ecthymatous,  with  a  markedly  in- 
flammatory base  and  areola.  Exceptionally,  as  in  the  variety  described 
by  Duhring2  as  impetigo  simplex  (impetigo  staphylogenes),  the  vesicular 
stage  of  the  disease  seems  to  be  wanting,  the  lesions  appearing  as  pure 
rounded  globular  pustules,  with  little  or  no  tendency  to  flattening;  and 


Fie  ioi  —Impetigo  contagiosa  of  slight  development  and  showing  a  circinate  patch;  of 
3    six  davs'  duration,  in  a  youth  of  eighteen.     Crusting  stage  already  reached. 


six  days'  duration,  in  a  youth  of  eighteen. 

which,  in  some  cases,  may,  instead  of  developing  into  ordinary  matured 
impetigo  lesions,  lead  to  deeper  invasion  by  the  organisms  and  to  boil 
formation.  As  Bockhart  has  shown  in  this  type,  the  lesion  is  usually 
follicular.  It  is  seen  not  infrequently  about  hairy  regions,  as  the  nape 
of  the  neck,  about  the  ankles,  and  other  general  surface  regions  in  hairy 
individuals;  and  in  those  cases  in  which  the  lesions  are  close  together  and 
almost  coalescent  could  be  clinically  well  described  as  a  pyogenic  derma- 
titis (dermatitis  pyogenica,  pyodermia,  pyodermatitis,  pyodermitis). 

It  is  probable  that  the  rare  condition,  vacciniform  ecthyma  of  infants, 
is  of  the  nature  of  impetigo  contagiosa;  it  usually  involves  the  gemtc 

i  See  remarkable  case  by  Schamberg,  Jour.  Cutan.  Dis.,  1896,  p.  169  (with  illustra- 

ti0n*  Duhring  (a  report  of  2  typical  examples),  Atner.  Jour.  Med.  ScL,  Oct.,  1888; 
also  Leslie  Roberts  (i  case),  Brit.  Jour.  Derm  1895,  p.  142. 

3  Colcott  Fox  "Vacciniform  Ecthyma  of  Infants,"  Brit.  Jour.  Derm.,  1907,  P- 
(with  seteral  illustrations),  reports  some  cases,  and  reviews  the  subject,  with  references; 
Halle,  Dermatolog.  Zeitschr.,  1908,  p.  215  (with  colored  plate). 


400 


INFLAMMA  TIONS 


and  anal  regions.  It  begins,  as  a  rule,  as  one,  several,  or  more  small 
papulo vesicular  elevations  on  an  erythematous  base;  the  vesicular  nature 
is  soon  manifest,  the  vesicles  becoming  larger,  flattened,  and  somewhat 
superficial,  and  with  central  depression,  giving  the  lesions  a  distinctly 
vacciniform  aspect.  Coalescence  may  occur  here  and  there,  resulting 
in  the  formation  of  an  irregular  surface,  or  crusted,  granulating,  eroded, 
or  diphtheroid  areas.  Sometimes  the  developed  lesions  become  eroded, 
and  with  the  slight  seropurulent  secretion  on  moist  surfaces  resemble  the 
eruption  of  syphilis  seen  in  this  region  in  infants.  The  intervening  skin 
may  be  erythematous  in  its  entirety  or  in  spots,  the  color  being  of  some- 
what dark  shade. 

In  exceptional  instances  the  common  sites  for  impetigo  contagiosa 
may  share  only  slightly  in  the  eruption,  or  may  be  entirely  exempt, 
the  lesions  appearing  in  unusual  regions.1 


Fig.  102. — Impetigo  contagiosa  of  the  ring-like  type  not  infrequently  seen  in  the  bearded 
region  of  the  male  adult  (courtesy  of  Dr.  H.  K.  Gaskill). 

When  seen  occurring  in  adults  the  eruption  consists  usually  of  a 
few  abortive  lesions  on  the  face  or  hands;  in  some  cases,  however,  it 
presents  numerous  discrete  and  closely  crowded  pea-  to  dime-sized 
or  slightly  larger  lesions  about  the  bearded  region  and  the  neck,  and  which 
quite  frequently  show  a  distinct  tendency  to  ring-like  development,  the 
serous  and  seropurulent  formation  is  often  quite  scanty,  and  in  such  cases 
the  lesions  may  show  considerable  resemblance  to  ringworm  patches. 
This  more  extensive  variety  is  met  with  in  the  male  adult  and  is  com- 
monly contracted  in  barber-shops. 

1  In  103  cases  observed  at  the  Philadelphia  Dispensary  for  Skin  Diseases  the  site 
was  as  follows:  Face,  49;  face  and  hands,  12;  face  and  limbs,  6;  face  and  scalp,  5;  face, 
scalp,  and  hands,  5;  face,  hands,  and  other  parts,  4;  face  and  trunk,  3;  face  and  but- 
tocks, 3;  face  and  feet,  i;  legs,  3;  trunk  and  legs,  2;  trunk  and  limbs,  i;  hands  and 
neck,  i;  hands  and  buttocks,  i;  scalp,  i;  buttocks,  i;  limbs,  i;  distribution  more  or 
less  general,  4. 


IMPETIGO   CONTAG1OSA 


401 


According  to  Unna,1  the  chief  differences  between  the  common  type 
observed  (his  impetigo  vulgaris — impetigo  contagiosa  of  T.  Fox)  and 
impetigo  circinata,  impetigo  staphylogenes,  and  impetigo  streptogenes 
are :  in  impetigo  circinata  there  are  no  thick  crusts,  but  scales  containing 
more  horny  cells  than  serum,  and  the  lesions  spread  at  the  borders,  form- 
ing discoid  and  gyrate  figures,  clearing  in  the  central  portions.  In 
impetigo  staphylogenes  (of  Bockhart)  the  lesions  are  small  pustules  with 
an  areola,  and  are  discrete  for  some  time  before  coalescing,  and  lead  to 
the  formation  of  comparatively  small  and  thin  crusts;  the  lesions  do  not 
remain  long  as  impetigines,  but  the  staphylococcus,  by  invading  the  hair- 
follicles,  leads  to  folliculitis, 
furuncles,  whitlows,  etc.  Im- 
petigo streptogenes  lesions 
commence  with  serous  exuda- 
tion, giving  rise  to  flaccid  bullae, 
generally  large  in  size,  and  with 
grayish-yellow,  turbid  contents. 

If  the  experience  of  other 
observers  is  at  all  similar  to 
mine,  there  are  instances  met 
with  in  which  the  characters 
of  these  several  types  are 
found  in  the  same  case;  Sa- 
bouraud's  investigations  dem- 
onstrate the  possible  admix- 
ture of  two  types,  primarily 
to  invasion  of  streptococci, 
secondarily  to  staphylococci. 

Etiology.— The  disease 
is  contagious  in  all  its  forms, 
inoculable  and  auto-inoculable. 
From  its  occasionally  occur- 
ring in  epidemics  it  would  al- 
most seem  as  though  the 
malady  might  in  some  in- 
stances be  infectious.  It  is 
observed  commonly  in  the 
lower  ranks  of  life,  although 


Fig.  103. — Impetigo  contagiosa  in  a  child 
of  three,  and  of  five  days'  duration.  Lesions 
scattered,  and  more  of  the  nature  of  the  type 
of  "impetigo  simplex"  described  by  Duhring. 


it  is  not  infrequently  seen  among  the  wealthier  classes.  It  is  largely 
a  disease  of  infancy  and  early  childhood,  being  most  common  between 
the  ages  of  two  and  ten;  in  recent  years  however  a  steady  increase  has 
been  noticeable  among  older  subjects  in  our  preparatory  schools  and 
colleges.  In  men,  occurring  about  the  bearded  region,  it  is  usually 
contracted  in  barber-shops.  Epidemics  have  also  been  noted  to  occur 
among  youths  and  adults  through  interchange  of  apparel  or  the  use 
of  common  or  insufficiently  cleansed  towels,  as  with  football  players 
(football  impetigo),  in  schools,  and  among  bathers  (bath-house  impetigo) 
at  the  shore. 

1  Quoting  from  the  abstract  of  his  paper  (loc.  cit.)  in  Brit.  Jour.  Derm.,  1899,  p.  332.. 


26 


402  INFLAMMA  TIONS 

A  relationship  to  vaccination1  has  been  noted  in  some  instances,  but 
the  same  relationship  may  be  said  to  exist,  I  believe,  to  other  suppurative 
processes  or  lesions.  It  is  also  seen  in  association  with  pediculosis  and 
scabies;  the  minute  punctures  made  by  the  parasites  and  the  excoriations 
produced  by  scratching  furnishing  opportunity  for  the  necessary  inocula- 
tion.2 

Pathology. — It  is  known  that  the  disease  is  due  to  pus-cocci, 
staphylococcus  aureus,  streptococcus  and  possibly  the  staphylococcus 
albus.  As  intimated  in  the  preliminary  remarks,  other  cocci  are  doubt- 


Fig.  104. — Impetigo  contagiosa  of  the  male  adult,  of  bearded  region  and  of  about  a 
weeJc's  duration,  showing  discrete  and  confluent  lesions;  usually  contracted  in  barber- 
shops and  presenting  lesions  more  especially  on  bearded  parts  of  the  face  and  neck,  and 
which  are  frequently  ring-like  in  character  (courtesy  of  Dr.  J.  F.  Schamberg). 

less  also  etiologic;  and  it  has  been  alleged  by  Unna  that  the  various 
forms  have  each  a  specific  coccus,  but  this  needs  further  confirmation. 
The  general  belief5  is  that  it  is  a  staphylococcic  affection  with  a  disposi- 

'  Stelwagon,  "Impetigo  Contagiosa:  Its  Individuality  and  Nature,"  Medical  News, 
Aug.  29,  1883  (out  of  88  cases,  in  6  only  did  it  follow  vaccination;  others  have,  how- 
ever, observed  this  association  in  larger  proportion.  This  paper  contains  most  litera- 
ture references  to  date). 

2  See  paper  by  Klotz  on  "The  Infected  Scratch  and  Its  Relations  to  Impetigo  and 
Ecthyma,"  Jour.  Cutan.  Dis.,  i8g6,  p.  46. 

3  Dr.  C.  J.  White,  "The  R61e  of  the  Staphylococcus  in  Skin  Diseases,"  Trans. 
Mass.  Med.  Soc'y  for  1899,  gives  a  good  brief  review  of  this  question. 


IMPETIGO   CONTAGIOSA 


403 


tion  to  view  the  other  findings  as  accidental;  although  French  observers 
for  the  most  part,  incline  to  consider  the  earliest  invasion  streptococcic, 
which  is  soon  concealed  or  overwhelmed  by  staphylococci.1  Excep- 
tionally the  ringworm  or  other  fungus  will  provoke  somewhat  similar 
lesions  (Kaposi,  Piffard,  Colcott  Fox,  Geber).  Crocker2  was  the  first 
to  demonstrate  clearly  that  the  disease  was  due  to  a  coccus,  and  the  in- 
vestigations by  Unna  and  Sabouraud,  if  carefully  examined,  appear,  in 
fact,  to  corroborate  the  correctness  of  these  earlier  findings  as  the  cause 
of  some  cases  of  the  disease.  In  some  instances — those  in  which  the 
eruption  is  epidemic  and  more  or  less  general  in  its  distribution,  and, 
more  especially,  the  bullous  type,  with  slight  constitutional  disturbance 
— the  disease  certainly  bears  resemblance  to  such  eruptive  fevers  as 
varicella;  it  is  difficult,  it  is  true,  to  reconcile  such  examples  with  the 
numerous  simple  cases  of  undoubted  pus-inoculation  lesions  occurring 
about  the  nose,  mouth,  and  hands. 

The  lesion  is  formed  (Robinson,  Unna,  Gilchrist,  and  others)  between 
the  rete  and  horny  layer,  this  latter  being  the  roof -wall;  there  is  a  sur- 
rounding mild  inflammation.  The  underlying  upper  part  of  the  corium 
displays  acute  inflammatory  action,  with  the  usual  features.  The 
lesion  contains  polynuclear  leukocytes  in  large  number,  some  round 
mononuclear  cells,  a  few  detached  epithelial  cells,  small  quantity  of 
fibrin,  and  a  large  quantity  of  coagulated  albumin  (serum),  and,  especially 
in  the  central  portion  of  the  lesion,  a  large  number  of  the  staphylococcus 
pyogenes  aureus,  often  streptococci,  as  well  as  sometimes  other  cocci. 

Diagnosis. — Impetigo  contagiosa  is  to  be  differentiated  from  pus- 
tular eczema,  ecthyma,  varicella,  and  pemphigus.  The  patches  formed 
by  coalescence  bear,  it  is  true,  a  rough  resemblance  to  pustular  eczema; 
but  this  latter  is  accompanied  with  other  symptoms  of  eczema,  such 
as  more  or  less  infiltration  and  thickening  of  the  involved  skin,  with 
intense  itching.  Moreover,  in  impetigo  contagiosa  discrete  lesions  are 
always  to  be  found,  and  these  differ  from  the  individual  pustules  of 
eczema  in  greater  size,  in  the  absence  of  a  tendency  to  rupture,  and  their 
course. 

Impetigo  contagiosa  differs  from  ecthyma  by  the  absence  of  the 
inflammatory  base  and  areola.  The  distribution  is  also  unlike  the  erup- 
tion in  the  latter  malady,  being  ordinarily  upon  the  face  and  hands  or 
face  and  several  other  parts,  while  that  of  ecthyma  is  commonly  seated 
upon  the  legs.  Moreover,  impetigo  contagiosa  is  essentially  a  disease 
of  childhood,  whereas  ecthyma  is  usually  observed  in  adults.  In  the 
former,  too,  the  process  is  superficial  and  the  crusts  are  thin ;  in  the  latter 
deep-seated,  and  the  crusts  are  thick. 

The  lesions  of  varicella  are  uniform  and  smaller,  rarely  larger  than 
split  peas,  and  more  or  less  disseminated,  with  no  tendency  to  patch- 
formation  and  with  insignificant  crusting.  In  those  rare  cases  of  im- 

1  Dubreuilh  and  Braudeis,  "Note  on  the  Bacteriology  of  Pyodermatitis,"  Annales, 
June,  1910,  p.  323;  British  Jour.  Derm.,  1911,  p.  91,  cannot   confirm   Sabouraud's 
dictum — "all  types  beginning  with  a  vesicle  or  bulla  due  to  streptococci,  those  beginning 
with  a  pustule  staphylococcus;"  but  believe  it  is  sometimes   one,  sometimes    the 
other,  and  in  some  cases  mixed. 

2  Crocker,  Lancet,  1881,  vol.  i,  p.  82. 


404  INFLAMMA  TIONS 

petigo  contagiosa  resembling  pemphigus  the  disease  must  be  studied 
in  its  entirety,  and  sometimes  for  several  days  before  it  is  possible  to 
be  positive  as  to  diagnosis.  Pemphigus  is  exceedingly  rare.  In  true 
pemphigus  the  lesions  spring  from  the  sound  skin  usually  as  blebs 
of  some  size  from  the  start,  whereas  in  impetigo  contagiosa  they  are 
small  in  the  beginning  and  grow  in  size  by  peripheral  extension. 
The  eruption  of  pemphigus  has  no  parts  of  predilection,  and,  more- 
over, is  generally  accompanied  by  symptoms  of  constitutional  dis- 
turbance. In  impetigo  contagiosa  some  of  the  characteristic  lesions 
are  usually  present,  or  frequently  another  member  of  the  family  will 
present  the  typical  disease. 

Prognosis. — The  effect  of  treatment  is,  as  a  rule,  prompt;  indeed, 
impetigo  contagiosa  in  most  instances  tends  to  spontaneous  disap- 
pearance in  ten  days  to  a  few  weeks;  but  in  exceptional  cases,  more 
especially  in  those  in  which  itching  is  present  to  a  sufficient  degree  to 
lead  to  scratching,  the  excoriations  thus  made  become  inoculated,  and 
in  this  manner  the  disease,  unless  actively  treated,  may  persist  for  one 
or  two  months.  A  pediculosis  capitis  is  also  at  times  a  causative  factor 
in  prolonged  cases. 

Treatment. — Treatment  consists  in  the  destruction  of  the  auto- 
inoculable  properties  of  the  crusts  and  contents  of  the  lesions.  The 
crusts  should  be  removed  by  warm  water  and  soap  washing,  fresh  or 
distended  lesions  being  first  opened.  An  ointment  of  10  to  20  (0.65-1.35) 
grains  of  ammoniated  mercury  to  the  ounce  (32.)  of  cold  cream  or  petro- 
latum should  then  be  gently  but  thoroughly  rubbed  into  the  secreting 
base  of  the  lesions  two  or  three  times  daily.  When  the  crusts  are  quite 
adherent  and  fail  to  come  off  with  ordinary  washing,  the  salve  just 
named  should  be  applied  over  the  patch,  and  the  washing  and  such 
anointing  repeated  two  or  three  times  daily  until  the  crusts  come  away, 
after  which  the  ointment  should  be  rubbed  into  the  secreting  base. 
In  many  of  these  latter  cases,  indeed,  partial  or  complete  healing  will 
be  found  to  have  taken  place  beneath  the  crusts.  In  some  instances 
a  drying  salve  such  as  Lassar's  paste  with  the  addition  of  the  white  pre- 
cipitate or  20  to  30  grains  (1.33-2.)  of  sulphur  to  the  ounce  (32.)  is 
more  satisfactory.  Any  mildly  antiseptic  ointment  will,  however,  be 
found  curative. 

In  markedly  itchy  cases,  in  which  the  disease  tends  to  continue 
from  inoculation  of  the  scratch-marks  thus  provoked,  a  lotion  of  the 
saturated  solution  of  boric  acid,  with  5  grains  (0.33)  of  either  carbolic 
acid  or  resorcin,  or  both,  to  the  ounce  (32.),  should,  as  a  preventive 
measure,  be  applied  two  or  three  times  daily  to  the  affected  parts  gener- 
ally. Ordinarily  in  all  extensive  cases  this  lotion  can  be  advised  along 
with  the  salve  as  a  routine  measure.  For  lesions  occurring  on  the  con- 
junctiva a  plain  boric  acid  lotion,  10  grains  (0.65)  to  the  ounce  (32.), 
may  be  dropped  in  the  eye  once  or  twice  daily. 

In  those  cases  of  more  or  less  general  distribution,  in  which  mild 
febrile  action  is  present,  in  this  respect  resembling  slightly  the  erup- 
tive fevers,  a  laxative  should  be  given  and  the  patient  kept  at  com- 
parative rest  for  a  day  or  two;  in  other  respect,  the  treatment  is  the  same. 


ECTHYMA  405 

ECTHYMA 

Definition. — Ecthyma  is  characterized  by  the  appearance  of  one 
or  several  or  more  discrete,  finger-nail-sized,  flat,  usually  markedly 
inflammatory  pustules. 

Symptoms. — The  eruption  is  seen  commonly  upon  the  legs, 
sometimes  upon  the  shoulders  and  upper  back  and  the  forearms,  but 
rarely  elsewhere.  The  lesions  begin  as  small,  usually  pea-sized  pus- 
tules, without  a  prepapular  or  prevesicular  stage.  They  increase  some- 
what in  size,  and  when  fully  matured  attain  about  the  area  of  a  small, 
or  sometimes  a  large,  finger-nail.  They  are  slightly  elevated,  flattened, 
and  have  a  markedly  inflammatory  base  and  areola,  with  usually  con- 
siderable infiltration  and  induration  of  the  underlying  tissue.  In  color 
they  are  at  first  yellowish,  but  soon  become,  from  the  admixture  of 
blood,  reddish  or  brownish.  They  gradually,  in  the  course  of  several 
days  to  several  weeks,  dry  to  brownish  or  blackish  crusts,  beneath 
which  will  be  found,  in  the  earlier  stages  of  this  process,  superficial 
excoriation.  If  a  maturing  pustule  is  pricked  or  accidentally  ruptured, 
the  fracture  may  close  by  drying  of  the  exuded  pus  and  the  lesion  fills 
up  again.  The  individual  pustules  usually  last  ten  days  to  a  few  weeks; 
but  new  lesions  may  continue  to  appear  from  day  to  day  or  week  to  week 
for  a  period  of  several  months  or  longer.  As  a  rule,  not  more  than  five 
or  ten  are  present  at  any  one  time.  Occasionally,  however,  they  are 
more  numerous,  small  and  less  deep,  and  may  be  limited  to  one  or  both 
legs  below  the  knees.  More  or  less  persistent  pigmentation,  and,  in 
some  instances,  superficial  scarring  may  remain  to  mark  the  site  of  the 
pustules.  The  subjective  symptoms  are  never  marked,  and  rarely  con- 
sist of  more  than  slight  pain  and  tenderness;  itching  is  occasionally  com- 
plained of,  but  is  never  severe. 

Etiology Ecthyma  is  distinctly  a  disease  of  the  lower  walks 

of  life,  and  occurs  in  those  debilitated  from  any  cause  whatsoever. 
It  is  therefore  more  commonly  seen  in  poor-houses,  prisons,  and  in  the 
slums  districts.  Improper  food,  living  under  bad  hygienic  conditions, 
are  predisposing.  Its  common  subject  is  the  adult  tramp  or  the  low- 
class  tenement  lodger.  It  is  not  uncommon,  according  to  Hallopeau, 
in  those  working  in  sugar-refineries.  It  occurs  infrequently  in  children. 
The  exciting  cause  of  the  disease  must  be  considered,  from  the  stand- 
point of  our  present  knowledge,  to  be  a  specific  micro-organism.  The 
malady  is  mildly  contagious.  Nor  can  it  be  doubted  that  the  slight 
breaks  in  the  continuity  of  the  cutaneous  tissues  produced  by  scratching 
and  by  vermin— the  bites  of  lice  and  bedbugs— in  those  whose  other  con- 
ditions and  surroundings  predispose,  are  in  many  cases  potential  factors 
in  the  production  of  the  disease.  It  is  to  be  borne  in  mind  also  that 
exceptionally  the  ingestion  of  certain  drugs,  as  iodids  and  bromids,  may 
produce  somewhat  similar  lesions. 

Pathology.— The  disease  is  allied  to  impetigo,  and  by  many  is 
considered  identical.  Experiments  with  direct  inoculations  (Vidal, 
McCormick)  and  cultures,  it  is  alleged,  always  produce  the  same  affec- 
tion; further  confirmation  is,  however,  needed  on  this  point.  Various 


406  INFLAMMATIONS 

investigators  (Mathieu  and  Netter,  Wickham,  Thibierge,  Unna,  and 
others)  have  found  a  streptococcus  in  the  lesion.  Studies  (Leloir,  Unna) 
of  the  pathologic  anatomy  show  that  the  process  begins  as  an  inflamma- 
tion in  the  lower  epidermal  layers,  fibrinous  centrally  and  edematous  per- 
ipherally, and  which  invades  the  derma  superficially  or  deeply;  minute, 
intercellular  cavities  form,  which  melt  together  and  are  filled  with  a 
fibrinous  and  purulent  fluid.  The  fluid  cavity  involves  the  upper  corium 
and  exceptionally  the  entire  corium.  The  pus,  which  is  inoculable  and 
auto-inoculable,  usually  contains  staphylqcocci  and  streptococci. 

Diagnosis. — Ecthyma  is  to  be  differentiated  from  the  impetigos 
(q.  v.}  and  the  large,  flat,  pustular  syphiloderm. 

The  flat  pustules  of  syphilis  are  ordinarily  sluggish,  much  less  in- 
flammatory, and  usually  lacking  the  extensive,  hard,  and  bright-red 
base  and  areola  of  ecthyma;  moreover,  the  ulceration  of  the  syphilitic 
lesion  is  deeper  and  more  sharply  cut,  and  the  secretion  is  thicker, 
drying  to  greenish  or  greenish-brown  crusts,  which  are  more  bulky 
and  inclined  to  be  heaped  up  like  an  oyster-shell.  The  flat  pustular 
syphiloderm  is  also  of  more  extensive  distribution,  frequently  with 
other  syphilitic  lesions  intermingled,  and  almost  invariably  accompanied 
with  other  symptoms  of  syphilis. 

Prognosis  and  Treatment.— Ecthyma  is  rapidly  amenable  to 
treatment.  It  is  to  be  kept  in  view  that  the  affection  occurs,  as  a  rule, 
only  in  those  in  a  depraved  state  of  health  and  those  who  have  been 
exposed  to  bad  hygienic  conditions,  and  these  possible  factors  should 
be  met  with  proper  measures  and  tonics. 

Cleanliness  is  necessary,  and  frequent  washings,  with  the  use  of  the 
ordinary  toilet  soap,  or  alkaline  baths,  are  to  be  advised;  these,  together 
with  remedial  unguent  applications,  soon  remove  the  crusts.  If  they 
are  firmly  adherent,  and  if  the  process  appears  to  go  deeply,  water 
dressings  or  starch  poultices  can  be  used  temporarily,  but  in  ordinary 
cases  this  is  not  necessary,  and  the  crusts  may  be  permitted  to  become 
detached  gradually,  healing  taking  place  beneath.  Applications  are 
to  be  made  twice  daily,  and  applied  spread  on  lint  or  any  suitable  ma- 
terial. The  local  treatment  is  similar  to  that  employed  in  impetigo 
contagiosa. 

IMPETIGO  HERPETIFORMIS1 

Definition. — An  extremely  rare  disease,  occurring  in  women 
almost  exclusively,  and  usually  while  in  the  puerperal  state,  charac- 

1  Literature:  Hebra,  Wien.  med.  Wochenschr.,  No.  48,  1872  (translation  in  Amer. 
Jour.  Syph.  and  Derm.,  1873,  p.  156);  Lancet,  March  23,  1872;  and  colored  plates  in 
Atlas  der  Hautkrankheiten,  H.  ix,  Taf.  ix  and  x,  1876;  Kaposi,  Archiv,  1887,  p.  273 
(based  upon  13  cases;  4  colored  plates);  Dubreuilh,  Annales,  April,  1892  (a  report  of 
a  new  case  and  an  analytic  review  of  all  authentic  previously  reported  cases,  almost 
all  of  which  were  observed  in  Germany  and  Austria).  Since  this  date  among  other 
cases  recorded  are:  Glaevecke,  Arch,  fur  Gyn.,  Bd.  ccxi,  H.  i,  p.  18 — abstract  in 
Jour.  Cutan.  Dis.,  1897,  p.  146  (recovery;  histologic  examination);  Hartzell,  Jour. 
Cutan.  Dis.,  1897,  p.  507  (in  a  woman  aged  eighty-four);  Whitehouse,  ibid.,  1898,  p. 
169  (in  a  male);  Wechselmann,  Archiv,  1910,  cii,  p.  207  (typical  Hebra  type;  bacte- 
riologic  examination,  negative;  no  eosinophilia) ;  Graham  Chambers,  Brit.  Jour.  Derm., 
1911,  p.  65  (male  patient;  case  and  histologic  illustration;  comparatively  mild  case; 
bacteriologic  examination  negative). 


IMPETIGO  HERPETIFORMIS  407 

terized  by  the  appearance  of  numerous  isolated  and  closely  crowded 
miliary  pustules,  with  a  decided  tendency  to  the  formation  of  circular 
groups  or  patches,  and  preceded  and  accompanied  by  grave  systemic 
disturbance,  and  usually  ending  fatally. 

Symptoms. — The  eruption  is  chiefly  upon  the  genitocrural  region, 
inner  and  flexor  aspects  of  the  thighs,  and  the  anterior  surface  of  the 
trunk,  although  other  parts  of  the  body  may  also  share  in  the  disease. 
It  consists  of  minute  pustules,  grouped  or  arranged  in  circles,  tending 
to  crowd  together  into  patches;  they  crust  over  and  new  lesions  and 
circular  groups  appear  at  the  periphery,  the  crusts  being  of  a  yellowish, 
greenish,  or  brownish  color.  In  this  manner  the  eruption  spreads, 
the  patches  coalesce,  and  large  areas  are  thus  involved.  The  surface 
beneath  the  crusts  is  red  and  moist  looking,  not  unlike  that  of  a  weeping 
eczema.  The  circular  grouping  and  spreading  are  more  or  less  charac- 
teristic, but  in  some  of  the  cases  reported  the  lesions  were  disseminated 
and  in  irregular  clusters.  The  pustules  come  out  in  crops,  and  the  malady 
goes  from  bad  to  worse,  so  that  a  great  part  or  almost  the  entire  surface 
may  become  invaded.  The  mucous  membranes  of  the  mouth,  nose, 
and  throat  may  also  show  involvement.  The  crusts  fall  off  as  the  case 
progresses,  new  epidermis  forms,  or  the  surface  continues  to  have  the 
moist  eczematous  aspects.  In  some  instances  patches  similar  to  those 
of  pemphigus  vegetans  are  observed.  In  a  few  of  the  cases,  too,  the 
eruption  was  polymorphous,  these  being  midway  in  their  cutaneous 
symptoms  between  this  affection  and  dermatitis  herpetiformis.  While 
the  disease  is,  as  a  rule,  continuous,  there  may  be  intermissions  of  partial 
or  complete  quiescence.  Along  with  the  cutaneous  outbreaks  there 
is  grave  constitutional  disturbance,  which  persists,  increases  in  severity, 
and,  with  but  few  exceptions,  finally,  from  exhaustion  or  some  inter- 
current  organic  disease,  the  patient  succumbs. 

Etiology  and  Pathology.— The  disease  is  obscure.  It  is  closely 
allied  to  dermatitis  herpetiformis  and  to  pemphigus,  cases  of  apparently 
mixed  symptomatology  having  been  reported  by  Heitzmann,1  Zeisler,2 
Fordyce,3  and  others.  Excepting  several  cases  in  males,  all  of  the  cases 
so  far  reported  were  in  women,  and  with  but  few  exceptions  in  women 
in  the  pregnant  state.  The  pathologic  anatomy  (T.  Du  Mesnil  and  Marx, 
Dubreuilh,  Glaevecke,  and  others)  shows  dilatation  of  the  blood-  and 
lymph-vessels,  with  swollen  endothelium  and  encompassed  with  embry- 
onic cells.  The  interpapillary  processes  of  the  epidermis  are  widened 
and  prolonged,  there  is  an  abundance  of  round-cell  infiltration  in  the  der- 
ma obscuring  its  structure,  and  which  in  the  pustular  area  completely 
obliterates  the  line  of  demarcation  between  the  pars  papillaris  and  the 
rete  layer.  Contrary  to  Du  Mesnil,  Dubreuilh  finds  that  the  smallest 
pustules  are  deepest  seated.  Several  micro-organisms  have  been  found 
by  some  observers,  while  with  others  the  bacteriologic  examination 
was  negative;  on  this  point  no  conclusion  is  yet  warranted.  The  disease 

1  Heitzmann,  Arch.  Derm.,  1878,  p.  37- 

2  Zeisler,  Monatshefte,  1887,  p.  950. 

3  Fordyce,  Jour.  Cutan.  Dis.,  1897,  p.  495  (with  colored  plate  and  several  hist 
logic  cuts). 


408  INFLAMMA  TIONS 

is  evidently  an  infection,  and  in  some  cases  its  septicemic  nature  seemed 
evident.  In  autopsies  nephritis  and  pulmonary  tuberculosis  have  been 
noted  in  some  instances. 

Diagnosis. — Its  clinical  features,  its  occurrence  in  women,  and 
generally  when  in  the  parturient  state,  are  usually  sufficiently  char- 
acteristic to  distinguish  it  from  pemphigus,  more  especially  pemphigus 
vegetans,  and  from  dermatitis  herpetiformis;  midway  cases  between 
it  and  the  latter  disease  are,  however,  likely  to  give  rise  to  difficulty, 
which  a  few  weeks'  observation  will  usually  solve. 

Prognosis  and  Treatment. — Not  much  hope  can  be  held  out 
to  the  patient,  as  the  disease  is  usually  fatal.  With  but  relatively  few  ex- 
ceptions all  have  died,  some  after  weeks,  some  after  months,  of  suffering.1 
Treatment  is  to  be  based  upon  general  principles,  and  the  plans  advised 
in  pemphigus  and  dermatitis  herpetiformis  seem  indicated.  Abortion 
should  be  induced.  The  cases  which  recovered  were,  as  a  part  of  the 
treatment,  kept  in  the  continuous  water-bath. 

FURUNCULUS 

Synonyms. — Furuncle;  Boil;  Fr.,  Furoncle;  Clou;  Ger.,  Furunkel;  Blutschwar. 

Definition. — Furunculus,  or  boil,  is  an  acute,  deep-seated,  inflam- 
matory, circumscribed,  rounded  or  more  or  less  acuminated,  firm, 
painful  formation,  usually  terminating  in  central  suppuration  and 
necrosis. 

Symptoms. — A  boil  usually  begins  in  one  of  two  ways.  There 
may  appear  a  small  painful  induration  in  the  skin  or  subcutaneous 
tissue,  over  which  the  skin  presents  a  rounded  or  imperfectly  defined 
reddish  spot;  it  increases  in  size,  and  the  surrounding  induration  and 
swelling  become  more  pronounced,  and  project  more  or  less  above 
the  surface  of  the  circumjacent  skin.  After  several  days,  when  well  ad- 
vanced, it  appears  as  a  pea-  to  a  cherry-sized,  circumscribed,  reddish, 
rounded  elevation,  with  more  or  less  surrounding  hyperemia  and  swelling, 
and  is  painful  and  tender;  it  gradually  begins  to  soften,  and  ends,  in 
the  course  of  several  days  to  one  or  two  weeks,  in  the  formation  of  a 
central  slough  and  suppuration.  The  central  overlying  skin  is  finally 
involved,  which  becomes  somewhat  pointed,  thin,  and  yellowish,  dis- 
closing the  pus  beneath.  This  central  point  soon  breaks,  the  opening 
enlarges,  and  there  are  discharged  more  or  less  pus  and  a  small,  grayish- 
yellow  or  greenish-white  pultaceous  mass,  the  so-called  "core";  the 
pain  immediately  abates,  the  inflammation  quickly  subsides,  the  swelling 
and  redness  disappear,  the  hollow  cavity  fills  up  with  granulation  tissue, 
and  healing  rapidly  takes  place,  leaving  behind  for  a  week  or  more  a 
reddish  spot,  with  slight  scar-formation,  which,  in  some  instances,  may 
be  so  slight  as  later  to  be  scarcely  perceptible. 

Or  instead  of  a  painful  cutaneous  or  subcutaneous  nodule,  the 
lesion  first  presents  as  a  minute  superficial  pustule,  usually  pierced  by 

1  Linser  ("Ueber  die  Behandlung  der  juckenden  Hautkrankheiten  mit  normalem 
menschlichen  Serum,"  Dermatolog.  Wochenschr.,  March  30,  1912,  liv,  p.  365)  records 
an  instance  of  cure  from  an  injection  of  serum  from  a  normal  pregnant  woman;  he  also 
records  instances  of  other  pruritic  dermatoses,  being  relieved  by  serum  injections. 


FURUNCULUS 

a  hair;  gradually  the  surrounding  and  underlying  parts  become  red 
and  slightly  indurated  and  swollen,  and  the  small  pustule  dries  and 
then  the  lesion  gradually  assumes,  to  a  great  extent,  the  characters 
of  an  ordinary  boil,  and  goes  through  the  stages  described.  Or  the 
small  pustule  breaks  and  discharges;  it  dries  over,  and  then  the  indura- 
tion, redness,  and  swelling  ensue.  Gradually  this  points,  presents  a 
yellowish  summit,  and  the  course  is  the  same  as  above  detailed. 
Exceptionally  the  opened  apex  may  dry  over  once  or  twice,  the  boil  fill 
up  again  before  the  core  is  discharged. 

There  may  be  one,  several,  or  more  present,  and  usually  in  close 
proximity,  although  in  some  cases  they  may  be  widely  separated.  If 
the  lesion  is  a  large  one,  or  if  several  form  simultaneously,  there  may  be 
slight  sympathetic  constitutional  disturbance.  The  neighboring  lym- 
phatic glands  may  show  some  enlargement. 

At  times  a  boil  shows  very  little,  if  any,  tendency  to  point  or  break 
down,  or  to  form  a  distinct  core,  constituting  the  so-called  blind  boil. 
This  may  disappear  in  its  early  stage,  or  may  continue  and  finally  go  on 
forming  a  soft  boggy  pea-  to  cherry-sized  elevation,  which  eventually 
breaks  and  discharges,  and  then  gradually  heals  up  as  in  the  ordinary 
form. 

Usually,  when  the  one  or  several  lesions  which  have  formed  sim- 
ultaneously or  one  after  another  disappear,  the  whole  process  is  ended. 
In  other  cases  there  is  a  constant  recurrence  of  one  or  several  lesions, 
in  the  same  localities,  or  on  different  regions,  and  this  sometimes  con- 
tinues for  weeks  and  months,  constituting  that  condition  termed  furun- 
culosis. 

While  boils  may  appear  on  any  part  of  the  body,  certain  regions, 
such  as  the  back  of  the  neck,  the  axilla,  buttock,  forearms,  and  legs 
are  its  most  common  sites,  and  most  frequently  the  first  named. 

Etiology. — Two  factors  are  to  be  considered  necessary  in  this 
disease,  essential  and  predisposing.  The  essential  factor,  and  the 
immediate  exciting  cause,  is  the  entrance  into  a  hair-follicle  or  seba- 
ceous gland-duct,  or  possibly  a  sweat-gland,  of  a  special  micro-organ- 
ism. The  frequently  observed  close  proximity  of  boils  is  indicative  of 
external  cause  and  auto-inoculability.  The  contributing  influences 
are  various,  but  may  be,  in  brief,  any  depraved  state  of  the  general 
health.  Albuminuria,  diabetes  mellitus,  disorders  of  the  digestive 
organs,  gouty  and  rheumatic  diatheses,  living  in  close  and  badly  venti- 
lated rooms  or  in  damp  and  musty  places,  and,  doubtless,  other  factors 
may  be  of  influence  in  bringing  about  a  condition  of  the  skin  favorable 
to  successful  inoculation.  Too  much  warmth,  with  its  consequent 
sweating,  and  friction  are  also  of  importance  in  bringing  the  skin  itself 
into  a  favorable  state  for  implantation  and  multiplication  of  pyogenic 
organisms.  Thus  boils  are  quite  frequently  a  part  of  a  persistent  miliaria 
in  dirty  and  overclad  children  or  even  adults;  and  especially  common 
about  the  nape  of  the  neck  and  axilla,  parts  subjected  to  rubbing  and 
chafing.  Workmen  in  paraffin  oils  and  petroleum  and  tar  products 
often  present  furuncles  and  subcutaneous  abscesses.  The  administra- 
tion of  certain  drugs,  notably  potassium  iodid,  may  be  in  some  instances 


4 1 0  INFLAMMA  TIONS 

an  important  etiologic  factor;  lesions  so  produced  are  not  infrequently 
seen  in  those  taking  "blood  purifiers,"  many  of  which  contain  this  drug. 

All  ages  and  both  sexes  are  liable,  but  the  formation  is  more  common 
between  the  ages  of  twenty  and  forty,  and  in  males. 

Pathology. — A  boil  is  an  inflammatory  formation  having  its 
starting-point  in  a  sebaceous  gland,  hair-follicle,  or  possibly  a  sweat- 
gland,  the  exciting  factor  being  the  staphylococcus  pyogenes  aureus. 
Both  Bockhart1  and  Garre2  have  experimentally  produced  furuncular 
lesions  on  themselves  by  rubbing  in  pure  cultures  of  this  organism;  the 
former,  a  pure  mixed  culture  of  the  staphylococcus  aureus  and  albus,  the 
latter  of  the  aureus  alone.  Its  pathogenic  importance  has  been  demon- 
strated by  Pasteur,  Sabouraud,  Unna,  Wickham,  and  others.3  It  is 
not  improbable,  however,  that  boils  may  also  be  produced  by.  other 
pus-producing  organisms.  The  core  or  central  slough  of  a  boil  is 
composed  of  pus  and  the  glandular  and  perifollicular  tissue  in  which  it 
had  its  origin.  The  intense  zone  of  inflammatory  deposit  around  the 
center,  by  shutting  off  the  vascular  supply,  results,  along  with  the 
liquefying  action  of  the  cocci  and  leukocytes,  in  the  breaking  down  of 
the  central  portion  and  the  production  of  the  core  mass. 

Diagnosis. — A  boil  is  so  well  known  that  usually  even  a  layman 
can  make  the  diagnosis.  In  the  earliest  stage  of  those  which  begin 
as  a  superficial  pustular  point  around  a  hair  it  might  be  readily,  and 
probably  properly,  looked  upon  as  a  simple  impetigo  lesion;  the  later 
phases  of  surrounding  and  underlying  inflammation,  with  the  gradual 
pointing  and  discharge,  are  quite  characteristic.  A  furuncle  is,  in 
fact,  to  be  distinguished  chiefly  from  a  carbuncle,  and  the  main  dis- 
tinguishing point  is  that  a  furuncle  is  a  single  formation  and  has  but 
one  point  of  suppuration  and  opening,  whereas  a  carbuncle  is  a  large, 
flattened,  intensely  painful  formation  usually  accompanied  with  con- 
siderable or  severe  constitutional  disturbance,  and  has,  moreover,  sev- 
eral or  more  points  of  suppuration. 

Prognosis. — An  average  boil  usually  runs  its  course  in  from  one 
to  two  weeks,  and  even  when  several  or  more  are  present  in  the  same 
locality,  a  favorable  issue  in  many  cases  soon  results.  In  some  of  these 
latter  instances,  however,  and  in  those  in  which  there  are  scattered  boils 
appearing  from  time  to  time  (f urunculosis) ,  a  favorable  result  is  not  so 
rapidly  reached,  although  complete  freedom  will  sooner  or  later  be  es- 
tablished. The  possibility  of  a  serious  underlying  factor,  such  as  diabetics 
living  in  a  damp,  unhygienic  atmosphere,  etc.,  must  be  considered. 

Treatment. — Remembering  that  boils  are  doubtless  due  to  the 
predisposing  factors  of  a  weakened  organism,  a  local  disturbance  of 
the  skin,  and  the  presence  of  the  specific  causative  microbe  will  sug- 
gest the  plans  of  treatment. 

The  constitutional  treatment  depends,  in  a  measure,  upon  the 
patient's  general  condition,  and  what  may  seem  to  be  the  etiologic 
factor.  A  generous  dietary  is  to  be  allowed.  In  cases  of  numerous 

1  Bockhart,  Monatshefte,  1887,  p.  450. 

2  Garre,  Fortschritle  der  Medicin,  1885,  p.  165. 

3  See  literature  under  Impetigo,  and  also  under  General  Etiology. 


FURUNCULUS 


411 


and  recurrent  boils,  the  urine  should  always  be  examined.  Irrespec- 
tive of  any  such  disease  as  diabetes,  albuminuria,  and  the  like,  the 
most  successful  plan  of  treatment  consists  in  the  administration  of 
tonics,  especially  iron,  cod-liver  oil,  strychnin,  and  similar  remedies. 
Occasional  laxatives  are  of  value.  The  digestion  should  be  considered, 
and  if  disordered,  the  necessary  treatment  instituted.  Recently  fresh 
brewer's  yeast,  a  teaspoonful  to  a  tablespoonful,  three  times  daily, 
has  been  again  brought  forward  as  a  valuable  remedy  by  Brocq,1  Gordon,2 
Turner,3  and  others.4  Purdon5  speaks  favorably  of  lactophosphate  of 
lime,  and  Duhring  of  sodium  hyposulphite.  Wright,  Gilchrist,  Engman, 
Gaskill,6  and  others  have  recently  reported  good  results  in  furunculosis, 
from  injections  of  antistaphylococcic  serum  or  "vaccine,"  the  dose  and 
frequency  to  be  regulated  by  the  opsonic  index  of  the  blood  (see  "Opso- 
nins,")  or,  as  more  recently,  by  the  effect  of  trial  doses. 

The  local  management  of  the  disease  is  of  importance,  and  its  success 
depends  upon  thoroughness.  Absolute  cleanliness  is  essential,  and 
for  this  purpose  frequent  washings,  at  least  once  daily,  with  soap  and 
water  should  be  enjoined;  and  in  multiple  or  recurrent  cases  the  tincture 
of  green  soap  may  be  used  for  this  purpose,  with  5  or  10  grains  (0.33- 
0.65)  of  resorcin  to  the  ounce  (32.).  The  beginning  formation  may  some- 
times be  aborted  by  the  injection  of  a  few  drops  of  a  5  per  cent,  solution 
of  carbolic  acid  into  the  lesion  or  by  plunging  a  wooden  toothpick 
charged  with  pure  carbolic  acid  into  the  apex  of  the  lesion.  An  ointment 
or  aqueous  solution  of  ichthyol,  25  per  cent,  strength,  kept  constantly 
applied,  will  succeed  sometimes.  It  forms  a  good  method  of  treatment 
of  the  lesion;  when  pointing  has  ensued,  an  incision  and  expression 
of  the  contents  and  its  reapplication  will  hasten  the  final  disappear- 
ance. While  most  boils  will  pass  through  their  various  stages  and 
disappear  satisfactorily  without  incision,  this  latter  hastens  the  process. 
After  incision  and  expression  of  the  contents  a  good  plan  is  to  cleanse 
the  cavity  with  hydrogen  dioxid  or  the  carbolic  acid  solution.  Poultices 
are,  as  a  rule,  not  to  be  employed.  In  addition  to  the  ichthyol  ointment 
and  the  soap-and-water  washings,  an  application  of  an  antiseptic  lotion 
to  the  boil  or  boils  and  the  entire  affected  region,  night  and  morning, 
is  a  measure  of  considerable  value  in  the  management  of  the  disease  and 
the  prevention  of  new  lesions.  Such  a  lotion  is  the  following:  1$. 
Resorcin,  gr.  xv-xxx  (i.-2.);  acidi  borici,  3iss  (6.);  alcoholis,  f5j  (32-); 
aquae  dest.,  f5v  (i6o.).7 

1  Brocq,  La  Presse  med.,  1899,  p.  45  (with  review  of  past  literature). 

2  Gordon,  Philada.  Med.  Jour.,  April  i,  1899. 

3  Turner,  Therapeutic  Gazette,  March  15,  1899. 

4  Aragon  and  Coutourieux,  Bull,  med.,  July  5,  1899. 
6  Purdon,  Dublin  Jour.  Med.  Sci.,  Feb.,  1898. 

6  Gaskill,  Jour.  Amer.  Med.  Assoc.,  April  15,  1911,  P-  i°99,  has  had  good  results 
from  opening  with  a  sharpened  cotton  applicator  dipped  in  carbolic  acid,  hypodermic 
injection  of  polyvalent  staphylococcus  vaccines,  and  application  of  a  5  to  15  per  cent. 
salicylic  acid  ointment. 

7  John  T.  Bowen,  "The  Treatment  of  Furunculosis,"  Jour.  Amer.  Med.  Assoc., 
July  16,  1910,  p.  209:  green  soap  and  water  washing  twice  daily,  the  skin  then  bathed 
with  saturated  solution  of  acidum  boricum— dried   without   wiping,  and  then  the 
individual  furuncles  dressed  with  an  ointment  of  boric  acid,  3j  (4-),  precipitated  sul- 
phur, 3j  (4.),  and  carbolized  petrolatum,  5j  (32.)— underwear  changed  daily. 


412  INFLAMMATIONS 

When  the  lesions  are  small,  superficial,  and  close  together,  as  not 
uncommon  upon  the  back  of  the  neck,  and  occasionally  on  the  lower 
part  of  the  leg,  the  free  use  of  this  lotion  after  thoroughly  cleansing 
the  parts  with  the  tincture  of  green  soap  and  water,  and  while  still 
wet  with  it  putting  on  a  thick  layer  of  boric  acid  powder  and  covering 
with  a  light  dressing  will  often  act  satisfactorily;  this  is  to  be  done  once 
or  twice  daily.  When,  too,  the  lesions  are  on  the  neck  region,  it  is  pos- 
sible that  the  scalp,  especially  the  hair  of  the  lower  occipital  region, 
may  be  the  harboring  place  of  the  micro-organisms  and  give  rise  to  re- 
currence; and  the  patient  is,  therefore,  directed  to  wash  this  latter  region 
thoroughly  once  daily,  and  the  entire  scalp  at  least  twice  weekly.  The 
same  is  to  be  advised  when  the  disease  is  on  other  parts,  wrhere  the  hair 
is  in  abundance,  as  in  or  about  the  axilla,  genitalia,  and  anal  region. 
With  this  plan  of  management — frequent  washings  and  the  general 
application  of  the  above  lotion  and  powder,  and,  in  the  larger  and  the 
maturing  lesions,  ichthyol  salve  application,  incision  when  necessary, 
along  with  the  indicated  constitutional  treatment — most  of  the  recurrent 
cases,  in  these  regions,  yield  comparatively  rapidly.  I  have  usually 
reserved  the  staphylococcic  injection  for  trial  in  rebellious  cases. 

CARBUNCULUS 

Synonyms. — Carbuncle;  Anthrax;  Anthrax  simplex;  Anthrax  benigna;  Fr.,  Car- 
boncle;  Ger.,  Carbunkel;  Brandschwar;  Kohlenbeule. 

Definition. — A  carbuncle  is  an  acute,  usually  egg-  to  palm-sized, 
more  or  less  circumscribed,  flattened,  phlegmonous  inflammation  of 
the  skin  and  subcutaneous  tissue,  terminating  in  a  slough  which  usually 
finds  exit  at  several  or  more  points. 

Symptoms. — The  first  indications  of  the  formation  of  a  carbuncle 
consist  in  some  local  tenderness  and  subcutaneous  induration,  along 
with  symptoms  of  constitutional  disturbance,  such  as  chilliness  and 
malaise  and  febrile  action,  which,  if  the  disease  is  situated  about  the 
face,  or  if  involving  an  extensive  area,  and  especially  if  the  patient 
is  asthenic,  may  be  of  a  severe  character.  Locally  the  induration 
becomes  more  pronounced,  is  somewhat  flat,  and  consists  of  a  firm,  dense 
infiltration  of  the  deeper  skin  and  subcutaneous  tissue,  with  the  over- 
lying skin  of  a  reddish  tinge.  It  spreads  laterally,  and  finally  involves 
an  area  of  several  or  more  inches  in  diameter.  It  projects  slightly  above 
the  surface,  and  extends  deeply,  is  tense  looking  and  of  a  dark-red  color, 
which  extends  for  some  distance  beyond  the  hardened  area.  After  a 
variable  time,  usually  some  days,  suppuration  and  softening  take  place, 
the  skin  at  several  or  more  points  shows  a  tendency  to  thinning  and 
discloses  the  yellowish-red  pus  beneath.  These  gradually  open  and  give 
exit  to  a  sanious  pus.  The  many  openings  give  the  surface  a  cribriform 
appearance.  Sloughing  is  noted  at  these  openings,  which  slowly  or 
rapidly  become  larger;  the  inclosed  pus  and  necrotic  tissue  are  gradually 
cast  off,  the  cavities  are  filled  with  healthy  granulations,  and  healing 
begins  to  take  place.  Or  in  other  cases,  as  soon  as  the  skin  has  broken 
through  at  several  or  many  places,  a  sloughing  of  the  whole  mass  ensues, 


CARBUNCULUS  413 

which  later  falls  out,  and  leaves  a  large  and  rather  deep-cut  ulcer, 
which  gradually  undergoes  the  reparative  process  and  heals.  Or, 
after  reaching  its  acme,  the  whole  mass  may  slough  without  previous 
opening.  The  necrotic  process  usually  stops  at  the  subcutaneous 
fascia,  but  in  exceptional  instances  (Weber,  Monnier)  it  goes  much  more 
deeply.  The  formation  is  painful,  often  of  a  dull  and  lancinating  char- 
acter. The  disease  area  may,  in  extreme  cases,  involve  a  whole  region. 
Especially  in  the  latter  cases,  the  constitutional  symptoms  are  of  a  grave 
character.  In  some  instances,  particularly  in  the  aged,  septic  poisoning 
ensues,  and  the  patient  gradually  or  rapidly  succumbs.  Instead  of 
beginning  as  a  subcutaneous  induration  a  carbuncle  may,  as  also  ob- 
served in  boils,  begin  as  a  superficial  pustule,  and  may,  in  such  instances, 
in  its  early  stage,  be  apparently  furuncular. 

There  is  usually  but  one  lesion  present.  The  favorite  sites  are  the 
nape  of  the  neck  and  the  upper  part  of  the  back.  It  is  most  common  in 
middle  age  and  advancing  years,  and  most  frequent  in  men.  Several 
weeks  or  one  or  two  months  may  elapse  before  recovery  is  complete. 

Etiology. — The  etiology  of  carbuncle  is  to  be  considered  as  essen- 
tially the  same  as  that  of  furuncle;  ill  health  from  any  cause,  a  depression 
of  the  vital  forces,  diabetes,  and  other  constitutional  diseases  being  pre- 
disposing. Added  to  the  predisposing  factor  or  factors  is  the  essential 
one  of  microbic  invasion,  the  organism  believed  to  be  the  same  as  in 
boils,  and  doubtless  always  the  staphylococcus  pyogenes  aureus,  although 
it  is  possible  that  other  pus-organisms  may  at  times  be  etiologic.  There 
may  be  an  invasion  at  many  points  in  this  malady,  which  results  in  the 
production  of  a  lesion  seemingly  made  up  of  a  number  of  closely  aggre- 
gated necrotic  centers. 

Pathology — The  pathology  of  this  lesion  is  closely  similar  or 
analogous  to  that  of  a  furuncle.  The  inflammation  starts  simultaneously 
from  numerous  points  from  the  hair-follicles,  sebaceous,  and  possibly 
sometimes  also  the  sweat-glands,  the  inflammatory  centers  break  down, 
and  the  pus  finds  its  way  to  the  surface;  finally  the  process  ends  in  gan- 
grene of  a  part  or  of  the  whole  area.  It  is  not  improbable  in  this,  as 
well  as  in  furuncle,  that  the  vascular  supply  is  shut  off  from  both  beneath 
and  laterally  by  the  intense  inflammatory  deposit,  with  resulting  necrosis. 
The  pyogenic  micro-organisms  are  present  in  abundance  in  the  tissues. 
Investigations  have  shown  that  the  inflammation  may  also  start  deeply 
down  from  some  point  or  points  in  the  subcutaneous  tissue.  The  pus 
forms,  spreads  laterally  along  the  line  of  least  resistance,  the  overlying 
skin  becomes  necrotic,  and  the  pus  finds  its  way  to  the  surface  along  the 
line  of  the  columnse  adiposae  and  along  the  hair-follicles  and  erector 
pili  muscles  (Warren).1  According  to  Winiwarter,2  there  is  primarily 
tissue  necrosis,  with  suppuration  and  fibrinous  coagulation,  and  early 
thrombosis  of  the  vessels. 

Diagnosis Carbuncle  differs  from  furuncle  by  its  flatness,  more 

extensive  area,  and  its  multiple  points  of  necrosis  and  suppuration, 

1  Warren,  Boston  Med.  and  Surg.  Jour.,  April  17,  1877;  Column*  adipose,  -with  their 
Pathologic  Significance  in  Carbuncles,  etc.,  Cambridge,  Mass.,  1881. 

2  Winiwarter,  "Furunkel   und   Carbunkel,"  Chirurgische  Krankheiien  der  Haul, 
Stuttgart,  1892. 


4 1 4  IN  FLA  MM  A  TIONS 

and  by  the  presence,  usually,  of  constitutional  disturbance  of  moderate 
or  severe  character.  Erysipelas  and  phlegmona  diffusa  may  also  at 
times,  more  especially  in  the  beginning,  bear  some  resemblance. 

Prognosis. — Carbuncle  is  always  a  serious  malady,  and  is  not 
infrequently  fatal  in  old  people  and  those  debilitated  by  disease  or 
who  have  a  grave  underlying  condition  of  ill  health.  About  the  face 
and  head  the  outlook  is  still  more  serious.  Septic  poisoning  is  always  a 
possibility;  death  from  thrombosis  or  embolus  has  also  occurred.  Except 
in  such  instances  as  named,  however,  full  recovery  is  to  be  expected. 

Treatment. — The  treatment  of  carbuncle  comes  usually  under 
the  care  of  the  surgeon.  Abortive  treatment,  by  keeping  the  surface 
soaked  in  a  strong  antiseptic  solution,  usually  5  to  10  per  cent,  carbolic 
acid  lotion,  may  exceptionally,  in  the  very  beginning,  when  the  forma- 
tion begins  superficially,  prove  successful;  likewise  the  application  of 
ichthyol,  pure  or  with  two  or  three  parts  water.  Mild  cases,  and  even 
severe  cases,  are  often  successfully  treated,  as  first  advocated  by  Verneuil, 
by  free  injection  of  carbolic  acid  in  glycerin  or  oil,  10  per  cent,  strength, 
at  several  or  more  points  in  the  lesion;  over  this  can  be  placed  a  thick 
covering  of  a  25  per  cent,  ointment  of  ichthyol,  using  equal  parts  of 
lanolin  and  zinc  oxid  ointment  or  spermaceti  as  a  base.  When  the 
growth  has  broken  down  at  a  number  of  points,  the  pus  and  detritus 
may  be  partially  drawn  out  by  means  of  a  cupping-glass,  and  the  car- 
bolized  oil  or  glycerin  injected  into  the  cavities  thus  made,  and  over  this 
the  same  dressing  as  above;  or  the  cavities  or  openings  can  with  advan- 
tage be  first  thoroughly  washed  out  with  hydrogen  dioxid.  The  slough 
usually  comes  away  in  the  course  of  several  days  or  a  week  or  so,  and 
healing  gradually  ensues.  Others  (Woods,  Taylor,  Manley)1  prefer  a 
saturated  solution  of  pure  carbolic  acid  as  less  likely  to  be  followed  by 
absorption.  Operative  treatment  has  long  been  the  favorite  method; 
deep  crucial  incisions  have  long  been  in  general  use,  and  still  have  their 
advocates;  and,  more  recently,  crucial  incision,  supplemented  by  com- 
plete extirpation  of  diseased  tissue  by  curet  or  knife  (Riedel,  Schleich, 
Parker).2  In  rapidly  sloughing  cases  thorough  curetting  and  the 
superimposing  of  an  antiseptic  dressing  are  advisable;  ichthyol  also 
serves  well  for  this  purpose. 

The  constitutional  treatment  of  carbuncle  consists  in  supporting 
the  patient's  strength  with  the  administration  of  alcoholic  stimulants, 
ammonium  carbonate,  strychnin,  quinin,  and  iron.  Wright's  plan  of 
opsonic  treatment  with  antistaphylococcic  vaccine  might  be  worth  a 
trial  in  the  more  severe  cases. 

PHLEGMONA  DIFFUSA 

Synonym. — Phlegmonous  cellulitis. 

Phlegmona  diffusa  is  a  somewhat  rare,  more  or  less  extensive  inflam- 
mation of  the  cutaneous  and  subcutaneous  tissues,  which  is  similar  to 

1  Woods,  Toledo  Med.  and  Surg.  Jour.,  1880,  p.  446;  Taylor,  Austral.  Med.  Gaz., 
1881-82,  p.  34;  Manley,  Med.  Record,  June  18,  1898. 

-  Schleich,  Methode  der  Wundheihmg,  Berlin,  1899;  Riedel,  Deutsche  med.  Wochen- 
schr.,  1891,  p.  845;  Parker,  Brit.  Med.  Jour.,  Nov.  26,  1898,  p.  1604. 


DISSECTION   WOUNDS  415 

or  closely  allied  to  cellulitis  and  to  erysipelas.  It  is  of  a  rather  ill-defined 
character,  presenting  a  conglomerate  symptomatology  of  deep  erysipelas 
and  later  of  extensive  flat  carbuncle.  There  are  often  prodromal  symp- 
toms akin  to  those  observed  in  erysipelas:  feeling  of  malaise,  followed  by 
a  decided  chill  or  by  repeated  rigors,  with  subsequent  febrile  action. 
There  is  usually  sharp  or  dull  pain  at  the  site  of  the  disease.  It  begins, 
as  a  rule,  as  a  hard  infiltration  of  lumpiness  somewhat  deeply  seated,  and 
is  attended  by  a  good  deal  of  swelling  and  edema,  which  may  involve 
considerable  area.  In  the  course  of  five  to  ten  days  some  softening  is 
observed,  and  the  indurated  swollen  area  gives  place  to  bogginess  and 
fluctuation.  Or  before  this  stage  is  so  clearly  reached  there  may  be 
retrogression  and  a  gradual  disappearance  of  the  swelling.  In  other 
cases  a  melting  away  or  necrosis  takes  place.  The  purulent  matter  may 
burrow  its  way  into  surrounding  tissues,  involving  those  in  the  process; 
or  there  may  be  a  gradual  working  toward  the  surface,  and  one  or  more 
openings  may  present,  and  discharge  pus  and  the  necrotic  tissue.  In 
favorable  cases  the  disease  then  gradually  declines.  In  severe  and  grave 
instances  septic  poisoning  may  ensue,  the  patient  rapidly  succumbing 
or  sinking  gradually  from  exhaustion.  In  these  severe  forms  the  con- 
stitutional symptoms  continue  from  the  very  beginning.  In  favorable 
cases  as  soon  as  there  is  cessation  of  pus-formation,  febrile  action,  as  a 
rule,  ceases,  and  the  patient  gradually  recovers.  Depending  upon  the 
amount  of  surface  necrosis,  the  scarring  may  be  slight  or  extensive. 

The  malady  is  of  a  somewhat  obscure  nature.  It  is,  as  judged  by 
kindred  diseases,  due  to  a  micro-organism.  It  may  be  the  ordinary 
pus  coccus,  with  some  unknown  favoring  conditions  added.  It  is 
really  a  phlegmonous  cellulitis,  and  is  probably  to  be  regarded,  as 
suggested  by  some  writers,  as  a  deep  form  of  erysipelas.  It  is  similar 
or  closely  allied  (Hyde  and  Montgomery)  to  the  gangrene  foudroyante 
of  the  French  and  to  the  acute  purulent  edema  of  English  authors. 
Unna's  investigations  would  indicate  that  the  process  is  due  to  infection 
by  the  erysipelas  coccus  and  pyogenic  staphylococcus. 

The  disease  varies  in  severity  from  comparatively  mild  form  to  a 
rapidly  fatal  variety.  With  cases  of  mild  or  moderate  severity  in  healthy 
and  vigorous  subjects  the  result  is  almost  invariably  favorable;  and  even 
in  some  of  the  more  extensive  cases  in  such  individuals  the  outlook  is 
not  hopeless.  It  is  always  to  be  considered,  however,  a  dangerous  affec- 
tion. Constitutional  treatment  is  to  be  of  supporting  character,  as  in 
erysipelas;  local  measures  are  essentially  surgical,  consisting  of  incision, 
thorough  drainage,  and  the  free  use  of  antiseptics. 

DISSECTION  WOUNDS 

Several  of  the  diseases  described  elsewhere  in  this  book,  such  as 
erysipelas,  impetiginous  lesions  from  pyogenic  cocci  and  the  like,  and 
various  kinds  of  irritation  from  the  chemicals  employed  in  preserving 
or  embalming,  usually  of  an  eczematous  character  and  belonging  to 
dermatitis  venenata,  are  sometimes  observed  in  those  having  to  do  witJ 
dead  bodies;  but  the  usual  manifestations  to  which  this  title  of 


4 1 6  INFLAMMA  TIONS 

tion  wounds  is  given  are  postmortem  pustule  and  anatomic  tuber- 
cle. As  the  latter  is  admittedly  tuberculous,  it  will  be  elsewhere  con- 
sidered. 

Postmortem  pustule  results  from  inoculation  of  some  unknown 
virus  from  cadavers  in  the  dissecting  room  or  from  postmortems; 
rarely  it  is  seen  in  butchers  and  others  who  have  to  do  with  dead  animals. 
There  is  a  presupposed  abrasion  or  break  of  continuity  in  the  skin, 
often  demonstrable,  but  occasionally  scarcely  recognizable,  through 
which  the  poison  enters.  The  lesion  first  presents  itself  shortly  after 
exposure,  as  an  itchy  red  spot,  which  soon  develops  into  a  vesicopustule 
or  pustule  having  a  slightly  or  markedly  inflammatory  base.  It  gradually 
dries,  or,  from  breakage  of  the  crust,  the  contents  find  exit;  the  crust 
closes  over  again,  or  the  process  goes  on  and  it  fills  up  again,  usually 
becoming  somewhat  larger.  This  may  continue  slowly  and  repeat  itself 
a  number  of  times  if  uncared  for,  or  it  may  finally  dry  up  and  disappear 
spontaneously.  If  the  crust  is  removed,  a  superficial  ulcer  is  disclosed. 
The  formation  is  more  or  less  painful  and  usually  dull  red  in  color,  and 
not  infrequently  attended  with  swelling  of  the  surrounding  parts;  occa- 
sionally red  streaks  extend  along  the  line  of  the  lymphatics.  Excep- 
tionally the  region  may  present  an  erysipelatous  aspect.  In  some  cases 
slight  or  severe  constitutional  disturbance  is  present.  In  other  instances 
the  local  lesion  may  remain  insignificant,  but  is  followed  by  some 
swelling  and  general  septic  symptoms  of  more  or  less  gravity.  The 
essential  (bacterial)  cause  of  the  disease  is  not  known. 

Treatment  consists  in  opening  the  pustule,  removing  the  crust, 
cleansing  with  hydrogen  dioxid,  and  the  use  of  wet  antiseptic  corro- 
sive sublimate  dressings;  or  a  powder  of  iodol  or  a  powder  of  3  parts 
boric  acid  and  i  part  acetanilid  can  be  freely  applied.  If  any  viru- 
lence is  displayed,  the  base  of  the  lesion  should  be  previously  cauterized 
and  the  subsequent  treatment  be  as  above.  Constitutional  treatment 
is  rarely  called  for,  and  its  character  would  depend  upon  indications. 

EQUINIA 

Synonyms. — Glanders;  Farcy;  Malleus;  Fr.,  Morve;  Farcin;  Ger.,  Rotz;  Rotz- 
krankheit. 

Definition. — An  inoculable  acute  or  chronic  disease  of  malig- 
nant type,  derived  from  the  horse,  mule,  or  ass,  and  characterized  by 
grave  constitutional  symptoms,  inflammations  of  the  nasal  and  res- 
piratory passages,  and  a  vesicopustular,  papulopustular,  or  deep-seated 
tubercular  or  nodular  ulcerative  eruption. 

Symptoms. — The  site  of  the  inoculation  may  be  on  exposed  parts 
through  any  break  or  lesion  of  the  skin,  or  it  may  gain  access  through 
the  mucous  membrane  of  the  eye,  nose,  mouth,  or  respiratory  tract. 
Its  port  of  entrance  is  not  always  ascertainable.  A  few  days  to  several 
weeks  after  inoculation  general  symptoms  of  malaise,  fever,  rheumatic 
pains,  and  possibly  chills  or  chilliness  are  noted.  The  local  symptoms 
at  the  point  of  inoculation  are  somewhat  varied.  The  spot  may  heal 
up  and  break  down  again,  a  decided  phlegmonous  inflammation  may 


EQU1NIA  417 

show  itself,  or  a  small  inflammatory,  dark-red  papulopustule  arises  and 
may  break  down  into  an  unhealthy-looking  ulcer,  which  tends  to  spread. 
Inoculation  of  the  mucous  membrane  of  the  eye  or  nose  may  lead  to 
destruction  of  the  part,  which  usually  not  only  extends  deeply  into 
the  soft  tissue,  but  may  involve  the  bony  structure.  Along  with  the 
symptoms  at  the  site  of  the  inoculation  and  the  advent  of  systemic  dis- 
turbance, or  somewhat  later,  the  general  surface,  or  parts  of  it,  as  well 
as  the  mucous  membranes,  becomes  the  seat  of  somewhat  flattened 
vesicopustules,  small  or  large  nodules  which  break  down  and  form 
ill-conditioned,  foul  ulcers,  which  increase  in  size  and  may  involve 
considerable  tissue.  Large  nodules  (so-called  farcy  buds)  may  appear 
deep  down  in  the  tissues,  in  the  lymph-glands,  and  the  lymphatic 
channels  may  be  thickened.  Some  may  melt  down  and  give  rise  to 
abscesses  and  extensive  destruction.  The  mucous  membranes  may 
also  show  lesions  of  similar  but  smaller  character,  more  especially  the 
mucous  membrane  of  the  nose,  the  latter  being  affected  in  a  large  number 
of  cases.  These  are  apt  to  undergo  the  same  destructive  changes  as 
those  upon  the  skin.  There  is  at  first  a  good  deal  of  mucoid  or  catarrhal 
discharge  from  the  nose,  somewhat  viscid,  which  may  later  be  mixed 
with  pus  and  blood.  In  some  instances  the  brunt  of  the  manifestations 
is  upon  the  mucous  membranes,  not  only  of  the  parts  named,  but  also 
of  the  intestinal  tract.  The  constitutional  symptoms  may  vary,  but 
in  the  acute  cases  the  febrile  action  is  usually  continuous  and  becomes 
more  marked,  the  symptoms  of  general  sepsis  are  added,  and  the  patient 
succumbs. 

The  chronic  cases  differ  often  considerably  from  the  acute.  The 
lesions  may  be  scanty  in  number,  develop  and  undergo  changes  less 
rapidly,  and  the  accompanying  constitutional  disturbance  is  less  marked. 
The  characters  of  the  acute  type  may  supervene,  and  the  patient  rapidly 
die.  The  duration  of  the  chronic  disease  may  be  months  or  longer. 
Death  usually  results  from  marasmus  or  renal  complication  (Besnier). 
If  recovery  takes  place,  the  ulcers  gradually  heal  and  other  symptoms 
abate.  Exceptionally  apparent  recovery  is  noted  (Hallopeau),  which 
may  last  a  year  or  more,  followed  finally  by  recrudescence  and  death. 

Etiology  and  Pathology.— The  disease  is  rather  rare  in  this 
country.  It  is  usually  contracted  from  horses,  and  is  seen  chiefly  in 
those  who  have  to  do  with  these  animals.  Its  transmissibility  from 
man  to  man  has  also  been  noticed  in  some  instances.  The  direct 
cause  is  the  glanders  bacillus  (bacillus  mallei),  similar  but  smaller  than 
the  tubercle  bacillus,  and  found  in  all  lesions,  the  blood  and  other  tis- 
sues (Schutz  and  Loffler,  Bouchard,  Capitan,  Charrin).  The  lesions 
are  made  up  of  round-celled  granulation  tissue,  which,  as  in  all 
granulomata,  is  unstable  and  breaks  down  readily. 

Diagnosis.— The  diagnosis  is  not  always  easy  in  the  earliest  period, 
but  after  the  cutaneous  manifestations,  nasal  discharge,  and  mucous 
membrane  lesions  have  presented,  the  picture  is  sufficiently  character- 
istic.    In  the  earliest  stage  it  has  been  mistaken  for  rheumatism  and 
typhoid  fever.     The  chronic  disease  may  bear  some  resemblance  i 
tuberculosis  and  syphilis.     Now  that  the  cause  is  known,  in  suspe< 
27 


4 1 8  INFLAMMA  TIONS 

cases  microscopic  examination  should  be  made  for  the  bacillus,  stain- 
ing with  methylene-blue;  or  inoculation  experiments  may  be  made. 

Prognosis  and  Treatment. — Acute  cases  almost  invariably  end 
fatally  within  six  weeks,  and  some  early  in  the  attack,  and  even  before 
the  skin-lesions  appear;  the  chronic  disease  is  fatal  in  about  half  the  cases. 

Treatment  is  purely  empirical,  the  strength  being  supported,  and 
the  lesions  treated  surgically  and  antiseptically.  It  is  possible  that  the 
toxins — mallein — of  the  bacilli  may  prove  of  service;  in  one  case  (Bon- 
ome)1  subcutaneous  injections  had  a  very  favorable  influence. 

PUSTULA  MALIGNA 

Synonyms. — Anthrax  ;  Anthrax  maligna  ;  Malignant  pustule  ;  Splenic  fever  ;  Car- 
buncle ;  Fr.,  Charbon  ;  Pustule  maligne  ;  Ger.,  Milzbrand  ;  Milzbrandcarbunkel. 

Definition. — Malignant  pustule  is  a  furuncle-  or  carbuncle-like 
gangrenous  lesion  resulting  from  inoculation  with  the  bacillus  anthracis, 
and  usually  accompanied  with  constitutional  symptoms  of  more  or  less 
gravity. 

The  general  infective  disease  (splenic  fever)  hi  which  the  bacillus 
gains  access  through  other  channels  than  that  of  the  skin  will  not  be 
considered. 

Symptoms. — The  lesion,  almost  always  single,  is  seen  commonly 
on  exposed  parts,  usually  the  hand  or  the  face,  and,  according  to  Koranyi,2 
who  has  given  a  good  deal  of  study  to  this  disease,  has  an  incubation 
period  of  from  one  to  three  days.  The  disease  begins  with  slight  burning 
and  itching  at  the  point  of  inoculation,  and  the  appearance  of  a  slight 
reddish  papular  elevation,  which  grows  larger.  These  symptoms  are, 
in  fact,  similar  to  those  frequently  observed  after  an  insect-bite.  In  the 
course  of  a  few  hours  or  a  day  or  so,  or  more  rapidly  in  some  instances, 
a  vesicle  or  bleb  forms  on  the  summit,  the  contents  of  which  may  quickly 
become  bloody  or  purulent,  and  intense  inflammatory  infiltration  ensues, 
which  may  involve  considerable  area.  It  soon  ruptures,  showing  a 
depression,  in  and  around  which  is  disclosed  a  blackish  eschar,  which 
may  increase  hi  extent.  The  surrounding  induration  and  swelling  be- 
come more  marked  and  extensive.  Around  about  the  central  depression 
and  eschar,  on  the  swollen  and  inflammatory  base,  groups  or  a  chain  of 
vesicles  form,  and  the  surrounding  tissue  may  become  still  more  swollen, 
tense,  and  infiltrated.  The  near-by  glands  and  lymphatics  are  affected. 
The  central  gangrenous  or  escharotic  area  may  enlarge,  grave  symptoms 
and  complications  of  general  infection  supervene,  and  death  result;  or 
the  process  halts,  and  the  gangrenous  area  is  cast  off,  leaving  a  cavity, 
as  in  carbuncle,  and  the  reparative  process  begins.  As  a  rule,  general 
infection  in  man  follows  only  in  a  minority  of  cases. 

Instead  of  the  symptoms  here  outlined,  inoculation  may  be  followed 
by  intense  edema  and  swelling  of  livid  color,  which  soon  involves  a  large 

1  Bonome,  Deutsche  med.  Wochensckr.,  1894,  p.  703. 

2  Koranyi,  "Der  Milzbrand,"  Wien,  1897,  in  Nothnagel's  Specielle  Pathologic  imd 
Therapie,  Wien,  1900,  vol.  v,  i.     This  contribution  is  a  complete  and  exhaustive 
exposition  of  the  subject,  with  full  bibliography  and  several  cuts,  a  few  of  which  are 
colored. 


PUSTULA    MALIGNA 


419 


area,  with  surface  bleb-formation  and  gangrenous  destruction  at  several 
or  more  points,  with  usually  rapid  systemic  infection  and  death,  within 
a  few  days  to  one  or  two  weeks. 

Etiology  and  Pathology.—  The  cause  of  the  malady  is  the  bacil- 
lus anthracis,  discovered  by  Pollender,  which  is  conveyed  to  man  from  in- 
fected animals,  directly  or  through  the  mediation  of  flies  or  other  insects; 
or  from  the  hides,  hair,  etc.,  of  animals  that  have  died  of  the  disease. 
The  last  method  seems  most  common.  In  animals  it  is  usually  observed 
in  the  herbivora,  being  uncommon  in  the  camivora.  In  man  the  disease 
is  met  with  in  those  who  have  to  do  with  cattle,  and  those  who  have  to 
work  in  their  products,  such  as  slaughterers,  tanners,  wool-sorters,  etc. 
Ravenel1  reports  an  outbreak  in  which  as  many  as  12  men  and  60  head 
of  cattle  died  of  the  disease  near  tanneries  (in  Pennsylvania)  in  the  course 
of  a  year;  the  men  were  operatives  at  the  tanneries,  while  the  cattle  were 
on  pastures  watered  by  the  streams  carrying  off  the  refuse  from  these 
tanneries.  Goldschmidt2  and  Merkel3  have  reported  cases  occurring 
among  the  employees  of  brush  factories.  The  disease,  for  obvious  rea- 
sons, is  most  commonly  seen  in  male  adults. 

Inflammatory  reaction  of  the  most  intense  character,  as  described, 
is  found  following  the  inoculation  of  this  germ.  The  usual  signs  of  such 
process  are  to  be  found,  and  in  the  advanced  lesion  are  closely  similar  to 
carbuncle.  According  to  Koranyi,  Unna,  Ziegler,  and  others  the  process 
is  essentially  a  serofibrinous  inflammation,  leading  rapidly  to  necrosis, 
the  microscopic  appearances  varying  according  to  the  stage  at  which  the 
lesion  is  examined.  Unna4  found  in  a  fresh  anthrax  nodule  of  the  lip 
covered  with  vesicles  that  the  development  of  the  bacillus  had  taken 
place  in  the  form  of  a  flat  area  at  the  level  of  and  around  the  subpapillary 
vascular  net,  and  penetrating  into  the  papillary  body  above  and  the 
epidermis;  in  this  region  the  whole  cutis  is  swollen,  and  the  bacilli  lie  so 
closely  that  their  number  must  be  reckoned  by  thousands;  there  were 
found  a  marked  dilatation  of  the  blood-vessels  and  a  severe  interstitial 
edema  of  the  skin  and  hypoderm,  the  escaped  lymph  in  many  places 
formed  into  fibrinous  nets.  The  bacillus  is  rod-shaped  and  multiplies 
rapidly;  in  the  body  it  multiplies  by  fission;  in  culture  the  rods  may  de- 
velop into  filaments,  undergoing  segmentation  and  producing  spores. 
These  retain  their  vitality  for  a  long  time. 

Diagnosis.—  The  appearance  and  subsequent  rupture  of  the  vesicle 
or  bleb,  the  central  depression  and  eschar,  the  rapidly  developed  ring 
of  vesicles  or  blebs  around  this  necrotic  center,  with  the  surrounding 
induration  and  swelling,  make  up  a  typical  picture  which  is  scarcely 

1  Ravenel,  "Anthrax—  The  Influence  of  Tanneries  in  Spreading    the    Disease," 
Philada.  Med.  Jour.,  April  22,  1899  (with  experiments  as  to  the  effects  of  tannn 
tions  on  the  germs  in  the  spore  stage).  W^K/M- 

2  Goldschmidt,  Verhandl.  der  Gesellsch.  der  Naturforschen  und  Aerzte,  Nur 


e:f°P*>n   and  Ghriskey,  . 

1899  (Dec.  14  meeting),  also  report  a  case  in  a  morocco  worker,  and  give  a  bi 
of  the  subject,  with  some  references.  ,.  , 

See  also  De  Langenhagen,  "Relation  de  plusieurs  cas  de  pustule  mahgne   cnez 
1'homme  coexistant  avec  une  epizootic  charbonneuse,"  Annales,  1899,  P-  7°S 

4  Unna,  Histo  pathology,  p.  456- 


42O  INFLAMMA  TIONS 

mistakable.  In  its  very  earliest  stage  it  might  be  mistaken  for  a  be- 
ginning boil  or  carbuncle,  but  the  above  features  would  serve  as  differ- 
ential points.  Poisoned  wounds  and  facial  chancre  are  also  to  be  ex- 
cluded. The  latter  is  relatively  indolent,  with  no  gangrenous  tendency 
and  with  no  febrile  constitutional  symptoms.  Occupation  of  the  patient 
may  give  a  clue.  In  doubtful  or  suspicious  cases  a  microscopic  examina- 
tion for  the  bacillus  should  be  made  immediately.  Some  of  the  liquid 
from  the  pustule  can  be  dried  on  the  cover-glass  or  slide  or  piece  of  glass, 
stained,  and  examined.  A  simple  staining  fluid  may  be  easily  improvised 
by  dissolving  a  piece  of  anilin  blue  pencil  in  water ;  the  bacilli  are  so  large 
that  they  may  be  easily  seen  with  an  ordinary  high-power  lens  (D.  W. 
Montgomery) . 

Prognosis. — The  disease  is  always  of  serious  import,  but  with  an 
early  diagnosis  and  prompt  treatment  most  cases  of  malignant  pustule 
recover.  The  cases  in  which  intense  and  extensive  edema  follows  inocu- 
lation, without  much  initial  change  at  the  point  of  inoculation,  are  usually 
fatal,  as  active  measures  of  treatment  cannot  be  so  well  and  satisfactorily 
carried  out.  In  any  case  if  there  is  grave  systemic  involvement,  showing 
that  the  bacillus  and  the  ptomains  or  other  septic  material  have  gained 
access  to  the  general  circulation,  the  outlook  is  involved  in  doubt.  The 
mortality  seems  variable  in  the  groups  of  cases  observed,  apparently 
indicating  that  there  may  be  some  difference  in  the  virulence  of  the 
bacillus  at  different  times  or  from  surrounding  conditions.  Thus  in 
Goldschmidt's  cases,  30  in  number,  there  were  only  3  deaths;  in  Miiller's1 
13  cases  not  a  single  fatality;  on  the  other  hand,  according  to  the  statistics 
of  Nasarow,2  among  180  cases  17  per  cent.  died. 

Treatment. — The  consensus  of  experience  indicates  that  the  best 
plan  is  excision  of  the  entire  diseased  area,  going  well  beyond  the  border, 
done  under  antiseptic  precaution  to  prevent  reinfection;  subsequently 
the  ordinary  treatment  of  open  wounds,  antiseptics  being  freely  employed, 
such  as  weak  corrosive  sublimate  solutions.  The  injection  of  iodin  tinc- 
ture or  5  per  cent,  solutions  of  carbolic  acid  at  five  or  six  points  around 
the  border  has  proved  successful,  repeated  after  several  hours  if  the 
process  is  unchecked.  Such  injections,  with  free  incisions  and  the  appli- 
cation of  pure  or  dilute  carbolic  acid,  have  been  employed  in  the  markedly 
edematous  cases.  Carbolic  acid  poisoning  must  be  watched  for.  On  the 
other  hand,  Miiller  had  good  results  in  his  cases  by  a  purely  expectant 
treatment. 

Constitutional  treatment  should  be  with  sodium  sulphite  or  hypo- 
sulphite, and  quinin  in  large  doses,  and  alcoholic  stimulants  and  ammo- 
nium carbonate  as  supporting  measures  if  indicated,  and  other  appro- 
priate remedies  as  special  conditions  may  demand. 

1  Kurt  Muller,  "  Der  Aeussere  Milzbrand  der  Menschen,"  Deutsche  med.  Wochen- 
schr.,  1894,  pp.  515  and  534. 

2  Quoted  from  Jarisch,  Die  Hautkrankheiten,  Wien,  1900,  p.  466. 


ER  YSIPELAS 

ERYSIPELAS1 


ftr.,  Rothlauf  ; 

Definition  —  Erysipelas  may  be  defined  as  a  specific  inflammation 
of  the  skin  and  subcutaneous  tissue,  most  commonly  of  the  face,  charac- 
terized by  shining  redness,  swelling,  edema,  heat,  and  a  tendency,  in 
some  cases,  to  vesicular  and  bleb-formation,  and  accompanied  by  more 
or  less  febrile  disturbance. 

Symptoms  —  Cases  of  moderate  severity  are  usually  preceded  for 
several  hours  to  one  or  two  days  by  prodromic  symptoms  of  constitu- 
tional disturbance,  such  as  malaise,  chilliness,  nausea,  and  sometimes 
vomiting;  a  decided  rigor  or  feeling  of  chilliness,  with  ensuing  febrile 
action,  is  rapidly  followed  by  the  appearance  of  the  cutaneous  eruption. 
This  latter  may  develop  rapidly,  soon  involving  an  area  the  size  of  a 
palm  or  larger,  or  its  evolution  is  more  gradual.  It  frequently  begins 
at  one  point,  usually  where  there  has  been  a  break  in  the  continuity  of 
the  skin;  an  area  of  a  dime  to  dollar  size  is  first  noticed,  elevated,  swollen, 
red,  and  shining,  with  a  glazed  appearance;  there  is  a  feeling  of  burning, 
often  some  tenderness,  and  sometimes  a  variable  degree  of  itching.  The 
border  is  sharply  defined,  elevated,  and  bright  red,  usually  scarlet  red; 
it  spreads  gradually  or  rapidly  by  peripheral  extension,  and  in  some  cases 
there  may  arise  new  points  of  infection  near  by,  spread,  and  merge  into 
each  other.  In  the  course  of  several  days  to  a  week  the  disease  has 
usually  reached  its  acme,  and  may  then  cover  a  great  part  of  the  face  or 
the  entire  region.  On  the  face  it  often  stops  at  the  edge  of  the  hair  or 
beard.  The  parts  are  elevated,  much  swollen,  and  somewhat  tense,  with 
the  peculiar  shining  dark-red  surface;  or  there  may  be  the  formation  of 
vesicles  and  blebs,  which  in  some  cases  may  subsequently  become  puru- 
lent; exceptionally  the  part  may  be  partially  undermined  with  serous 
effusion.  In  other  instances  the  deeper  parts  are  involved  seriously, 
and  some  sloughing  may  ensue.  Hutchinson  has  observed  cases  in  which 
the  characteristics  of  erysipelatous  inflammation  are  not  always  present 

1  Some  pertinent  literature:  General:  Hutchinson,  Archives  of  Surgery,  1894,  vol. 
v,  p.  300;  1897,  vol.  viii,  p.  i;  Allen,  Medical  News,  1899,  i,  p.  426;  Kaposi  (report  of 
investigating  committee  of  erysipelas  in  General  Hospital,  Vienna,  1882-84),  Wien. 
med.  Wochenschr.,  1887,  Nos.  30  to  35,  and  full  resume1  in  Archiv,  1888,  vol.  xx,  p.  250. 

Etiology  and  pathology:  Fehleisen,  Die  Aetiologie  des  Erysipelas,  Berlin,  1883; 
Pawlowsky  (concerning  specificity  of  streptococcus,  with  some  experiments  as  to  the 
action  of  certain  drugs  upon  it),  Berlin,  klin.  Wochenschr.,  1888,  p.  255;  Leroy  (showing 
persistent  vitality  of  streptococcus),  La  Gazette  Medicale  de  Montreal,  January,  1890; 
Pfahler  (cases  apparently  due  to  other  coccus),  Philada.  Med.  Jour.,  January  13,  1900; 
Guarnieri  (autopsy  showing  general  streptococcic  infection),  Archivio  per  Ic  scienze, 
1887,  No.  2—  abstract  in  Annales,  1888,  p.  249;  Denucd,  Etude  sur  la  pathogenic  et 
Vanatomie  pathol.  de  Verysipele  (showing  general  infection),  Paris,  1885. 

Treatment—  Antistreptococcic  serum:  Marmorek,  Compt.  Rend.  Soc.  de  Biol., 
1895,  p.  230,  and  Annales  de  I'lnstitut  Pasteur,  1895;  Andr6,  Archives  de  Med.  e(  de  Phar- 
macie  militaires,  1898,  p.  340;  Cotton,  Boston  Med.  and  Surg.  Jour.,  1899,  i,  p.  105; 
Bristow,  New  York  Med.  Soc.  Trans.,  1899,  p.  382;  Baum,  Medicine,  1899,  p.  23. 
These  four  papers  are  all  valuable  as  showing  the  present  status  of  this  remedy,  and 
give  literature  references;  Cotton  gives  full  bibliography. 

Ichthyol:  Unna,  Aerztl.  Vereinsblatt  fur  Deutschland,  1885,  No.  158;  Fessler, 
Klinische-experimentelle  Studien  iiber  Chirurgische  Infectionskrankheiten  (clinical  and 
experimental  evidence  of  action  of  ichthyol),  Munich,  1891;  Jamieson,  Brit.  Med.  Jour., 
Aug.  6,  1898. 


422 


INFLAMMA  TIONS 


together;  the  florid  congestion  may  exceptionally  be  lacking,  the  edema- 
tous  swelHng  practically  constituting  the  disease,  and  to  which  the  term 
"white  erysipelas"  could  be  well  applied. 

When  the  erysipelas  involves  a  limb  or  part  of  the  body  other  than 
the  face,  there  may  be  some  extension  in  the  form  of  streaks  along  the 
line  of  the  lymphatics.  The  constitutional  symptoms  are  of  various 
grades  from  slight  to  grave,  with  the  temperature  elevated  one  to  several 
or  more  degrees  above  the  normal,  according  to  the  extent  and  severity 
of  the  disease.  The  temperature  is  highest  toward  night;  a  marked 
exacerbation  usually  signifies  renewed  activity  or  a  new  area  of  disease. 
Occasionally  the  temperature  is  subnormal.  In  severe  cases  delirium  or 
stupor  may  be  present,  and  grave  complications  of  other  organs  some- 
times occur,  probably  due  to  toxin  poisoning  or  to  general  streptococcic 
invasion. 

After  remaining  a  few  days  stationary  the  process  begins  to  subside, 
the  swelling  becomes  less  pronounced,  the  redness  goes  into  a  brownish 
red,  and  later  yellowish  and  yellowish-white  shade,  the  constitutional 
symptoms  abate,  and  the  disease  in  ten  days  to  a  few  weeks  is  prac- 
tically at  end.  Desquamation  ensues,  slight  or  marked,  according  to 
the  severity  of  the  process.  When  there  has  been  pronounced  vesic- 
ular or  bullous  development,  these  dry  into  crusts,  which  finally  fall 
off,  leaving  behind  temporarily  a  reddish  surface,  which  gradually  fades. 

In  some  instances  as  the  disease  spreads  at  the  periphery  the  older 
part  clears  permanently  or  again  lights  up.  Or  the  disease  may  appear 
at  a  site  close  by  or  somewhat  distant  from  the  original  point  of  infection. 
Thus  the  case  may  go  on  for  several  weeks  or  longer,  constituting  that 
variety  known  under  the  name  of  erysipelas  ambulans,  or  erysipelas 
migrans.  This  rare  recurrent  ambulant  type  is  sometimes  designated 
chronic  erysipelas,  although  this  term  is  also  often  given  erroneously  by 
laymen,  and  occasionally  by  practitioners,  to  cases  of  chronic  eczema. 

While  the  face  is  the  most  common  site  of  erysipelas,  and  the  one  of 
chief  interest  to  the  dermatologist,  other  parts  are  also  not  infrequently 
the  seat  of  the  disease;  in  the  latter  instances  usually  starting  from  some 
injury  or  succeeding  a  surgical  operation.  That  on  the  face  may  extend 
over  the  entire  scalp  and  may  even  push  into  the  mouth  and  throat  and 
nose,  or  exceptionally  may  have  its  starting-point  in  the  latter  regions, 
and  may,  indeed,  in  rare  instances  be  limited  to  these  and  neighboring 
mucous  membranes  (Arnott,  Mosny,  Porter).  In  the  extreme  examples 
of  this  class  the  head,  face,  ears,  lips,  and  mouth  are  much  swollen,  and 
the  patient  disfigured  beyond  recognition.  In  a  large  majority  of  the 
cases  observed  by  dermatologists  in  skin  dispensaries  the  disease  is  of  a 
somewhat  slight  and  limited  character;  usually  starting  at  some  point  of 
the  face,  or  not  infrequently  at  or  just  within  the  nasal  orifice,  it  may 
involve  only  an  area  of  a  few  inches,  lasting  two  or  three  days  and  then 
rapidly  beginning  to  subside,  with  or  without  desquamation.  The 
constitutional  symptoms  in  such  walking  cases  are  mild,  sometimes 
scarcely  noticeable,  but  there  may  be  temperature  elevation  for  a  few 
days  of  one  to  three  degrees  and  yet  the  patient  persist  in  going  about  his 
employment. 


ER  YSIPELAS 


423 


Etiology. — The  disease  is  both  contagious  and  infectious,  at  times 
to  a  marked  degree,  at  other  times  apparently  scarcely  at  all.  There 
are  probably  three  causes  operative  in  erysipelas — essential,  contributory, 
and  predisposing.  The  essential  cause  is  now  believed  to  be  a  specific 
streptococcus,  the  streptococcus  of  Fehleisen.  That  the  essential  cause 
may  consist  of  varieties  of  micro-organisms  other  than  this  streptococcus 
is  not  beyond  dispute;  in  8  cases  investigated  at  the  Philadelphia  Hospital 
presenting  all  the  symptoms  of  erysipelas  a  special  diplococcus  was  noted 
differing  from  the  streptococcus  of  Fehleisen  (Pf abler),  and  Hajek  has 
found  that  the  disease  may  be  caused  by  the  pyogenic  organisms.  The 
contributing  cause,  as  an  abrasion,  prick,  or  slight  injury,  a  lesion  of 
continuity  of  the  skin,  may  doubtless  be  almost  considered  essential, 
although  it  is  not  always  demonstrable.  Infection  may,  indeed,  take 
place  through  the  mucous  membrane  of  the  mouth,  throat,  or  of  the  nose, 
possibly  through  a  break  or  abrasion,  or  from  some  pent-up  pus-collec- 
tion. A  not  uncommon  point  of  infection  in  derma tologic  experience  is 
a  sycosiform  inflammation  just  inside  the  nostril  orifice.  Frequently 
this  latter  produces  but  a  small  erythematous  and  moderately  swollen 
area,  starting  at  the  nose  and  extending  slightly  toward  the  eye  and  cheek, 
which  in  many  instances  can  scarcely  be  called  true  erysipelas;  in  others, 
however,  a  distinct  erysipelatous  area  arises,  and  in  others  again  a  typical, 
somewhat  extensive,  development  of  the  disease  ensues.  Ulcers,  ex- 
coriations, abrasions,  a  nasolabial  fissure,  ear-piercing,  injuries  of  various 
kinds,  may  all  be  instrumental  in  the  development  of  the  disease. 

As  predisposing  causes  may  be  mentioned  a  poor  condition  of  the 
health,  general  debility,  alcoholism,  or  failing  health  from  organic  dis- 
ease; in  fact,  anything  which  depresses  or  weakens  the  vital  forces  and 
lessens  the  resisting  power  of  the  organism.  Age  seems  to  be  in  a  meas- 
ure of  etiologic  import,  the  disease  being  much  more  common  in  those 
between  twenty  to  forty  and  rather  unusual  in  the  young  or  old. 

Anders,1  from  a  study  of  his  tabulation  of  2010  collated  cases,  ex- 
tending over  a  period  of  twenty  years,  shows  that  seasonable  influences 
must  be  counted  in  considering  the  etiology  of  the  disease.  August  gave 
the  fewest  cases,  and  from  then  there  is  a  gradual  monthly  increase  until 
April  is  reached,  which  gives  the  largest  number,  and  then  follows  a 
rapid  decrease.  One-half  of  the  cases  occurred  in  February,  March, 
April,  and  May,  April  giving  16  (15.9)  per  cent.  It  was  further  found 
that  a  low  barometer  and  mean  relative  humidity  invariably  corre- 
spond with  the  annual  period  in  which  the  greatest  proportion  of  cases 
occur,  and  the  highest  mean  relative  humidity  with  the  months  affording 
the  fewest  attacks. 

Pathology.— Unna's  investigations  show  that  the  typical  erysip- 
elatous inflammation  of  the  cutis  is  purely  of  a  serofibrinous  nature, 
which  may  result  in  necrosis,  the  specific  germ  being  the  sole  pathogenic 
factor.  One  attack  of  the  disease  does  not  protect  against  other  attacks; 
on  the  contrary,  it  becomes  a  predisposing  factor  of  some  import.  Doubt- 
less this  may  be  due  to  the  fact  that  some  of  the  micro-organisms  may 

1J.  M.  Anders,  "Seasonable  Influence  in  Erysipelas,  with  Statistics,"  Trans. 
Amer.  Climatol.  Assoc.,  1893-94,  vol.  x,  p.  43- 


424  INFLAMMA  TIONS 

remain  in  the  integument  (Besnier,  Hutchinson,  Allen,  and  others). 
Maclachlan1  believes,  from  his  observations,  that  succeeding  attacks 
become  milder  and  milder. 

There  is  nothing  strikingly  peculiar  in  the  histologic  findings.  The 
disease  is  really  an  infectious  dermatitis,  involving  the  integument  and 
deeper  parts.  There  is  a  variable  amount  of  serous  exudation  into  the 
skin  and  subcutaneous  tissues,  some  deposit  of  fibrin  and  swelling  of  the 
connective-tissue  fibers,  and  enlargement  of  the  blood-vessels  and  lym- 
phatics. In  hairy  regions  the  serous  exudation  involves  the  follicles  and 
hair-sheath,  and  may  result  in  extensive  or  complete  hair  fall.  The 
corium  is  invaded,  in  severe  cases,  by  the  streptococci,  especially  the 
lymph-spaces,  and  this  invasion  may  extend  down  into  the  subcutaneous 
tissue.  Unna  finds  that  in  every  case  the  hypoderm  swarms  with  cocci. 
In  rare  instances  general  invasion  has  been  observed — streptococci  being 
found  in  various  organs  (Guarnieri,  Denuce,  Lukowsky).  Metschnikoff 
found  an  inverse  proportion  between  the  collection  of  leukocytes  and 
the  proliferation  of  cocci  in  the  skin,  which  he  viewed  as  a  warfare  between 
these  two  powers.  The  serous  exudation  may  be  so  rapid,  especially 
in  points  or  places,  that  vesiculation  or  bleb-formation  ensues.  Re- 
peated attacks  are  apt  to  leave  a  permanent  thickening  of  the  skin, 
especially  when  on  the  legs. 

Diagnosis. — The  diagnosis  of  erysipelas  is  rarely  attended  with 
difficulty,  especially  when  it  occurs  upon  the  face  and  after  surgical 
injuries.  The  important  diagnostic  points  are  the  character  of  the  onset, 
the  shining  redness,  the  swelling,  the  sharply  defined  elevated  border, 
and  the  accompanying  constitutional  disturbance.  The  diseases  which 
at  times  resemble  it,  especially  in  its  beginning,  are  phlegmona  diffusa, 
erythemata,  acute  eczema,  and  dermatitis.  Those  most  likely  to  give 
difficulty  are  the  latter  two.  Dermatitis  from  poison-ivy  or  from  some 
drugs,  such  as  iodoform,  may  at  first  present  a  somewhat  similar  appear- 
ance, but  this  lacks  the  sharply  defined  border,  is  usually  free  from  any 
constitutional  disturbance,  and  may  start  simultaneously  from  several 
points.  Acute  eczema  also  lacks  the  sharp  elevated  border,  rarely  de- 
velops from  a  single  point,  and  is  attended  by  marked  itching,  and, 
except  in  infants  and  young  children,  is  seldom  accompanied  by  any  pro- 
nounced systemic  disturbance.  In  fact,  erysipelas  is  so  distinct  a  malady 
that  it  ordinarily  admits  of  ready  diagnosis,  and  is  rarely  to  be  confused 
with  other  disease,  except  with  anomalous  examples  of  the  several  affec- 
tions mentioned.  In  doubtful  cases  several  hours'  or  a  day's  observa- 
tion is  usually  sufficient  to  solve  the  difficulty. 

The  slight  and  limited  erysipelatous  swelling  consequent  upon  a 
chronic  folliculitis  of  the  nasal  fossa,  while  it  may  develop  into  true 
erysipelas,  can  scarcely  be  invariably  looked  upon  as  of  such  nature,  but 
rather  an  erythema  due  to  pus  absorption. 

Prognosis. — Erysipelas  is,  under  proper  management,  not  often 

a  fatal  disease,  a  factor  which  is  not  sufficiently  taken  into  consideration 

when  estimating  particular  claims  made  for  the  various  remedies  usually 

employed,  all  of  which  belong  in  the  class  of  antiseptics,  and  therefore 

1  Maclachlan,  Edinburgh  Med.  Jour.,  Aug.,  1899. 


ERYSIPELAS  435 

appropriate  for  the  treatment.  Extensive  and  especially  the  deep- 
seated  cases,  with  grave  systemic  disturbance  and  high  fever,  and  those 
of  distinctly  septic  type,  are  to  be  looked  upon  as  of  possible  fatal  ending. 
Erysipelas  which  invades  the  entire  scalp  is  also  to  be  considered  dan- 
gerous. Arising  after  severe  injuries  or  operations,  it  is  also  to  be  viewed 
as  of  possible  serious  portent,  occurring,  as  it  does,  in  one  probably  already 
debilitated  and  with  lessened  resisting  power.  In  alcoholics  and  those 
with  nephritic  disease  the  prognosis  is  also  of  greater  gravity.  On  the 
other  hand,  the  mild  and  moderate  cases,  which  make  up  the  largest 
number,  usually  run  a  somewhat  rapid,  favorable  course.  Depending 
upon  the  extent  and  severity  of  the  disease,  its  course  is  run  in  from  one 
to  several  weeks.  In  those  instances  in  which  there  is  a  continual  crop- 
ping out  of  new  areas  the  duration  may  be  somewhat  prolonged,  but, 
except  in  severe  cases,  more  than  a  month's  continuance  could  be  con- 
sidered rather  uncommon.  Loss  of  hair  is  usually  replaced. 

Treatment. — The  constitutional  treatment  of  erysipelas  consists 
in  the  administration  of  remedies  of  a  tonic,  stimulating  character,  plain 
but  nourishing  food, — chiefly  milk  in  severe  cases, — and  the  use  of  drugs 
with  alleged  specific  properties.  In  this  latter  class  tincture  of  the 
chlorid  of  iron  and  quinin  are  those,  especially  the  first,  which  have  the 
greatest  support.  As  routine  practice  it  is  well  to  advise  both  these 
remedies,  the  former  in  doses  of  15  to  40  minims  (i.-2.5o),  the  latter, 
2  to  3  grains  (0.13-0.2),  along  with  moderate  doses  of  strychnin,  three 
to  five  times  daily,  according  to  the  severity  of  the  attack.  Other 
remedies  for  special  conditions  or  complications  will  suggest  themselves. 
In  great  depression  alcoholic  stimulants  and  ammonium  carbonate  are 
of  value.  Favorable  results  in  grave  cases  from  a  few  injections  of  anti- 
streptococcic  serum — about  10  c.c.  at  an  injection — have  been  reported 
(Marmorek,  Cotton,  Robinson,  Andre,  Bristow,  Baum,  and  others). 

After  all,  the  external  treatment  is  probably  of  greatest  importance, 
especially  if  the  accepted  theory  of  the  cause  of  the  disease  is  considered. 
In  most  of  the  cases  it  alone  would  suffice.  Many  remedies  have  been 
variously  advised,  but  they  may  all  be  included  under  the  head  of  mild 
antiseptics.  Along  with  the  remedial  applications  the  larger  vesicles 
and  the  blebs  should  be  opened  from  time  to  time.  When  involving  the 
scalp,  cutting  the  hair  is  an  advantage,  and  in  severe  cases  should  always 
be  done.  A  simple  and  strongly  advised  application  is  a  i  per  cent, 
lotion  of  carbolic  acid,  made  with  equal  parts  of  water  and  alcohol 
(White).  Ichthyol  as  an  ointment  or  aqueous  solution  of  10  to  25  per 
cent,  strength  has  probably,  at  the  present  time,  the  greatest  number  of 
supporters  (Unna,  Nussbaum,  Jamieson,  Allen,  Elliot,  and  others), 
and  to  the  value  of  which  I  can  warrnly  subscribe.  The  lotion  is  applied 
similarly  to  the  above;  the  ointment  spread  upon  patent  lint  or  other 
fabric,  and  applied  as  a  plaster,  changing  one  to  three  times  daily,  accord- 
ing to  the  condition.  The  ointment  is  more  grateful  to  some  patients, 
and  more  suitable  for  those  cases  in  which,  especially  in  the  later  stage, 
there  is  crust  formation.  The  base  of  the  ointment  can  be  petrolatum,  or 
equal  parts  of  lanolin  and  cold  cream,  stiffened,  if  necessary,  with  wax 
or  spermaceti.  These  several  plans  have  afforded  me  good  results  in  all 


426  INFLAMMATIONS 

the  cases  met  with,  although  in  most  of  the  patients  the  disease  was  of  a 
mild  grade. 

The  extension  of  the  process  can  seemingly  be  sometimes  prevented 
by  painting  over  the  bordering  skin  an  inch-wide  band  of  a  strong  solu- 
tion of  silver  nitrate  or  of  iodin  tincture. 

The  milder  cases  of  surgical  erysipelas  can  also  be  treated  satisfac- 
torily with  the  above  remedies,  but  for  the  treatment  of  the  more  severe 
cases  of  this  class  the  reader  is  referred  to  works  on  surgery. 

There  are  many  other  remedies  and  methods,  such  as  sodium  salicylate 
solution  (i  :  20)  compresses  (Besnier,  Hallopeau),  i  per  cent,  picric  acid 
solution,  kept  constantly  applied  (Cavelli,  Tassi),  and  frequent  local 
baths  of  95  per  cent,  alcohol  (Behrend).  Pawlowsky's  laboratory  ex- 
periments show  that  this  last  rapidly  destroys  the  streptococcus. 

ERYSIPELOID1 

Synonyms. — Erythema  migrans;  Erythema  serpens  (Morrant  Baker). 

This  affection,  first  clearly  described  by  Morrant  Baker,  and  later 
studied  clinically  and  bacteriologically  by  Rosenbach,  is  rare,  and 
clinically  bears  a  slight  resemblance  to  erysipelas,  lacking  the  constitu- 
tional and  the  more  violent  local  symptoms  of  the  latter.  It  is  observed 
in  those  who  handle  putrid  or  spoilt  meats  and  fish,  such  as  butchers, 
fish-dealers,  poultry-dealers,  and  cooks,  and  occasionally  with  those  who 
handle  animal  products.  For  obvious  reasons  it  is  almost  invariably 
seen  on  the  ringers  and  hands,  although  Elliot  refers  to  a  case  in  which  the 
disease  was  conveyed  from  the  hands  to  the  toes  by  scratching.  It  is, 
as  a  rule,  observed  to  follow  some  slight  traumatism  or  break  in  the  con- 
tinuity of  the  skin,  the  disease  starting  from  this  point.  It  consists,  at 
first,  of  a  dull  red  or  purplish  spot  or  zone,  scarcely  elevated,  which  tends 
to  spread;  as  it  spreads  the  first  part  involved  usually  clears  up.  If 
infection  takes  place  at  several  points,  many  zone-like  erythematous 
areas  may  merge  into  each  other,  presenting  then  an  eruption  of  a  fes- 
tooned character.  The  advancing  border  of  the  erythema  is  sharply 
denned  against  the  surrounding  skin,  and  is  slightly  elevated,  and  com- 
monly purplish  red  or  even  livid  in  color.  Sometimes  some  swelling  and 
puffiness  are  noted.  There  may  be  itching  and  burning,  and  these 
symptoms  are  sometimes  marked.  Its  progress  is  slow,  and  it  rarely 
involves  much  area,  remaining  limited  to  a  finger  or  small  part  of  the 
hand.  Subsiding,  it  changes  to  a  yellowish  color,  and  finally  disap- 
pears. There  is  no  scaliness. 

The  disease  is,  according  to  Rosenbach,  due  to  a  micro-organism 

1  Literature:  Morrant  Baker  (under  the  name  "Erythema  serpens";  based  upon  16 
cases,  with  colored  plate),  St.  Bartholomew's  Hospital  Reports,  1873,  vol.  ix,  p.  198; 
Rosenbach,  Verhandl.  der  Deutschen  Gesellschafl  fur  Chirurgie,  1887,  vol.  xvi,  p.  76 
of  part  ii;  Elliot,  Jour.  Cutan.  Dis.,  1888,  p.  12;  Tilbury  Fox,  under  the  title  "Ery- 
thema of  the  Hands  from  Dyes"  (Brit.  Med.  Jour.,  1870,  p.  132),  described  2  cases 
which  seem  to  be  examples  of  this  disease,  one  in  a  patient  who  handled  kid  shoes,  and 
the  other  in  a  clothing  dealer;  Gilchrist,  New  York  Med.  Rec.,  1896,  vol.  xlix,  p.  783, 
and  Jour.  Cutan.  Dis.,  1904,  p.  507  ("Erysipeloid,"  with  a  record  of  329  cases,  of  which 
323  were  caused  by  crab-bites  or  lesions  produced  by  crabs),  reviews  the  literature, 
with  references. 


DERMATITIS   GANGRAENOSA   INFANTUM  427 

which  is  found  in  dead  or  decomposing  animal  matter,  and  probably 
of  the  family  of  cladothrix,  from  cultures  of  which  the  malady  has  been 
experimentally  produced.  Gilchrist  found  no  organisms;  experiments 
with  smears  were  negative,  and  attempts  to  produce  the  disease  by  ex- 
perimental inoculation  were  likewise  negative.  He  believes  that  the 
disease  is  probably  produced  by  a  special  ferment.  In  almost  all  of  his 
cases  the  disease  had  followed  crab-bites.  It  is  to  be  distinguished  from 
erysipelas  and  ringworm,  but  the  absence  of  the  more  inflammatory  and 
the  constitutional  symptoms  of  the  former  and  the  elevated  and  often 
vesicopapular  and  subsequent  scaly  border  of  ringworm  will  serve  to 
differentiate.  It  could  scarcely  be  confounded  with  dermatitis  repens 
or  erythema  multiforme;  in  the  former  there  is  serous  undermining,  the 
upper  epidermis  separating  from  the  rete,  and  in  the  latter  the  eruption 
presents  other  symptoms  and  is  usually  extensive. 

The  disease  tends  to  spontaneous  disappearance  in  from  one  to  several 
weeks,  but  its  course  may  be  influenced  by  treatment,  which  is  usually 
rapidly  successful,  as  the  nature  of  the  affection  would  indicate.  Treat- 
ment consists  of  antiseptic  dressings,  of  which  those  employed  in  ery- 
sipelas are  the  most  satisfactory,  especially  the  ichthyol  applications. 

SPHACELODERMA 

Synonyms. — Dermatitis  gangraenosa;  Erythema  gangrsenosum;  Spontaneous 
gangrene  of  the  skin. 

Sphaceloderma,  or  dermatitis  gangraenosa,  is  a  term  applied  to  various 
cases  of  cutaneous  disease  in  which  gangrene  is  the  essential  and  constant 
feature.  The  predisposing  causes  are,  doubtless,  many  and  diverse. 
There  is  a  constitutional  factor,  such  as  neurasthenia,  hysteria,  diabetes, 
sepsis,  systemic  infection,  central  nervous  disease,  or  the  like.  In 
addition,  there  is,  in  all  probability,  a  local  microbic  element.  The 
condition  is  a  rather  rare  one,  and  the  size,  behavior,  character,  extent, 
and  distribution  of  the  lesions  vary  somewhat  in  the  different  instances. 
The  propriety  of  considering  the  several  varieties  under  separate  heads 
is,  in  my  judgment,  a  questionable  one,  as  there  is,  doubtless,  a  close 
analogy,  especially  as  to  the  infantile  type,  adult  type,  and  diabetic  type, 
the  underlying  factor  being  diverse,  but  the  essential  local  factor  probably 
identical. 

DERMATITIS  GANGRAENOSA  INFANTUM1 

Synonyms—  Varicella  gangraenosa  (Hutchinson) ;  Pemphigus  gangraenosus;  Mul- 
tiple cachectic  gangrene;  Infantile  gangrenous  ecthyma;  Multiple  disseminated  gan- 
grene of  the  skin  in  infants;  Rupia  escharotica;  Fr.,  Ecthyma  t6rebrant;  Ecthyma 
infantile  gangreneux;  Ger.,  Ecthyma  gangraenosum. 

Definition.— Dermatitis  gangraenosa  infantum  may  be  denned 
as  a  gangrenous  eruption  observed  in  children  and  infants,  arising  spon- 

'  Literature:  Hutchinson,  "On  Gangrenous  Eruptions  in  Connection  with  Vaccina- 
tion and  Chicken-pox,"  London  Med.-Chirurg.  Soc'y  Tram ^,1882,  p.  i,  with t  plate 
(this  writer  also  refers  to  it  briefly  in  Rare  Diseases  of  the  Skin  p.  235  ,  5>tokes      A 
Case  of  Vaccinia  Gangraenosa,"  Dublin  Jour.  Med.  Set.,  June,  1880;  Howard      ACa 
of  Gangrenous  Varicella,"  Brit.  Med.  Jour.,  May  12,  1883,  P-  904;  Atkinson,  A 


42  8  J NFL  AM  MA  TIONS 

taneously   or   following   other  vesicular   or   pustular   eruptions,   more 
especially  varicella  and  vaccinia. 

Symptoms. — A  large  number  of  the  cases  of  this  rare  disease,  first 
clearly  described  by  Hutchinson,  and  later  by  Crocker  and  others,  have 
followed  varicella.  The  vesicles,  instead  of  drying  up  and  disappearing 
in  the  usual  manner,  become  crusted  centrally,  often  with  a  pustular 
border,  and  surrounded  with  an  inflammatory  areola.  Ulceration  begins 
beneath  the  crust  and  may  also  take  place  peripherally,  resulting  in  a 
grayish  or  grayish-black  eschar.  Closely  contiguous  lesions  may  become 
confluent  and  form  an  irregular  ulcer  of  some  size  and  depth.  After  a 
variable  time  these  eschars  begin  to  separate,  showing  shallow  or  deep- 
seated  ulcers,  finally  drop  off,  and  leave  behind  a  rounded  or  oval  shallow 
pea-  to  dime-sized  or  larger  superficial  scar.  As  is  to  be  expected,  these 
escharotic  lesions  are  most  numerous  in  those  regions  upon  which  the 
varicellar  eruption  is  most  abundant.  The  disease  has  also  been  known 
to  follow  vaccinia,  in  which  instances  it  takes  its  starting-point  in  the 
neighborhood  of  the  vaccine  pustule.  Cases  which  arise  spontaneously, 
without  preceding  exanthem,  usually  are  seen  first  about  the  buttocks, 
and  commonly  appear  as  small  papulopustules.  The  malady  varies 
considerably  in  severity  and  gravity.  In  some  the  lesions  are  almost 
bullous,  sometimes,  especially  in  the  grave  cases,  hemorrhagic.  In  others 
the  eruption  is  comparatively  mild  and  scanty.  New  lesions  may  appear 
from  day  to  day  for  a  few  weeks  or  longer. 

The  constitutional  symptoms,  as  a  rule,  bear  relation  to  the  cuta- 
neous features.  There  may  be  high  fever,  vomiting,  diarrhea,  cardiac 
and  pulmonary  complications,  and  even  septicemia.  On  the  other  hand, 
in  mild  examples,  the  systemic  disturbance  is  not  marked. 

Etiology  and  Pathology  .—The  disease  is  rare,  and  is  seen  usu- 
ally in  debilitated  and  anemic  infants  and  young  children.  It  is  observed 
in  those  under  the  age  of  three,  most  commonly  in  the  first  year,  and 
more  frequently  in  females.  Tuberculosis  and  syphilis  have  both  been 
alleged  as  possible  causes,  but  an  examination  of  the  literature  of  the 
subject  and  my  own  scant  observations  would  give  but  little  credence 
to  these  factors.  While  it  probably  follows  varicella  in  most  instances, 
yet  a  number  of  cases  have  been  observed  which  arose  independently. 
It  is  doubtless  due  to  some  micro-organism,  although  there  has  been  as 
yet  no  uniformity  in  the  findings;  Baudouin  and  Wickham  found  in  a 
case  examined  by  them  the  streptococcus  pyogenes,  but  were  not  con- 
vinced of  its  pathogenetic  importance.  The  bacillus  pyocyaneus  has 
considerable  support  (Ehlers,  Hitschmann,  Kreibich,  and  others);  and 

Jour.  Med.  Sci.,  Jan.,  1884;  Crocker,  "Multiple  Gangrene  of  the  Skin  in  Infants  and 
Its  Causes,"  London  Med.-Chirurg.  Soc'y  Trans.,  1887,  p.  397  (full  account  of  his 
own  cases  and  a  review  of  others);  Baudouin  et  Wickham,  "Ecthyma  terebrant  des 
enfants,"  Annales,  Dec.,  1888  (with  bacteriologic  examination);  Elliot,  "Dermatitis 
Gangraenosa  Infantum,"  Med.  Record,  May  16,  1891,  p.  862;  Ehlers,  "Deux  cas  d'ec- 
thyma  terebrant  des  Enfants,"  Annales,  1891,  p.  793;  Hitschmann,  Fritz,  and  Kreibich, 
"  Pathogenese  des  Bacillus  pyocyaneus  und  zur  Aetiologie  des  Ecthyma  Gangraenosum, " 
Wien.  klin.  Wochenschr.,  1897,  No.  50,  and  "Ein  weiterer  Beitrag  zur  Aetiologie  des 
Ecthyma  Gangraenosum,"  Archiv,  1899,  vol.  1,  p.  81;  Marshall  (i  case),  Pediatrics, 
Feb.,  1898;  Lipes,  "Dermatitis  Gangraenosa  Infantum,"  Albany  Med.  Annals,  Jan., 
1900,  p.  i. 


MULTIPLE    GANGRENE    OF  THE  SKIN  IN  ADULTS        429 

doubtless  in  some  of  the  reported  cases  the  bacillus  diphtheria  may  have 
been  the  pathogenic  organism.'  Some  of  these  cases  are  classified  bv 
some  writers  under  ecthyma. 

Diagnosis  and  Prognosis.-The  appearance  of  small  vesico- 
pustular  or  pustular  lesions  leading  to  crusting  and  tissue  destruction 
in  infants  and  young  children  leaves  but  little  chance  for  an  error  in 
diagnosis.  Syphilis  should  be  excluded. 

In  very  young  infants,  and  especially  those  in  which  the  lesions  are 
numerous,  with  considerable  destruction,  the  outlook  is  unfavorable 
I  he  advent  of  general  septic  symptoms,  too,  must  be  regarded  as  of 
serious  import.  On  the  other  hand,  many  cases  recover,  even  some  of 
apparently  very  serious  nature. 

^  Treatment — The  constitutional  treatment  is  to  be  tonic  and 
stimulating,  with  abundant  proper  nourishment.  The  various  remedies 
to  be  advised  will  depend  upon  circumstances;  in  short,  the  treatment  is 
symptomatic  and  expectant.  Sodium  salicylate,  opium,  and  zinc  sul- 
phocarbolate  have  each  been  commended. 

As  the  disease  is  doubtless  infective,  the  local  management  is  to  be 
of  an  antiseptic  character.  A  5  to  10  per  cent,  ichthyol  ointment  or 
lotion,  a  saturated  solution  of  boric  acid  with  2  or  3  grains  (0.13-0.2) 
of  resorcin  to  the  ounce  (32.),  washings  with  corrosive  sublimate  solution, 
about  i :  2000,  are  all  satisfactory.  Aristol  or  boric  acid  powder,  with 
10  to  20  grains  (0.65-1.33)  of  acetanilid  to  the  ounce  (32.),  may  be  used 
to  dust  over  the  ulcerations. 

MULTIPLE  GANGRENE  OF  THE  SKIN  IN  ADULTS 

This  term  is  employed  to  include  several  similar  manifestations  of 
cutaneous  gangrene,  not  dependent  upon  an  underlying  diabetes,  which 
have  been  variously  described  under  the  name  of  spontaneous  gangrene 
of  the  skin,  disseminated  gangrene,  hysteric  gangrene,  gangrenous 
zoster,  and  dermatitis  gangraenosa.2 

Doubtless  some  of  the  instances  of  gangrene  in  hysteric  girls  and 
women  are  of  artificial  origin,3  but,  as  Van  Harlingen4  and  others  have 

1  Diphtheria  of  the  skin,  as  usually  understood,  is  a  term  employed  to  describe  those 
instances  in  which  a  diphtheritic  membrane  has  formed  upon  existing  cutaneous  wounds 
or  sores,  in  some  becoming  extensive  and  fatal.     But  it  is  quite  probable  that  some  cases 
of  gangrenous  ecthyma,  and  of  impetiginous  and  bullous  eruptions,  as  well  as  some  types 
of  whitlow  and  similar  affections,  might  likewise  be  so  regarded;  cases  are  on  record  of 
such,  in  which  the  Loffler  bacillus,  usually  with  the  staphylococcus  or  streptococcus,  has 
been  found  in  the  lesions.     Several  papers  of  recent  date  treating  on  the  subject  are: 
Labbe  and  Demarque,  Rev.  Mens.  des  Mai.  de  I'Enfance,  Feb.,  1905,  p.  49  (Impetigo 
and  Ecthyma);  Slater,  Lancet,  Jan.  4,  1908.  p.  15;  Bolton,  Lancet,  April,  1905;  Eddowes, 
Lancet,  Feb.  i,  1908,  p.  284  (Ecthyma);  Schucht,  Archiv,  Neisser's  Festschaft,  1907, 
p.  105;  abstracts  in  Brit.  Jour.  Derm.,  1908,  p.  239;  Dawson,  "Cutaneous  Diphtheria," 
Brit.  Med.  Jour.,  Sept.  24,  1910. 

2  Rona,  Archil),  1905,  vol.  Ixxv,  p.  25,  has  recorded  5  cases  in  hysteric  individuals, 
similar  to  the  herpes  zoster  gangrasnosus  hystericus  of  Kaposi,  and  in  all  of  which  he 
believed  the  lesions  were  self-inflicted. 

3  Riecke  (4  cases  of  artificial  origin),  Wien.  klin.  Wochenschr.,  1899,  No.  14. 

4  Van  Harlingen,  "The  Hysterical  Neuroses  of  the  Skin,"  Amer.  Jour.  Med.  Sci., 
July,  1897  (a  most  admirable  paper,  with  a  comprehensive  review  of  the  subject  and  a 
wealth  of  references,  to  which  the  reader  is  referred  for  the  literature  of  the  disease); 
Balzer  and  Michaux  (in  hysteric  girl),  Annales,  1898,  p.  53;  Corlett  (girl  of  fifteen, 
apparently  free  from  hysteric  tendencies),  Jour.  Cutan.  Dis.,  1897,  p.  551;  Wende  (2 


432  INFLAMMA  TIONS 

Etiology  and  Pathology. — Considering  the  number  of  cases  of 
diabetes,  diabetic  gangrene  must  be  considered  extremely  rare.  Three 
factors  are  doubtless  contributory  or  essential  in  its  production:  The 
abnormal  impregnation  of  the  tissues  and  blood  with  sugar,  making  the 
former  favorable  soil  for  microbic  development ;  lessened  resisting  power, 
superinduced  by  the  diabetes;  and  microbic  infection,  probably  taking 
place  through  some  break  in  the  continuity  of  the  skin.  Gussenbauer1 
inclines  to  the  belief  that  the  gangrene  is  not  so  much  due  to  the  sugar 
in  the  tissues,  as  to  the  loss  of  resisting  power  and  to  the  bad  effects 
following  infective  processes  in  such  individuals.  The  spontaneous 
form  is  possibly  purely  trophic  in  origin,  but  in  these  cases  an  unnoticed 
insignificant  injury  or  break  in  the  skin  may  have  preceded.  Morrow 
states  that  it  mainly  occurs  in  the  old  and  obese,  is  usually  of  the  moist 
type,  and  that  the  blood-vessels  are  found  to  be  pervious.  Wallace2 
found  the  arteries  in  23  out  of  24  cases  decidedly  atheromatous,  the 
patients  averaging  sixty- three  years;  and  that  the  disease  was  relatively 
more  frequent  in  males. 

Prognosis  and  Treatment.— The  disease  is  a  grave  complication 
or  accident  in  the  course  of  a  serious  disease,  and  the  outlook  is  rendered 
less  favorable.  The  gangrene  is  apt  to  extend,  and  new  areas  may  arise. 
The  patient  may  finally  die  from  septic  poisoning.  Exceptionally 
cases  do  recover,  however,  particularly  those  of  spontaneous  origin. 

The  diabetes  itself  must  be  carefully  treated,  both  by  dietetic  and 
medicinal  means.  The  gangrenous  spots  or  areas  are  to  be  managed 
upon  general  principles,  with  applications  of  antiseptics,  until  the  slough 
separates;  or,  better  still,  as  soon  as  the  slough  has  formed  it  may  be 
removed  by  curetting,  if  necessary,  and  the  parts  treated  antiseptically. 
Gussenbauer  points  out  that  the  best  plan  consists  in  thorough  surgical 
removal  of  the  diseased  tissue.  Wallace  believes  the  best  treatment  is 
removal  of  the  limb  early,  before  sepsis  has  caused  great  depression. 

SYMMETRIC  GANGRENE 

Synonyms. — Local  asphyxia;  Raynaud's  disease;  Fr.,  Asphyxie  locale  des  ex- 
tremites;  Ger.,  Raynaud'sche  Krankheit. 

Definition — An  affection,  usually  of  the  extremities,  of  probably 
trophic  nature,  characterized  by  local  ischemia  and  asphyxia,  which 
usually  terminate  in  the  gangrene  of  the  skin  and  underlying  tissue. 

While  considerable  irregular  information  was  known  as  regards  this 
affection,  Raynaud's3  description  was  the  first  well-defined  presentation; 
his  contributions,  with  those  of  Barlow  and  others,  have  given  a  clear 
portrayal  of  its  clinical  symptoms  and  behavior. 

Symptoms — The  extremities,  such  as  fingers  and  toes,  the  ears, 
nose,  and  occasional  other  parts  may  be  the  seat  of  the  disease.  On 

1  Gussenbauer,  Wien.  med.  Blatt,  Feb.  2,  1899. 

2  C.  S.  Wallace,  Lancet,  Dec.  23,  1899  (a  record  of  26  cases  observed  in  a  period 
of  eleven  years  in  St.  Thomas'  Hospital,  London). 

T;v3Rjay£aud'  "De  ^Ph}™6  locale  et  de  la  gangrene  symetrique  des  extremites," 
1  fiese  de  Pans,  1862.  Also  paper  by  same  writer,  Arch.  Gen.  de  Med.,  1874,  vol.  i,  pp. 
5  and  189.  English  translation  in  New  Syd.  Soc'y  publication,  Selected  Monographs, 
1888,  by  Barlow,  with  valuable  additional  notes. 


SYMMETRIC   GANGRENE  433 

the  ears  and  nose,  however,  the  gangrenous  stage  is  rarely  reached.1 
It  is,  generally,  symmetric.  The  first  symptoms2  are,  as  a  rule,  cold- 
ness and  paleness  of  the  parts — local  ischemia;  pain  and  numbness  may 
or  may  not  have  preceded.  Sooner  or  later  the  second  stage  is  reached, 
that  of  local  asphyxia,  in  which  the  parts  become  dark  red,  livid,  and 
bluish,  and  sometimes  swollen,  with  not  infrequently  tenderness  and 
shooting  pains.  There  may  be,  in  either  of  these  periods,  a  repeated 
retrogression  and  reappearance  for  some  time,  and  occasionally  it  does 
not  progress  beyond  the  second  stage.  Finally,  however,  the  condition 
usually  eventuates  in  gangrene,  generally  of  a  dry  character;  there  may 
be  formation  of  vesicles  or  bullae  along  the  edge  of  the  gangrenous 
margin.  Or,  instead  of  gangrenous  changes,  the  part  affected, 
especially  if  the  fingers  or  toes,  may  gradually  become  atrophic, 
withered,  and  indurated. 

In  many  cases  the  process  goes  on  until  it  reaches  the  beginning  of 
the  third  stage,  that  of  persistent  lividity,  of  bluish  or  bluish-black 
color,  and  may  remain  in  this  state  an  indefinite  time.  Or  in  some 
instances  complete  resolution  may  take  place,  to  be  followed  by  recurrent 
attacks. 

On  fingers  or  toes  the  gangrene  may  involve  considerable  area. 
It  may  be  of  a  dry  and  mummified  character,  and  gradually  drop  off; 
or  it  may  be  cast  off  by  underlying  inflammatory  and  suppurative  action; 
or,  instead  of  dry  gangrene,  it  is  of  the  moist  character,  with  some  puru- 
lent infiltration  of  the  subjacent  tissue.  The  resulting  ulcers  heal  slowly. 

Etiology  and  Pathology — The  causes  maybe  varied;  in  fact, 
it  is  questionable  whether  Raynaud's  disease  is  a  distinct  entity  or 
merely  a  symptom  of  many  underlying  affections.  It  has  been  ascribed 
to  many  agencies:  cold,  exposure,  general  disturbance  of  nutrition,  a 
sequence  or  associated  condition  of  severe  systemic  fever  or  disease, 
nephritic  disorders,  and  to  various  neuroses.  In  some  instances  malarial 
fever  seemed  of  etiologic  bearing  (Key,  Mourson,  Fischer,  Calmette  and 

1  Fordyce,  Jour.  Cutan.  Dis.,  1896,  p.  87,  records  a  case  in  which  the  ear-tips  alone 
were  affected  and  gangrenous. 

2Bronson,  "A  Case  of  Symmetrical  Gangrene,"  Jour.  Cutan.  Dis.,  1903,  p.  456 
(with  case  illustration),  describes  a  peculiar  case  in  which  not  only  was  the  so-called 
local  syncope  entirely  lacking,  but  the  usual  situations  were  spared,  the  malady  involv- 
ing symmetric  areas  on  the  legs  and  ankles  and  clinically  characterized  by  recurrent 
attacks  of  pain  and  inflammation,  exactly  symmetric,  together  with  the  development  of 
a  necrotic  process;  the  author  viewing  the  case  as  a  possible  transitional  form  between 
Raynaud's  disease  and  erythromelalgia. 

In  this  connection  the  condition  described  under  the  name  dermatitis  symmetnca 
dysmenorrhoica,  by  Matzenhauer-Polland  (Archiv,  March,  1912,  and  Oct.,  1912,  p.  185), 
Kreibich  (ibid.,  April,  1912),  Friedeberg  (ibid.),  and  Mathes  (ibid.,  Oct.,  1912)  may  be 
referred  to.  The  patients  were  dysmenorrhceic,  with  disturbances  of  the  heart  and 
vasomotor  systems,  and  often  psychic  abnormalities.  The  eruptive  conditions,  almost 
always  symmetric,  and  mostly  nocturnal  in  appearing,  consist  of  a  moist  dermatitis, 
an  urticarial  erythema,  or  a  spontaneous  necrosis.  It  is  usually  ushered  in  with  an 
intense  burning  sensation,  becoming  later  urticarial  in  appearance.  It  may goon  tc 
vesicles  and  bullse  formation,  and  dry  into  brownish  yellow  crusts,  which  fall  oti 
leave  stains.  In  some  places  there  may  result  superficial  necrosis.  In  the  severa 
cases  reported  the  sides  of  the  face,  arms,  and  legs  and  anterior  aspect  of  trunk  were 
favorite  localities.  Both  Kreibich  and  Mathes  believe  the  lesions  have  an  angioneurotic 
basis;  Friedeberg  leans  toward  Freund's  theory  that  pathologic  alterations  of  metabolism 
may  result  as  a  sequel  to  abnormal  menstruation,  and  provoke  the  skin  symptoms. 
Self-production  of  the  lesions  was  considered,  but  eliminated. 
28 


432  INFLAMMATIONS 

Etiology  and  Pathology. — Considering  the  number  of  cases  of 
diabetes,  diabetic  gangrene  must  be  considered  extremely  rare.  Three 
factors  are  doubtless  contributory  or  essential  in  its  production:  The 
abnormal  impregnation  of  the  tissues  and  blood  with  sugar,  making  the 
former  favorable  soil  for  microbic  development ;  lessened  resisting  power, 
superinduced  by  the  diabetes;  and  microbic  infection,  probably  taking 
place  through  some  break  in  the  continuity  of  the  skin.  Gussenbauer1 
inclines  to  the  belief  that  the  gangrene  is  not  so  much  due  to  the  sugar 
in  the  tissues,  as  to  the  loss  of  resisting  power  and  to  the  bad  effects 
following  infective  processes  in  such  individuals.  The  spontaneous 
form  is  possibly  purely  trophic  in  origin,  but  in  these  cases  an  unnoticed 
insignificant  injury  or  break  in  the  skin  may  have  preceded.  Morrow 
states  that  it  mainly  occurs  in  the  old  and  obese,  is  usually  of  the  moist 
type,  and  that  the  blood-vessels  are  found  to  be  pervious.  Wallace2 
found  the  arteries  in  23  out  of  24  cases  decidedly  atheromatous,  the 
patients  averaging  sixty- three  years;  and  that  the  disease  was  relatively 
more  frequent  in  males. 

Prognosis  and  Treatment — The  disease  is  a  grave  complication 
or  accident  in  the  course  of  a  serious  disease,  and  the  outlook  is  rendered 
less  favorable.  The  gangrene  is  apt  to  extend,  and  new  areas  may  arise. 
The  patient  may  finally  die  from  septic  poisoning.  Exceptionally 
cases  do  recover,  however,  particularly  those  of  spontaneous  origin. 

The  diabetes  itself  must  be  carefully  treated,  both  by  dietetic  and 
medicinal  means.  The  gangrenous  spots  or  areas  are  to  be  managed 
upon  general  principles,  with  applications  of  antiseptics,  until  the  slough- 
separates;  or,  better  still,  as  soon  as  the  slough  has  formed  it  may  be 
removed  by  curetting,  if  necessary,  and  the  parts  treated  antiseptically. 
Gussenbauer  points  out  that  the  best  plan  consists  in  thorough  surgical 
removal  of  the  diseased  tissue.  Wallace  believes  the  best  treatment  is 
removal  of  the  limb  early,  before  sepsis  has  caused  great  depression. 

SYMMETRIC  GANGRENE 

Synonyms. — Local  asphyxia;  Raynaud's  disease;  Fr.,  Asphyxie  locale  des  ex- 
tremites;  Ger.,  Raynaud'sche  Krankheit. 

Definition — An  affection,  usually  of  the  extremities,  of  probably 
trophic  nature,  characterized  by  local  ischemia  and  asphyxia,  which 
usually  terminate  in  the  gangrene  of  the  skin  and  underlying  tissue. 

While  considerable  irregular  information  was  known  as  regards  this 
affection,  Raynaud's3  description  was  the  first  well-defined  presentation; 
his  contributions,  with  those  of  Barlow  and  others,  have  given  a  clear 
portrayal  of  its  clinical  symptoms  and  behavior. 

Symptoms — The  extremities,  such  as  fingers  and  toes,  the  ears, 
nose,  and  occasional  other  parts  may  be  the  seat  of  the  disease.  On 

1  Gussenbauer,  Wien.  med.  Blatt,  Feb.  2,  i8oq. 

2  C.  S.  Wallace,  Lancet,  Dec.  23,  1899  (a  record  of  26  cases  observed  in  a  period 
of  eleven  years  in  St.  Thomas'  Hospital,  London). 

TH*  ^aX"aHd'  "De  1'asphyxie  locale  et  de  la  gangrene  symetrique  des  extremites," 
1  Mse  de  Pans,  1862.  Also  paper  by  same  writer.  Arch.  Gen.  de  Med.,  1874,  vol.  i,  pp. 
50oo  u  9V>  fnSllsh  translation  in  New  Syd.  Soc'y  publication,  Selected  Monographs, 
1888,  by  Barlow,  with  valuable  additional  notes 


SYMMETRIC   GANGRENE  433 

the  ears  and  nose,  however,  the  gangrenous  stage  is  rarely  reached.1 
It  is,  generally,  symmetric.  The  first  symptoms2  are,  as  a  rule,  cold- 
ness and  paleness  of  the  parts — local  ischemia;  pain  and  numbness  may 
or  may  not  have  preceded.  Sooner  or  later  the  second  stage  is  reached, 
that  of  local  asphyxia,  in  which  the  parts  become  dark  red,  livid,  and 
bluish,  and  sometimes  swollen,  with  not  infrequently  tenderness  and 
shooting  pains.  There  may  be,  in  either  of  these  periods,  a  repeated 
retrogression  and  reappearance  for  some  time,  and  occasionally  it  does 
not  progress  beyond  the  second  stage.  Finally,  however,  the  condition 
usually  eventuates  in  gangrene,  generally  of  a  dry  character;  there  may 
be  formation  of  vesicles  or  bullae  along  the  edge  of  the  gangrenous 
margin.  Or,  instead  of  gangrenous  changes,  the  part  affected, 
especially  if  the  fingers  or  toes,  may  gradually  become  atrophic, 
withered,  and  indurated. 

In  many  cases  the  process  goes  on  until  it  reaches  the  beginning  of 
the  third  stage,  that  of  persistent  lividity,  of  bluish  or  bluish-black 
color,  and  may  remain  in  this  state  an  indefinite  time.  Or  in  some 
instances  complete  resolution  may  take  place,  to  be  followed  by  recurrent 
attacks. 

On  fingers  or  toes  the  gangrene  may  involve  considerable  area. 
It  may  be  of  a  dry  and  mummified  character,  and  gradually  drop  off; 
or  it  may  be  cast  off  by  underlying  inflammatory  and  suppurative  action; 
or,  instead  of  dry  gangrene,  it  is  of  the  moist  character,  with  some  puru- 
lent infiltration  of  the  subjacent  tissue.  The  resulting  ulcers  heal  slowly. 

Etiology  and  Pathology.— The  causes  maybe  varied;  in  fact, 
it  is  questionable  whether  Raynaud's  disease  is  a  distinct  entity  or 
merely  a  symptom  of  many  underlying  affections.  It  has  been  ascribed 
to  many  agencies:  cold,  exposure,  general  disturbance  of  nutrition,  a 
sequence  or  associated  condition  of  severe  systemic  fever  or  disease, 
nephritic  disorders,  and  to  various  neuroses.  In  some  instances  malarial 
fever  seemed  of  etiologic  bearing  (Key,  Mourson,  Fischer,  Calmette  and 

1  Fordyce,  Jour.  Cutan.  Dis.,  1896,  p.  87,  records  a  case  in  which  the  ear-tips  alone 
were  affected  and  gangrenous. 

2Bronson,  "A  Case  of  Symmetrical  Gangrene,"  Jour.  Cutan.  Dis.,  1903,  p.  456 
(with  case  illustration),  describes  a  peculiar  case  in  which  not  only  was  the  so-called 
local  syncope  entirely  lacking,  but  the  usual  situations  were  spared,  the  malady  involv- 
ing symmetric  areas  on  the  legs  and  ankles  and  clinically  characterized  by  recurrent 
attacks  of  pain  and  inflammation,  exactly  symmetric,  together  with  the  development  of 
a  necrotic  process;  the  author  viewing  the  case  as  a  possible  transitional  form  between 
Raynaud's  disease  and  erythromelalgia. 

In  this  connection  the  condition  described  under  the  name  dermatitis  symmetnca 
dysmenorrhoica,  by  Matzenhauer-Polland  (Archiv,  March,  1912,  and  Oct.,  1912,  p.  185), 
Kreibich  (ibid.,  April,  1912),  Friedeberg  (ibid.),  and  Mathes  (ibid.,  Oct.,  1912)  may  be 
referred  to.  The  patients  were  dysmenorrhceic,  with  disturbances  of  the  heart  and 
vasomotor  systems,  and  often  psychic  abnormalities.  The  eruptive  conditions,  almost 
always  symmetric,  and  mostly  nocturnal  in  appearing,  consist  of  a  moist  dermatitis, 
an  urticarial  erythema,  or  a  spontaneous  necrosis.  It  is  usually  ushered  in  with  an 
intense  burning  sensation,  becoming  later  urticarial  in  appearance.  It  may goon  to 
vesicles  and  bulte  formation,  and  dry  into  brownish  yellow  crusts,  which  fall  ott 
leave  stains.  In  some  places  there  may  result  superficial  necrosis.  In  the  several 
cases  reported  the  sides  of  the  face,  arms,  and  legs  and  anterior  aspect  of  trunk  were 
favorite  localities.  Both  Kreibich  and  Mathes  believe  the  lesions  have  an  angioneurotic 
basis;  Friedeberg  leans  toward  Freund's  theory  that  pathologic  alterations  of  metabolism 
may  result  as  a  sequel  to  abnormal  menstruation,  and  provoke  the  skin  symptoms. 
Self-production  of  the  lesions  was  considered,  but  eliminated. 
28 


434 


INFLAMMA  TIONS 


Leloir,  and  others)  ;l  Osier,2  in  9  cases  observed  by  him,  was  not  able  to 
confirm  this  in  a  single  instance.  An  arteritis  of  syphilitic  origin, 
probably  beginning  peripherally,  is,  doubtless,  as  Jacoby3  has  strongly 
pointed  out,  responsible  for  some  cases  reported  as  examples  of  Ray- 
naud's  disease.  It  is  doubtless  in  most  instances  of  purely  neurotic 
origin — a  vasomotor  nutritive  disturbance. 

There  is,  first,  a  contraction  of  the  arterioles  and  capillaries  (Ray- 
naud),  which  explains  the  first  stage;  this  is  followed  by  dilatation  and 
paralysis  of  the  vessels,  giving  rise  to  the  livid  or  blue  color.  It  is  alleged 
by  Weiss,  however,  that  these  later  changes  are  due  to  a  contraction  of 
the  veins.  At  all  events  the  local  disturbance  is  a  circulatory  one,  and 
this  may  be  due  to  peripheral  or  central  causes.  According  to  Leloir, 
its  most  common  subjects  are  between  the  ages  of  fifteen  and  thirty- 
five,  and  four-fifths  of  them  are  females. 

Diagnosis  and  Prognosis. — The  symmetric  character  of  the 
disease  and  the  sites  affected,  together  with  its  course,  are  sufficiently 
characteristic. 

The  outlook  for  permanent  recovery  is  not  very  favorable.  Some- 
times recovery  takes  place  after  one  attack.  As  a  rule,  however,  and 
even  in  seemingly  favorable  cases,  there  are  likely  to  be  recurrences, 
or  one  part  after  another  may  become  involved.  If  it  is  possible  to 
recognize  the  etiologic  factor,  and  this  be  susceptible  of  removal,  a  per- 
manent cure  may  result.  In  unfavorable  cases,  septic  infection  may 
gradually  ensue. 

Treatment. — The  recognition  of  the  underlying  causative  factor 
is  all-important  for  a  result.  Treatment  is,  therefore,  somewhat  different 
in  different  cases,  although  in  the  most  it  is  probably  empiric.  As  a  rule, 
invigorating  treatment,  especially  directed  toward  the  nervous  system, 
and  a  full  generous  diet  and  attention  to  hygiene  will  have  an  influence. 
Remedies  having  an  action  upon  the  peripheral  circulation,  such  as  amyl 
nitrite  and  nitroglycerin,  and  others  have  been  advocated  but  are  of 
questionable  value.  Inhalations  of  oxygen  have  also  been  advised.  A 
method  of  treatment  commended  by  Raynaud,  which  in  some  instances 
seems  to  be  of  decided  service,  is  that  by  the  galvanic  current  with  the 
positive  pole  applied  at  the  fifth  cervical  vertebra  and  the  negative  over 
the  last  lumbar  vertebra  or  over  the  sacrum;  the  current  should  be 
moderately  strong,  and  continued  for  five  to  ten  minutes  daily.  The 
negative  electrode,  with  weaker  current,  can  also  be  applied  to  the  affected 
region.  Application  of  the  faradic  current  to  the  parts  should  also  be 
employed  from  time  to  time. 

In  the  earlier  stages  cold  application,  frictions  with  stimulating  lini- 
ments, and  massage  are  of  service.  Later,  the  local  treatment  is  essen- 
tially antiseptic  and  surgical. 

1  Calmette,  Gas.  medicate,  1876,  No.  44;  Leloir,  "Diseases  of  Skin,"  Twentieth 
Century  Practice,  vol.  v,  p.  807. 

2  Osier,  Johns  Hopkins  Hasp.  Bull.,  Feb.,  1900. 

3  Jacoby, "  A  Contribution  to  the  Diagnosis  of  Raynaud's  Disease,"  New  York  Med. 
Jour.,  Feb.  7,  1891  (with  a  good  bibliography);  see  also  paper  (3  cases)  by  H.  H. 
Morton,  Jour.  Cutan.  Dis.,  1894,  p.  249,  and  the  paper  (with  illustrations)  by  Howard 
Fox,  Med.  Review  of  Reviews,  May,  1907,  and  Jour.  Cutan.  Dis.,  Aug.,  1907. 


435 


Definition.— This  term  includes  cases  of  dermatitis  of  varying  grade, 
due  to  the  action  of  heat  or  cold.  The  condition  may  be  so  slight  as  to 
be  simply  an  erythema  or  congestion— erythema  caloricum;  or,  if  the 
cause  has  been  extreme,  death  of  the  part  may  result.  Two  forms  are 
described:  that  due  to  excessive  heat — dermatitis  ambustionis,  or  burns 
— and  that  due  to  excessive  cold  (extreme  absence  of  heat) — dermatitis 
congelationis,  or  frost-bites. 

DERMATITIS  AMBUSTIONIS 

Symptoms — Burns  may  vary  from  a  slight  redness,  as,  for  example, 
that  produced  by  exposure  to  the  sun's  rays — erythema  solare,  eczema 
solare — to  that  in  which  rapid  destruction  or  necrosis  ensues.  They 
are,  according  to  their  severity,  usually  divided  into  three  degrees:  In 
that  of  the  first  degree  (dermatitis  ambustionis  erythematosa)  there  is 
simply  redness,  accompanied  with  more  or  less  heat  of  the  affected  part, 
and  at  times  with  slight  swelling;  in  that  of  the  second  degree  (dermatitis 
ambustionis  bullosa) ,  to  the  above  symptoms  are  added  vesiculation  and 
the  formation  of  bullae,  due  to  considerable  serous  exudation,  and  along 
with  these  there  may  be  greater  swelling,  and  the  part  may  even  have  an 
erysipelatous  aspect.  In  both  of  these  grades  the  subjective  symptoms 
of  heat  and  burning  are  present;  hi  those  of  the  second  degree,  more  or 
less  tenderness  and  actual  pain.  In  the  third  grade  (dermatitis  ambus- 
tionis escharotica)  of  burns,  to  the  characters  already  named,  are  added 
those  of  eschar  otic  action,  involving  superficially  or  deeply  according  to 
the  intensity  and  duration  of  the  exposure.  In  the  more  severe  instances, 
and  even  in  the  milder  cases  of  any  extent,  there  are  usually  constitu- 
tional symptoms  of  considerable  violence.  In  fact,  if  the  burn  is  severe 
or  very  extensive,  the  patient  may  suffer  profoundly  from  shock,  from 
which,  in  the  most  extreme  cases,  he  does  not  rally.  In  serious  burns, 
especially  those  of  escharotic  character,  various  and  grave  complica- 
tions of  the  internal  organs  may  occur;  or  the  patient  may  suffer  from 
the  drain  of  the  suppurative  action  which  ensues.  In  favorable  instances 
of  the  severe  type  the  slough  is  gradually  cast  off  and  repair  takes  place; 
or,  after  tissue  repair,  there  may  remain  considerable  surface  which  fails 
to  skin  over. 

Prognosis  and  Treatment — Burns  of  the  first  and  second  de- 
grees almost  invariably  make  rapid  recovery,  unless  extensive ;  the  latter 
are  always  serious,  and  may  be  rapidly  fatal  from  shock.  The  cause  of 
death  has  been  variously  suggested  as  due  to  induced  changes  in  the  red 
blood-corpuscles  (Wertheim,  Lesser,  and  others)  or  to  the  development 
of  toxins  or  ptomains  (Lustgarten,  Spiegel,  and  others).  The  prognosis 
in  those  of  the  third  degree  depends  upon  the  extent  of  the  destruction. 
In  all  grades  the  extremes  of  life  are  the  most  dangerous  periods. 

In  severe  cases  constitutional  measures  of  supporting  character  are 
made  necessary  by  the  general  condition  of  the  patient.  Stimulants, 
and  sometimes  narcotics  also,  are  required.  The  local  treatment  de- 
pends, in  part  at  least,  upon  the  degree  of  inflammation  or  destruction, 


436  I  NFL  A  MM  A  TIONS 

and  whether  it  be  limited  or  extensive.  If  of  a  mild  degree,  the  applica- 
tion of  sodium  bicarbonate  as  a  powder,  covering  the  parts  thoroughly, 
is  often  sufficient;  or  it  may  be  applied  in  solution,  from  3  to  5  grains 
(0.2-0.33)  or  more  to  the  ounce  (32.),  enveloping  the  part  with  linen 
cloths  kept  constantly  wet  with  it.  The  application  of  cold-water 
compresses,  or  compresses  wet  with  boric  acid  solution,  will  also  be  of 
value.  Dilute  lead-water  is  often  very  grateful  and  satisfactory,  and 
can  be  used  when  the  surface  is  not  large.  In  those  cases  with  vesicles 
and  bullae,  these  should  be  carefully  punctured,  the  contents  gently 
pressed  out,  and  the  dressings,  such  as  above,  applied.  In  those  involv- 
ing extensive  surface  relief  is  often  obtained  by  the  well-known  lini- 
mentum  calcis  (Carron  oil) ;  if  the  area  is  not  too  large,  this  can  be  made 
more  effective  in  painful  cases  by  the  addition  of  a  small  amount  of 
carbolic  acid,  \  to  5  grains  (0.033-0.33)  to  the  ounce  (32.).  Many  of 
the  soothing  applications  advised  in  the  acute  types  of  eczema  will  also 
give  relief  hi  the  majority  of  the  milder  burns.  If  very  extensive,  espe- 
cially when  there  is  profound  shock,  the  continuous  immersion  of  the 
patient  in  a  warm  bath  affords  great  comfort  and  relief.  In  recent  years 
a  i  per  cent,  solution  of  picric  acid  has  been  extolled  (Thiery,  Debacq, 
Power,  Dakhyle,  and  others),  especially  in  the  first  and  second  grades; 
it  is  applied  in  the  form  of  compresses,  but  should  not  be  applied  over  a 
large  surface  for  fear  of  absorption.  In  suppurative  surfaces  attention 
should  be  given  to  cleanliness  and  frequent  change  of  applications. 
The  graver,  escharotic  cases  belong  properly  to  the  surgeon.  In  some 
of  these  skin-grafting  will  be  eventually  necessary. 

DERMATITIS  CONGELATIONIS 

Symptoms. — Various  grades  of  dermatitis  from  exposure  to  cold 
are  met  with,  varying  from  a  simple  hyperemia  to  that  of  deep  tissue 
necrosis.  As  in  burns,  it  is  usual  to  give  a  somewhat  arbitrary  division 
into  three  degrees.  In  the  first  the  part  is  noted  to  be  hyperemic,  some- 
times of  a  dark  or  dusky  hue;  in  this  type  there  sometimes  results  weak- 
ening of  the  circulation  of  the  part,  and  the  congestion  persists,  or  is 
readily  provoked  upon  exposure  to  cold  or  to  moderate  heat.  This 
condition — chilblains — is  often  persistent  and  gives  rise  to  a  good  deal 
of  burning  and  itching  when  the  part  becomes  warm.  In  frost-bites 
of  the  second  degree  there  may  be  a  bright  red  or  livid  skin,  with  more 
or  less  serous  exudation,  usually  in  the  form  of  vesicles  and  blebs,  although 
there  is  sometimes  a  serous  undermining  of  the  entire  epiderm.  In  the 
third  degree  the  part  is  at  first  noted  to  be  pale,  stiff,  and  even  brittle; 
if  not  severe  or  if  it  may  not  have  been  long  exposed,  gradual  reddening 
takes  place  and  the  circulation  is  reestablished,  the  surface  presenting 
moderate  or  marked  vesiculation  and  bleb-formation,  with  some  under- 
lying superficial  ulceration;  or  complete  normality  may  be  restored.  Or 
the  part  may  go  immediately  into  a  state  of  necrosis  or  gangrene,  a  line 
of  demarcation  gradually  forming.  As  in  dermatitis  from  exposure  to 
heat,  there  may  be  constitutional  disturbances,  if  the  part  involved  is 
very  extensive,  and  especially  if  the  case  is  of  the  third  degree.  Even 


DERMATITIS   TRAUMATICA 


437 


in  limited  areas  of  this  last  grade  there  may  develop  some  fever  later, 
and  possibly  septicemic  symptoms  may  supervene  as  the  part  is  cast  off 
and  undergoes  suppurative  action.  If  the  exposure  has  been  prolonged 
and  involves  a  greater  portion  or  the  entire  surface,  the  patient  fails  to 
rally. 

Prognosis  and  Treatment — The  prognosis  is  usually  favorable, 
both  for  the  patient  and  for  the  part  involved,  if  exposure  has  not  been 
too  prolonged  and  the  region  involved  not  too  large.  Extensive  cases, 
however,  and  particularly  if  the  resulting  damage  is  of  the  third  degree, 
are  always  of  serious  import.  The  patient's  general  condition  may  de- 
mand the  free  use  of  stimulants  to  overcome  any  shock  and  to  support 
the  strength. 

The  local  treatment  of  established  chilblain  has  been  considered 
under  Erythema  Hyperaemicum.  If  the  case  is  seen  immediately  after 
exposure,  the  parts  are  to  be  brought  back  to  the  normal  temperature  by 
first  rubbing  gently  with  snow  or  by  applications  of  cold  water,  gradually 
replacing  these  with  water  of  higher  degree  until  the  normal  temperature 
is  reached;  soothing  lotions  or  ointments  may  then  be  applied  for  a 
short  time. 

If  the  action  is  of  the  second  degree,  the  same  preliminary  measures 
of  gradually  bringing  the  part  back  to  the  normal  temperature  are  to  be 
adopted.  Subsequently  the  vesicles  and  blebs  are  to  be  carefully  opened, 
and  soothing  remedies  employed,  such  as  are  used  in  diseases  with  similar 
lesions.  Weak  ointments  of  salicylic  acid,  from  10  to  20  grains  (0.65- 
1.33)  to  the  ounce  (32.)  of  zinc  oxid  ointment,  or  with  the  addition  of  5 
or  10  grains  (0.33-0.65)  of  carbolic  acid  to  the  ounce  (32.);  or  boric  acid 
ointment,  or  one  with  5  to  10  per  cent,  ichthyol,  will  usually  be  all  that 
is  required.  Wet  dressings,  the  same  as  referred  to  in  burns,  sometimes 
prove  more  grateful.  Cases  of  the  third  degree,  especially  the  more 
extensive  forms,  properly  belong  to  the  domain  of  surgery.  In  limited 
areas  the  treatment  is  the  same  as  in  the  other  varieties.  Proper  anti- 
septic precautions  should  be  taken. 

DERMATITIS  TRAUMATICA. 

Under  this  head  are  comprised  all  those  cases  of  cutaneous  disturb- 
ance or  inflammation  due  to  traumatic  agencies,  such  as  friction,  con- 
tusions, abrasions,  excoriations,  surgical  operations,  animal  parasites, 
continued  scratching,  and  the  like.  The  amount  of  disturbance  depends 
upon  the  character  of  the  cause  and  the  duration  of  its  action  or  its 
repetition.  Very  often  this  does  not  go  beyond  simple  erythema  (ery- 
thema traumaticum).  When  the  action  has  been  prolonged,  a  variable 
degree  of  thickening  of  the  skin  and  pigmentation  may  result.  Infection 
from  without  may  be  added  to  the  ordinary  symptoms  of  traumatic 
break  in  the  continuity  of  the  derma,  and  give  rise  to  complications. 

The  various  other  examples  of  this  variety  of  dermatitis  scarcely 
need  special  mention.  The  irritation  and  inflammation  sometimes  due 
to  tight-fitting  garments,  bandages,  to  constant  pressure  (bed-sores), 
etc.,  are  additional  illustrations.  The  mild  traumatic  dermatitis  which 


438  INFLAMMA  TIONS 

the  various  implements  of  trade  produce  in  those  of  sensitive  skin  unac- 
customed to  their  use  is  well  known;  nature,  by  gradually  producing  a 
thickening  or  callousness  of  the  parts  pressed  upon,  protects  from  further 
damage. 

The  management  of  dermatitis  traumatica  consists  simply  in  with- 
drawal or  modification  of  the  causative  factor,  and,  if  necessary,  the 
application  of  soothing  lotions  or  ointments,  such  as  referred  to  in  ery- 
thema hyperaemicum;  in  bed-sores  soap-plaster,  or  equal  parts  of  soap- 
plaster  and  petrolatum,  with  or  without  I  to  5  per  cent,  of  ichthyol  to 
the  ounce,  is  of  advantage. 

DERMATITIS  VENENATA 

Definition  and  Causes — Under  the  head  of  dermatitis  venenata 
are  included  all  those  inflammatory  conditions  of  the  skin  due  to  con- 
tact with  or  to  the  action  of  caustics,  chemical  irritants,  drugs,  plants, 
and  other  deleterious  substances.  These  agents  are  for  the  most  part 
essentially  chemical.  The  substances  which  may  be  responsible  for 
dermatic  inflammation  are  almost  innumerable.  Many  of  them  are 
more  or  less  irritating  to  all  skins,  some  are  harmless  or  practically  so 
to  a  large  number,  while  in  others  again  the  action  is  so  exceptional  as 
to  be  due  to  some  peculiar  idiosyncrasy.  Among  the  most  common  are 
the  various  irritant  drugs,  as  arnica,  mustard,  cantharides,  mercurials, 
iodoform,  iodin,  carbolic  acid,  oil  of  turpentine,  dye-stuffs,  petroleum 
products,  alkalies  and  acids,  and  many  others;  among  irritating  articles 
of  wearing  apparel  and  every-day  use  irritant  to  some  individuals  may 
be  mentioned  strong  soaps,  anilin  and  corallin  dyes,  especially  in  socks 
and  veils,  many  of  the  quack  stimulating  oils  for  rheumatism,  etc. 
Among  the  trade  causes  may  be  mentioned  the  constant  handling  of 
sugars,  flour,  polishing  material,  pastes,  tobacco,  and  similar  substances. 
Metol,  used  by  photographers,  is  occasionally  responsible  for  an  eczema- 
toid  dermatitis. 

Workers  in  petroleum  products,  especially  coal-tar  and  its  com- 
pounds,1 occasionally  exhibit  various  kinds  of  cutaneous  lesions  resulting 
therefrom — dry  erythematous  and  erythematosquamous  skin,  come- 
dones, acne,  pigmentation  resulting  from  the  chronic  irritation,  papules, 
pustules,  furuncles,  warty  growths,  and  other  keratoses — hence  the 
terms  tar  acne,  tar  dermatitis,  pitch  dermatitis,  etc.  Warty  and  kera- 
totic  growths  from  these  sources  not  infrequently  have  shown  an  epi- 
theliomatous  tendency. 

Plants  also  furnish  a  somewhat  prolific  source  of  dermatic  inflamma- 
tion. As  with  almost  all  other  substances,  certain  plants  are  more  fre- 
quently causative,  while  some  others  may  only  occasionally  bring  about 
such  action,  and  by  far  the  large  majority  are  wholly  devoid  of  irritating 
properties.  Idiosyncrasy  plays  an  important  part.  The  various  plants 
which  may  provoke  such  irritation  in  susceptible  subjects  are  at  least 

1  Ehrmann,  Monatshefte,  1909,  vol.  xlviii,  p.  18,  has  had  an  observation  of  25  to  30 
cases  among  the  workers  in  these  products  in  Mannheim,  and  Zweig  has  also  recently 
(Dermatolog.  Zeitschr.,  1909,  vol.  xvi,  p.  85,  with  some  literature  references)  considered 
the  subject  in  its  relation  to  its  finally  engendering  cancer. 


DERMATITIS    VENENATA 


439 


sixty  or  seventy.  The  most  common  and  best  known  of  this  group  are 
the  rhus  plants.  These  furnish,  in  season,  our  clinics  with  a  large  num- 
ber of  examples  of  dermatitis  venenata  of  varying  grade.  The  several 
plants  of  the  rhus  species  are  somewhat  common  in  different  parts  of  our 
country,  and  some  are  more  poisonous  than  others.  These  plants  are: 
rhus  toxicodendron,  a  climbing  plant  (poison  ivy),  and  as  an  independent 
shrub  or  small  tree  (poison  oak);  rhus  venenata,  a  shrub  or  small  tree 
rarely  exceeding  the  height  of  fifteen  or  sixteen  feet,  also  known  as  poison 
dogwood,  poison  sumac,  and  poison  elder;  rhus  diversiloba,  and  rhus 
pumila,  the  former  a  climbing  and  the  latter  a  creeping  shrub,  both  of 
rather  limited  distribution;  and  rhus  vernix,  from  which  the  varnish  for 
Chinese  lacquer  work  is  made. 

The  various  other  plants1  which  are  sometimes  provocative  are  too 
numerous  to  mention  individually,  and,  moreover,  are  much  less  fre- 


Fig.  105. — Dermatitis  venenata  from  exposure  to  poison-ivy,  following  shortly  after 
exposure;  vesicular  and  bullous  lesions;  not  an  uncommon  type;  hands  and  forearms 
involved;  a  few  days'  duration. 

quently  causative.  Among  the  best  known  are  urtica  doica  (nettle), 
primula  obconica  (primrose),  mucuna  pruriens  (cowhage),  polygonum 
punctatum  (smartweed),  podophyllum,  balsamum  Gileadense  (balm 
of  Gilead),  nerium  oleander  (oleander),  and  ruta  (rue).2  Primrose 
dermatitis,3  of  variable  degree,  usually  from  the  hot-house  or  domesti- 

1  For  further  information  on  this  and  other  points,  the  reader  is  referred  to  the 
monograph  on  Dermatitis  Venenata  by  Dr.  James  C.  White,  Boston,  1887;  and  to  Dr. 
P.  A.  Morrow's  work  on  Drug  Eruptions,  New  York,  1887,  and  "Dermatitis  Venenata 
— A  Supplemental  List,"  by  Dr.  James  C.  White,  Jour.  Cutan.  Dis.,  1903,  p.  441  (with 
references);  Evans,  Brit.  Jour.  Derm.,  1905,  p.  447,  refers  to  several  cases  occurring  in 
workers  on  teak  wood. 

2  E.  Hoffmann,  Munch,  med.  Wochenschr.,  No.  44,  1904,  in  addition  to  referring  to 
the  dermatitis  produced  by  the  primrose,  states  that,  among  other  plants,  he  has  seen 
cases  due  to  the  chrysanthemum,  fresh  squill-root,  and  arbor  vitae. 

3  Foerster,  "Primula  Dermatitis,"  Jour.  Amer.  Med.  Assoc.,  Aug.  20,  1910,  with 
review  of  subject  and  references,  thinks  it  due  to  secretion  and  not  hairs  of  the  plant — 
alcohol   dissolves   secretion;    Zeisler,   "Some   Uncommon    and   Often   Unrecognized 
Forms  of  Toxic  Dermatitis,"  Jour.  Amer.  Med.  Assoc.,  Jan.  29, 1912,  p.  2024;  Sharpe, 
"Primula  Dermatitis,  Its  Occurrence  in  Rural  Districts,"  Jour.  Amer.  Med.  Assoc., 
Dec.  14,  1912,  p.  2148  (from  wild  primrose,  primula  farinosa). 


44O  INFLAMATA  TIONS 

cated  variety,  but  also  from  the  wild  plant,  is  quite  frequently  observed 
in  England  and  the  United  States,  a  number  of  such  cases  having  come 
under  my  observation  in  the  past  few  years. 

Symptoms. — The  symptoms  of  dermatitis  venenata  are  varied,  de- 
pending upon  the  individual  susceptibility  and  upon  the  character  and 
duration  of  contact  of  the  irritating  substance.  All  degrees  are  met 
with,  from  that  of  simple  irritation  to  that  of  gangrenous  action.  In- 
termediate degrees  of  papulation,  vesiculation,  erysipelatous  and  edema- 
tous  swelling,  and  the  formations  of  bullse  are  all  encountered;  and,  in 
rare  instances,  superficial  destruction  and  ulceration. 

In  almost  all  cases  the  dermatitis  runs  a  somewhat  acute  course  and 
terminates  spontaneously  in  recovery,  and,  except  in  the  rare  and  ex- 
treme instances  of  suppurative  and  destructive  action,  without  trace 
or  scar.  In  subjects  eczematously  inclined  the  artificial  dermatitis 


Fig.  106. — Dermatitis  venenata  from  exposure  to  poison  ivy;  the  hands,  forearms,  and 
face  involved,  with  numerous  vesicles  and  blebs. 

may  develop  into  a  true  eczema,  more  especially  after  two  or  three 
attacks,  or  from  persistent  action  of  the  irritant.  The  subjective  symp- 
toms of  burning  and  itching  are  somewhat  variable;  they  may  be  ex- 
tremely troublesome  or  very  slight,  and  even  wanting. 

Some  of  the  cases  due  to  the  more  common  causes  may  be  referred 
to.  That  irritation  is  produced  by  many  drugs  is  well  known.  Even 
the  constant  use  of  the  various  antiseptics  in  susceptible  individuals 
tends  eventually  to  bring  about  a  variable  dermatitis,  essentially  an 
eczema,  usually  slight,  but  sometimes  persistent.  This  is  not  infre- 
quently encountered  in  surgeons  and  nurses  (surgeons'  eczema;  nurses' 
eczema),  especially  after  a  series  of  prolonged  operations,  during  which 
the  hands  have  been  more  or  less  constantly  in  contact  with  corrosive 
sublimate,  carbolic  acid,  or  formaldehyd  solutions;  the  repeated  use  of 


DERMATITIS    VENENATA 


441 


strong  soap,  such  as  sapo  viridis  or  the  tincture  of  green  soap,  used  in 
washing  the  hands,  is  also  often  a  factor.  A  mild  degree  of  dermatitis 
is  sometimes  encountered  in  patients  from  the  use  of  antiseptics  and 
antiseptic  gauzes  and  other  dressings.  In  many  of  these  instances  there 
is,  of  course,  a  pronounced  individual  idiosyncrasy. 

lodoform  (iodoform  dermatitis,  iodoform  eczema),  more  especially 
when  used  in  powder  form,  is  a  not  infrequent  source  of  such  irritation 
(Neisser,  Taylor,  Watkins,  and  many  others) .  The  use  of  this  drug  is 
responsible  for  occasional  inflammatory  action,  which  may  be  quite 
positive,  and  sometimes  long  continued.  The  character  of  the  inflam- 
mation varies  from  that  of  erythematous  to  vesicular  and  bullous;  often 


Fig.  107. — Dermatitis  venenata  from  exposure  to  poison  ivy.  Marked  edematous 
swelling  of  the  scrotum  and  penis;  also  slight  involvement  of  face  and  hands;  two 
days'  duration,  developing  ten  or  twelve  hours  after  exposure. 

it  is  of  an  apparently  eczematous  character.  It  usually  starts  at  the 
seat  of  the  dressing,  and  may  continue  to  be  so  limited;  often,  however, 
it  spreads  from  this  point  and  involves  the  immediate  neighborhood, 
and  may  even  extend  to  other  regions.  I  have  met  with  several  cases 
of  rebellious  eczema  which  had  their  start  in  the  local  use  of  this  drug. 
It  may,  moreover,  through  absorption,  also  be  provocative  of  more  or 
less  general  cutaneous  manifestations  of  varied  character,  and  if  exten- 
sive or  severe,  with  associated,  temporarily  at  least,  systemic  disturbance 
(see  Dermatitis  Medicamentosa) . 

The  popular  use  of  arnica  tincture  has  also  been  the  cause  of  some 
cases  of  violent  dermatitis  (Cartier,  Bauvais,  Mouillot,  Bowles,  Dale, 
and  others),  which  may  extend  much  beyond  the  part  to  which  it  is 


442  INFLAMMATIONS 

applied,  and  present  as  an  erythematous,  erysipelatous,  vesicular, 
bullous,  and  even  gangrenous  inflammation;  and  in  some  cases  there 
may  be  severe  constitutional  symptoms  accompanying.  Occasionally 
other  drugs1  will  provoke,  in  certain  subjects,  a  variable  degree  of  der- 
matic inflammation,  among  which  may  be  mentioned  tincture  of  iodin, 
chrysarobin,  blue  ointment  and  other  mercurial  ointments,  tar  prepara- 
tions, and  pyrogallol.  The  symptoms  vary  with  these,  usually  being  of 
mild  character — erythematous,  erythematosquamous,  and  vesicular; 
pyrogallol  may  exceptionally  lead  to  superficial  destruction.  Hair- 
dyes  occasionally  furnish  interesting  cases  of  an  acute  and  subacute 
type,  often  extending  on  to  forehead,  face,  neck,  and  ears;  especially  a 
rather  common  proprietary  one  of  recent  years,  the  dermatitis  being 
apparently  due  to  paraphenylene  diamin.2 

The  dermatitis  observed  is  those  working  in  trades  is  usually,  when 
coming  under  observation,  of  distinctly  eczematous  nature ;  for  instance, 
the  so-called  bakers'  itch,  grocers'  itch,  the  irritation  seen  in  book- 
pasters,  polishers,  etc. ;  the  dermatitis  produced  by  some  of  these  factors 
may  occasionally  be  acute  in  type,  but,  as  a  rule,  it  is  gradual,  and  in  the 
latter  resulting  in  a  veritable  eczema.  This  subject  (occupation  der- 
matoses)  is  more  fully  referred  to  under  Eczema. 

The  cases  of  dermatitis  venenata  most  frequently  met  with  are, 
however,  those  in  which  the  action  has  been  due  to  exposure  to  the  rhus 
plants  (rhus  poisoning,  ivy  poisoning).  Some  persons  are  entirely 
immune;  some,  but  slightly  susceptible;  others,  quite  vulnerable,  while 
not  a  few  can  scarcely  go  near  the  plants  without  an  attack.  In  some 
instances  a  gradual  immunity  seems  to  be  established,  more  especially 
as  the  patient  grows  older,  but  this  is  rather  exceptional  than  the  rule. 
The  irritation  may  be  almost  immediate,  but  it  generally  follows  some 
hours  or  a  day  or  so  after  exposure.  The  hands,  forearms,  sometimes 
face,  and  not  infrequently  the  genitalia  and  anal  region,  are  favorite 
localities.  It  presents  either  an  erythematous  rash,  with  more  or  less 
swelling,  or  may  have  a  pronounced  erysipelatous  aspect;  sometimes 
the  affected  regions  are  studded  over  with  vesicles,  or  in  some  cases 
with  both  vesicles  and  bullae.  In  others  again  the  blebs  may  be  con- 
fluent and  the  integument  in  places  more  or  less  denuded,  and  presenting 
a  weeping  red  surface;  occasionally  there  is  also  pus-formation.  The 
first  parts  usually  attacked  are,  for  obvious  reasons,  the  hands  or  face, 
to  which  it  may  remain  limited,  or  other  regions  may  later  become  in- 
volved, either  as  the  effect  of  the  same  exposure  or  as  a  result  of  the  irri- 
tant being  conveyed  by  the  hands.  It  would  seem  possible,  too,  that 
the  irritant  might  be  conveyed  by  a  person  himself  immune  to  one  sus- 
ceptible. If  the  disease  is  caused  by  the  oily  constituent  of  the  plant 
known  as  toxicodendrol,  there  is  explanation  why,  in  the  early  part  of 
the  attack,  it  may  be  auto-inoculable,  and  also  be  even  conveyed  from  one 
person  to  another;  this  latter  accident  is,  however,  extremely  rare.  In 

1  Orthoform,  as  well  as  many  other  drugs,  commonly  thought  to  be  innocuous,  will 
occasionally  provoke  irritation  and  even  severe  dermatitis:  Dubreuilh,  "Des  Eruptions 
ortnoformiques,"  La  presse  medicde,  No.  40,  May  18,  1901  (with  bibliography). 

Mewborn,  Jour.  Amer.  Med.  Assoc.,  May  18,  1901 ;  Editorial,  ibid.,  Sept.  4,  1900: 
Cnipman,  California  Stale  Jour,  of  Med.,  Aug.,  1911;  Zeisler,  loc.  cit. 


DERMATITIS    VENENATA 


443 


extensive  and  markedly  inflammatory  cases  there  may  at  first  be  some 
constitutional  disturbance. 

The  dermatitis  produced  by  these  plants  usually  subsides  in  mild 
forms  in  the  course  of  several  days  to  a  week;  in  the  more  pronounced 
cases  it  may  last  for  several  weeks  to  a  few  months,  and,  as  already 
stated,  it  may  gradually  run  into  a  persistent  eczema.  A  spontaneous 
recurrence  of  the  irritation  for  several  successive  seasons  has  been  alleged, 
but  this  is  doubtless  due  to  the  fact  of  reexposure,  although  often  such 
patients  may  not  be  aware  of  it. 

Diagnosis — It  may  occasionally  be  difficult  to  reach,  at  first,  a 
positive  diagnosis  as  between  some  cases  of  dermatitis  venenata  and 
eczema.  A  history  of  the  onset,  occupation,  and  exposure  will  be  of  aid. 
Rhus  poisoning  frequently  begins  between  the  fingers,  is  usually  markedly 
acute  in  character,  with  a  good  deal  of  swelling,  with  often  large  vesicles 
and  blebs,  these  latter  being  rarely  seen  in  eczema;  in  fact,  the  acuteness, 
rather  violent  characters,  and  the  distribution  of  the  eruption,  together 
with  a  history  of  possible  exposure,  make  up  a  picture  ordinarily  con- 
clusive. 

Prognosis  and  Treatment.— The  prognosis  has  already  been  in 
part  referred  to.  The  various  types  of  dermatitis  usually  subside 
spontaneously  after  the  removal  of  the  cause,  requiring  more  or  less  time 
according  to  the  degree  of  inflammatory  action  present. 

Treatment  is  essentially  that  of  other  inflammatory  diseases  of  like 
clinical  character,  notably  that  of  eczema  of  the  acute  type.  Rhus 
poisoning  has  had  innumerable  remedies  brought  forward,  but  those 
advancing  them  fail  to  keep  in  view  the  natural  tendency  of  the  disease 
to  spontaneous,  and,  in  many  instances,  usually  rapid,  disappearance. 
In  fact,  many  slight  cases  will  get  rapidly  well  of  themselves,  many 
others  with  simple  applications;  others  are  more  rebellious  and  yield 
slowly.  The  essential  treatment  consists  in  the  employment  of  mild 
soothing  and  slightly  astringent  applications.  As  a  rule,  one  of  the  best 
plans  is,  as  in  acute  eczema,  the  conjoint  use  of  black  wash  with  an  equal 
part  of  lime-water,  followed  by  the  plain  zinc  oxid  ointment;  or  a  boric 
acid  lotion,  2  to  3  per  cent,  strength,  followed  by  the  zinc  ointment.  The 
calamin-zinc-oxid  lotion,  frequently  applied,  is  also  an  admirable  appli- 
cation; or,  better  still,  linen  cloths  kept  constantly  wet  with  it,  may  be 
continuously  applied.  Weak  alkaline  lotions  of  borax,  sodium  carbonate, 
or  ammonium  muriate,  of  the  strength  of  i  (0.065)  to  2  (o^s)  Or3  (°-2) 
grains  to  the  ounce  (32.),  are  useful,  especially  in  the  milder  erythema- 
tous  types.  Weak  solutions  of  sodium  hyposulphite,  i  to  10  grains 
(0.065-0.65)  to  the  ounce  (32.),  are  also  of  value.  A  lotion  of  the  fluid 
extract  of  grindelia  robusta,  i  to  2  drams  (4--8.)  to  about  4  ounces  (128.) 
of  water,  and  continuously  applied  (Duhring) ;  a  lotion  of  zinc  sulphate, 
\  to  2  grains  (0.033-0.13)  to  the  ounce  (32.),  with  2  to  5  grains  (0.13-0.33) 
of  carbolic  acid,  will  likewise  often  prove  useful.  The  larger  vesicles 
and  the  blebs  should  be  punctured  and  the  contents  pressed  out.  Once 
every  one  or  two  days  the  parts  should  be  gently  bathed  with  warm 
water,  tapped  dry,  and  the  treatment  immediately  resumed;  occasionally 
the  washing  can  be  done  with  a  weak  alkaline  lotion.  The  various  mild 


444 


INFLAMMA  TIONS 


ointments  may  also  be  employed,  either  alone,  or  preferably  conjointly 
with  a  lotion  as  already  suggested.  An  ointment  of  calamin,  i  dram 
(4.),  to  the  ounce  (32.)  of  zinc  ointment  is  often  effective. 

X-RAY  DERMATITIS 

Synonyms. — X-ray  burn;  Rontgen-ray  dermatitis  or  burn. 

The  "Rontgen  ray"  discovery  has  added  much  to  the  resources  of 
medicine,  especially  in  a  diagnostic  way,  and  to  some  extent  therapeu- 

tically,  but  as  now  known  it  is 
not  the  harmless  agent  it  was 
at  first  thought. 

Its  deleterious  effects  upon 
the  integument,  and  sometimes 
subcutaneous  tissues,  and  excep- 
tionally extending  to  the  bone, 
are  now  matters  of  record,  and 
have  led  to  its  more  careful 
employment,  although  in  spite 
of  all  precautions,  probably  from 
some  extreme  susceptibility  of 
the  skin  in  certain  subjects,  an 
occasional  case  of  cutaneous  in- 
jury still  continues  to  be  reported 
from  time  to  time. 

The  first  signs  of  cutaneous 
disturbance  sometimes  do  not 
present  for  several  days  or  longer 
after  exposure.  The  mildest 
phase  of  the  #-ray  action  is  a 
peculiar  reddish  flush  or  ery- 
thema, resembling  somewhat 
closely  sunburn,  and  which  in 
the  course  of  several  days  or  a 
few  weeks  gradually  disappears. 
In  other  instances  of  seemingly 
similar  mild  type  the  flush  con- 
tinues for  a  longer  period,  and 
not  infrequently  there  is  an  ex- 
tremely slight  feeling  of  local  dis- 


Fig.  108. — The  hand  of  an  #-ray  opera- 
tor, showing  the  atrophic  condition  of  the 
nails  and  skin;  the  latter  is  dry,  slightly 
scaly,  with  pigmentation,  thinning,  and 
wrinkling. 


comfort,  such  as  a  sensation  of 
warmth,  burning,  or  itching.  A 
continuance  of  exposures,  and 
occasionally  after  only  a  few  exposures,  this  flush  is  succeeded  by  a  varying 
number  of  brown  to  black  freckles,  and  a  slight  general  pigmentation  of 
the  skin.  These  conditions  may  persist  for  several  weeks,  and  in  extreme 
cases  much  longer;  exceptionally  an  insignificant  growth  of  down  and 
telangiectases  are  added.  On  the  other  hand,  accidental  exposure  of 
a  hairy  region  will  exceptionally,  even  though  of  comparatively  short 


X-RA  Y  DERMA  TITIS  445 

duration,  cause  falling  of  the  hair — followed,  sooner  or  later,  by  regrowth. 
In  other  cases  the  erythema  is  rapidly  succeeded  by  a  superficial,  ill- 
defined  vesiculation,  and  with  or  without  an  associated  trifling  swelling 
or  puffiness.  These  are  usually  much  more  persistent,  and  may  be 
attended  with  the  ordinary  subjective  symptoms  of  irritation.  In 
some  instances  a  slight  dry  branny  or  insignificant,  sometimes  lamellar, 
scaliness  or  exfoliation  follows  the  erythema,  appearing  several  days  or 
later,  or  first  showing  itself  as  the  redness  is  fading  away.  In  those 
whose  hands  are  constantly  exposed  to  the  ray,  as  with  those  making 
frequent  use  of  it  professionally,  a  mild  erythematosquamous  condition 
of  these  parts  not  infrequently  develops,  and  is  more  or  less  persistent, 
and  is  succeeded  by  variable  pigmentation,  wrinkling  and  other  atrophic 
changes  in  the  skin.  Brittleness  and  thinning  of  the  nails  are  also  often 
noted.  When  such  exposures  have  been  long  continued  these  changes 
persist  for  several  months  to  several  years,  or  more,  after  the  operator 
has  given  up  #-ray  work ;  in  fact,  in  some  instances  the  hands  never  fully 
recover  their  normal  condition,  and  in  a  few  cases  keratoses  are  super- 
added,  which  may  develop  into  carcinoma.1  The  possibility  of  these 
atrophic  changes  are  to  be  kept  in  mind  in  the  employment  of  x-ray 
treatment  for  the  benign  dermatoses,  such  as  acne,  for  in  a  few  instances 
a  thinning,  atrophic,  and  freckle,  or  other  pigmentary  and  old-age  changes 
(wrinkling,  atrophic  spots,  telangiectases,  etc.)2  have  been  noted.  Two 
such  cases  have  come  under  my  own  observation. 

A  far  more  serious  state  of  affairs  is  occasionally,  but  fortunately 
infrequently,  noted,  in  which  the  erythematous  flush,  sometimes  with 
subsequent  vesicular  development,  is  followed  by  a  dry,  leathery,  super- 
ficial or  deep  slough  or  ulcer.  The  ulcer  is,  as  a  rule,  shallow,  sluggish- 
looking,  with  a  slightly  or  moderately  hyperemic  or  inflammatory  border, 
and  covered  with  a  rather  adherent  grayish,  often  tough  and  leathery 
crust  or  membrane;  it  is  persistent,  with  but  little  if  any  tendency  to 
spontaneous  reparative  change,  and  the  accompanying  pain  is  often 
excruciating,  as  in  cases  observed  by  Orleman,3  Cassidy,4  and  others. 

Etiology  and  Pathology.— There  is  much  divergence  of  opinion 
as  to  the  exact  etiologic  factor  in  the  production  of  *-ray  burns.  Gil- 
christ5  and  others  have  suggested  that  it  might  be  due  to  the  entrance 
of  minute  particles  of  the  conducting  metal  used;  others  (Leonard,6 

1  Johnston,  Phila.  Med.  Jour.,  Feb.  i,  1902;  Macleod    (Brit.  Jour.  Derm.,  1906, 
p.  104),  reports  an  epithelioma  developing  on  an  *-ray  scar  in  a  case  of  lupus  vulgans; 
Bunch,  "  Z-Ray  Dermatitis  and  Epithelioma,"  Brit.  Jour.  Derm.,  1910,  P- 339,  reports 
a  somewhat  similar  case,  and  the  tendency  to  epitheliomatous  changes  m  the  keratoses 
consequent  upon  x-ray  dermatitis.     That  this  latter  may  be  finally  serious  is  evidenced 
by  several  or  more  reported  deaths.     A  late  example  of  this  was  Dr.  Kesabian,  a  well- 
known  radiographer,  of  Philadelphia,  epitheliomatous  changes  starting  in  the  nanc 
keratoses,  and  in  spite  of  hand  amputation,  finally  involving  the  axillary  glands,  am 
other  parts.  w 

2  Freund  and  Oppenheim,  "Uber  bleibende  Hautveranderungen  nach  Rontgen  Ver- 
strahlung,"  Wien.  kUn.  Wochenschr.,  1904,  No.  12. 

3  Orleman,  Wien.  med.  Wochenschr.,  1899,  No.  39. 

4  Cassidy,  Med.  Record,  Feb.  3,  1900  (with  illustrations). 

8  Gilchrist,  Johns  Hopkins  Hosp.  Bull.,  Feb.,  1897  (with  an  illustration  and  review 
of  published  cases,  with  bibliography). 

6  Leonard,  New  York  Med.  Jour.,  July  2,  1898. 


446  INFLAMMA  TIONS 

Oudin,  Barthelemy  and  Darier,1  and  others)  that  the  current,  and  not 
the  rays,  is  responsible;  the  latter  believing,  as  now  generally  accepted, 
that  too  short  a  distance  of  the  tube  and  a  current  of  high  intensity  are 
the  dangerous  factors.  Tuttle2  suggested  that  the  exposure  to  the 
tf-ray  generated  by  the  static  machine  was  apparently  not  productive 
of  injury,  but  this  is  refuted  by  Cassidy's  extreme  case  (loc.  tit.)  and 
probably  by  others.  The  light-ray  itself  does  not  seem  to  me  to  have 
been  given  full  consideration  as  the  possible  causative  or  influencing 
factor.  The  pathology  of  the  malady  is  not  clearly  understood,  although 
many  observers  berieve  that  the  cutaneous  disturbances  are  not  primary, 
ascribable  to  local  action  on  the  cells  of  the  derma,  but  that  they  are 
rather  of  a  trophoneurotic  nature,  due  to  neuritis;  and  this,  according  to 
Oudin,  Barthelemy,  and  Darier  (loc.  tit.),  is  not  a  peripheral  neuritis 
connected  with  the  dermic  nerve  terminals,  but  is  probably  at  first  central, 


Fig.  109. — X-ray  dermatitis  of  mild  degree,  showing  an  erythematosquamous  condi- 
tion, and  also  diffused  and  freckle-like  pigmentation  (case  of  acne — cured — skin  regained 
its  normal  state  in  several  weeks). 

during  the  period  which  might  be  called  that  of  the  incubation  of  the 
phenomena,  to  become  subsequently  centrifugal  and  to  manifest  itself 
by  distinct  alterations  of  nutrition.3  Behrend4  is  of  the  opinion  that 
the  integumentary  changes — scaliness,  vesiculation,  falling  of  the  nails 
and  hair — are  due  to  the  serous  exudation  induced  in  the  cutaneous 
tissue. 

Macleod,5  after  reviewing  the  investigations  of  others,  gives  the  fol- 

1  Oudin,  Barthelemy  and  Darier,  La  France  Medicale,  1898,  No.  12    (a  valuable 
conjoint  paper,  based  upon  its  use  in  400  cases,  detailing  the  various  accidents  and  dis- 
cussing the  pathology);    Zarubin,  Monatshefte,  1899,  vol.  xxviii,  p.  489,  also  gives  a 
valuable  resume  and  bibliography. 

2  Tuttle,  Soc's  Trans.,  Philada.  Med.  Jour.,  Feb.  26,  1898. 

3  Quoted  from  review  of  the  subject  in  Progressive  Medicine,  Sept.,  1899. 

4  Behrend,  Berlin,  klin.  Wochenschr.,  June  6,  1898. 

6  Macleod,  Brit.  Jour.  Derm.,  1903,  p.  365  (with  brief  review  and  reference  to  the 
works  of  Oudin,  Barthelemy  and  Darier,  Schiff,  Freund,  Doutrelepont,  Beck,  Fernet, 
Scholtz,  Skinner,  Norman  Walker  and  Gardiner,  and  others). 


X-RA  Y  DERMA  TITfS  447 

lowing  tentative  propositions  as  fairly  representative  of  the  present  state 
of  our  knowledge  of  the  subject:  (a)  That  the  *-rays  in  small  doses  have 
a  stimulating  effect  on  the  elements  of  the  healthy  skin;  (6)  that  in  large 


Fig.  no. — X-ray  dermatitis  of  considerable  severity;  shows  the  importance  of  protect- 
ing the  lips  in  sensitive  subjects,  or  when  the  exposure  is  somewhat  prolonged. 

doses,  by  long  exposures,  close  proximity  of  the  tube  to  the  skin,  or  the 
employment  of  soft  tubes,  the  rays  are  capable  of  devitalizing  the  tissue 
elements,  interfering  with  the  process  of  reproduction,  and  causing  their 


Fig.  in. — Atrophic  spots,  somewhat  depressed,  coarseness  of  the  skin,  pigmenta- 
tion, and  telangiectases,  developing  several  months  after  x-r&y  exposures  had  been 
discontinued;  there  was  also  considerable  "old-age  wrinkling,"  but  this  has  largely 
disappeared. 

degeneration;  and  that  this  power  is  the  result  of  a  direct  specific  action 
of  the  rays;  (c)  that  the  more  highly  differentiated  structures,  such  as 
the  hair-follicles,  glands,  nails,  and  blood-vessels,  are  more  readily  and 
severely  affected  by  the  rays  than  the  less-differentiated  epidermal  cells 


448  INFLAMMA  TIOA'S 

or  the  fibrous  stroma  of  the  corium;  (</)  that  pathologically  altered  cells, 
whether  of  epiblastic  or  mesoblastic  origin,  are  far  less  resistant  to  the 
rays  than  healthy  cells,  and  are  devitalized  with  small  doses  of  the  rays, 
and  that  this  destructive  action  on  diseased  elements  may  be  taking 
place  while  the  healthy  elements  in  the  neighborhood,  instead  of  having 
their  vitality  inhibited,  may  be  stimulated  to  a  process  of  repair;  (e)  that 
the  action  of  the  rays  is  cumulative,  and  that  when  the  cellular  degenera- 
tion reaches  a  certain  degree  the  toxic  products  of  the  breaking-down 
cells  are  capable  of  setting  up  an  inflammatory  reaction,  which  is  a 
secondary  phenomenon;  (/)  that  this  inflammatory  reaction  is  peculiar 
in  that  it  occurs  in  a  tissue  the  vitality  of  whose  various  elements  has 
already  been  impaired  by  the  action  of  the  rays,  and  in  that  it  is  associated 
with  greater  destructive  changes  than  those  produced  by  the  actinic 
rays,  and  is  apt  to  lead  to  ulceration  and  necrosis,  and  is  liable  to  be 
followed  by  an  imperfect  process  of  repair.  Wolbach1  ascribes  this 
failure  of  repair  very  largely  to  the  degenerative  changes  set  up  in  the 
blood-vessels. 

Treatment. — The  best  treatment  of  #-ray  burns  is,  so  to  speak, 
their  prevention.  The  dangers  of  too  long  and  too  frequent  exposure, 
too  close  proximity,  and  a  high-current  intensity  are,  so  far  as  possible, 
to  be  avoided.  Leonard,  Oudin,  Barthelemy  and  Darier,  and  others 
have  advised  the  interposition  of  grounded  thin  or  perforated  sheets  of 
conducting  material,  which  permits  penetration  of  the  rays,  but  such 
a  plan  has  not  been  generally  followed.  In  the  "raying"  or  treatment 
of  limited  areas  it  is,  however,  advisable  to  protect  the  surrounding  parts 
by  a  thin  sheet  of  lead.  The  mild  and  moderate  forms  of  x-ray  derma- 
titis require  the  ordinary  palliative  applications  employed  in  the  acute 
types  of  eczema  (q.  i>.)  and  in  dermatitis  from  other  causes.  Soothing 
applications  are  usually  sufficient  to  bring  the  irritation  to  a  more  rapid 
disappearance.  The  x-ray  ulcers  in  most  instances  are  obstinate,  and 
the  most  satisfactory  plan  in  refractory  cases  is  to  curet  and,  if  necessary, 
skin-graft.  In  such  patients,  where  operation,  for  the  time  at  least,  is 
not  feasible,  the  local  applications  are  to  be  the  mildest  possible;  oint- 
ments containing  cocain,  opiates,  menthol,  acetanilid,  for  the  control  of 
the  intense  pain,  are  to  be  variously  tried.  In  a  case  under  my  own  care 
at  the  Howard  Hospital  almost  all  applications  intensified  the  painful- 
ness,  and  the  only  ointment  giving  relief  was  one  containing  i  or  2  drams 
(4.-8.)  of  orthoform  to  the  ounce  (32.).  No  progress  was  made  in  this 
case  toward  healing,  and  a  year  or  so  later  the  area  was  curetted  and  skin 
grafted  by  my  colleague,  Dr.  C.  H.  Frazier,  and  recovery  finally  resulted. 

DERMATITIS  FACTITIA 

Synonym. — Feigned  eruptions;  Dermatitis  artefacta. 

By  this  term  is  meant  an  eruption  of  artificial  origin,  usually  limited 
in  extent,  and  purposely  produced  with  the  object  of  gaining  sympathy 
or  for  malingering,  and  of  which  many  cases  are  now  on  record  (Startin, 

1  Wolbach,  "Pathologic  Histology  of  Chronic  *-Ray  Dermatitis  and  Early  *-Ray 
Carcinoma,"  Jour.  Med.  Research,  Oct.,  1909. 


DERMATITIS  FACTITIA 


449 


Fagge,  Lavgier,  Mattel,  Mackintosh,  Van  Harlingen,  Colcott  Fox,  and 
others).1 

Symptoms — The  lesions  may  be  of  an  erythematous,  vesicular, 
bullous,  or  ulcerative  nature.  They  are  rarely  numerous,  as  a  rule, 
one  or  several  patches  being  present.  The  individual  spots  are  usually 
small,  but  exceptionally  may  cover  considerable  area.  The  most  com- 
mon lesion  met  with  is  probably  the  small  erythematous  area,  with  slight 
crusting,  usually  somewhat  longer  than  wide,  and  at  times  distinctly 
linear,  resulting  from  persistent  friction,  as  in  a  case  of  my  own,2  or  from 
the  application  of  some  mild  irritant.  Blebs  are  also  not  an  uncommon 
manifestation.  Occasionally  the  lesions  are  shallow  ulcers.  In  fact, 


Fig.  112. — Dermatitis  factitia — note  the  unusually  uniform  and  regular  character  and 
arrangement  of  the  lesions. 

almost  all  varieties  of  dermatic  lesions  may  be  produced  by  the  ordi- 
nary means  at  hand,  such  as  acids,  strong  alkalies,  and  other  chem- 
icals, heat,  friction,  or  other  traumatic  agencies.  Carbolic  acid  is  fre- 
quently employed,  and  is,  as  with  other  caustics,  apt  to  give  rise  to 
patches  with  somewhat  irregular  edges,  due  to  careless  or  unskilful  ap- 
plication. The  lesions,  for  obvious  reasons,  make  their  appearance  sud- 

1  Van  Harlingen  and  Stout,  Morrow's  System,  vol.  iii  (Dermatology),  p.  364,  give  a 
brief  but  good  resume  with  some  references;  consult  also  Lavgier,  "Maladies  simu- 
lees,"  Diet,  de  Med.  et  de  Chir.  Pratiques;  Rasch,  Dermal.  Centralblatt,  Aug.,  1899,  p. 
322,  relates  a  case  of  vesicobullous  and  gangrenous  character  and  refers  to  several  others; 
F.  J.  Shepherd  (4  cases),  Jour.  Cutan.  Dis.,  1807,  p.  544;  ibid.,  1906,  p.  164.     For  other 
literature  bearing  upon  the  subject,  see  under  "Multiple  Gangrene  of  the  Skin  in 
Adults." 

2  Stelwagon,  Arch.  Derm.,  1882,  p.  236. 

29 


450  INFLAMMA  TIONS 

denly,  and  apparently  during  the  night  or  at  other  time  when  the  patient 
is  unlikely  to  be  seen  or  disturbed.  They  are,  moreover,  usually  seated 
on  parts  readily  reached  by  the  hands— not  infrequently  are  on  the  one 
side  of  the  body.1  The  most  common  sites  are  the  anterior  or  lateral 
aspects  of  the  legs  and  arms;  occasionally  the  face  and  the  trunk. 

The  lesions  are  scarcely  gone  before  new  ones  make  their  appearance 
suddenly  near  by  or  elsewhere  upon  the  surface;  or  the  original  spot  or 
patches  may  be  kept  purposely  in  a  constant  state  of  irritation.  Thus 
the  affair  may  continue  almost  indefinitely  until  the  patient  is  weary  of 
the  annoyance  or  the  special  object  desired  is  attained  or  despaired 
of.  They  have  an  artificial  look,  are  usually  sharply  defined,  and  do 
not  correspond  to  either  the  appearance  or  distribution  of  ordinary 
cutaneous  diseases.  Doubtless  some  of  the  cases  of  superficial  gangrene 
(erythema  gangraenosum,  dermatitis  gangraenosa,  neurotic  excoriations) 
have  their  origin  in  such  manner.  The  subjects  of  these  various  mani- 
festations are,  for  the  most  part,  hysteric  women,  but  they  are  also  met 
with,  for  the  purpose  of  malingering,  in  criminals  and  mendicants,  in 
soldiers,  sailors,  and  others  desiring  to  be  relieved  of  work  or  their  duties. 
Towle,  Fernet,  and  a  few  others  suggest  the  possibility  that  in  some  of 
the  cases  in  hysteric  women  the  subjects  may  not  be  actually  aware 
of  their  own  instrumentality  in  the  production  of  the  lesions,  the  act 
having  been  done  while  in  a  pseudohypnotic  or  somnambulistic  state. 

The  diagnosis  is  sometimes  fraught  with  difficulty,  but  attention  to 
the  features,  behavior,  and  persistence  and  repetition  of  the  eruption 
will  usually  arouse  suspicion,  and  the  patient  can  be  kept  under  secret 
surveillance.  An  irregular  outline  and  the  presence  of  staining  at  the 
borders  from  the  chemical  used  are  suggestive.  A  fixed  dressing  to  the 
parts  involved  will  result  in  prompt  cure,  and  if  new  lesions  appear,  they 
will,  of  necessity,  be  on  other  situations.  Too  often,  unfortunately,  a 
statement  of  the  correct  diagnosis  to  the  family  of  the  patient  will  be 
received  not  only  with  incredulity,  but  often  with  dismissal. 

Treatment  of  the  lesions  depends  upon  their  characters  and  is  essen- 
tially that  of  the  forms  of  dermatitis  to  which  they  may  belong. 

1  Parts  not  accessible  by  the  hands  are,  however,  occasionally  the  seat  of  the 
lesions  also,  the  acid  being  conveyed  by  a  stick  with  a  cotton  or  rag  swab  on  the  end — 
as  in  the  case  recorded  by  Menage  ("  An  Interesting  Neuro-dermatological  Case ") , 
New  Orleans  Med.  and  Surg.  Jour.,  Dec.,  1910.  The  cunning  and  deception  practised 
by  these  patients  are  almost  beyond  belief,  as  shown  in  Parkes  Weber's  case  (Brit. 
Jour.  Derm.,  1912,  p.  78;  nineteen  months'  duration:  Woman  aged  thirty-seven, 
had  a  chronic  bullous  eczema-like  eruption  with  superficial  ulceration  on  the  front 
of  the  abdomen;  a  starched  bandage  was  applied,  but  this  became  loosened  and 
probably  (by  deflating  the  abdomen)  the  patient  was  able  to  introduce  her  hand  under 
the  upper  anterior  portion;  when  bandage  was  removed  bullae  were  found  over  the  cor- 
responding portion;  dark  specks  were  also  found  in  the  raised  epidermis  over  some  of 
the  bullae,  which  on  microscopic  examination  proved  to  be  powdered  cantharides. 
In  connection  with  this  case  Weber  referred  to  a  case  described  by  Hirsch  (at  a  meeting 
of  Gynecologic  Society  of  Munich),  of  a  woman  who  within  two  years  had  had  several 
abdominal  operations,  and  who  later  being  treated  by  *-rays,  developed  ulcers  which 
gradually  spread  over  her  whole  abdomen;  it  was  subsequently  discovered  that  these 
spurious  *-ray  ulcers  were  self-inflicted  by  means  of  hydrochloric  acid. 


DERMATITIS  MEDICAMENTOSA  45  l 

DERMATITIS  MEDICAMENTOSA1 

Synonyms—  Medicinal  eruptions;  Drug  eruptions;  Fr.,  Eruptions  medicamen- 
teuses;  Lrer.,  Arznei-exantheme. 

Definition.— Dermatitis  medicamentosa  is  a  term  used  to  desig- 
nate all  those  congestive,  inflammatory,  and  other  conditions  of  the  skin 
due  to  the  ingestion  or  absorption  of  drugs. 

It  might  well  be  considered  also  to  include  those  cases  of  dermatitis 
due  to  their  external  application,  but  the  disturbance  called  forth  by 
this  latter  use  of  them  is  due  to  their  direct  irritant  properties,  and 
should  therefore,  I  believe,  be  classed  under  the  head  of  dermatitis 
venenata. 

Symptoms.— The  symptomatology  of  drug  eruptions  is  essentially 
the  symptomatology  of  the  various  erythematous,  exudative,  and  in- 
flammatory diseases.  Thus  all  the  various  skin-lesions  are  encountered 
in  different  cases,  such  as  erythema,  papules,  vesicles,  pustules,  tubercles, 
blebs,  purpura,  and  even  gangrene.  The  carbuncular  or  anthracoid 
eruption  and  papillomatous  nodules  or  plaques  produced  by  iodin  and 
bromin  compounds  are,  however,  somewhat  peculiar,  and  will  be  referred 
to  later  when  discussing  each  drug.  In  most  instances  there  is  more  or 
less  uniformity  in  the  type  of  lesion  in  the  same  individual  from  a  par- 
ticular drug,  but  not  infrequently  an  eruption  of  a  mixed  type  may  result, 
such  as,  for  example,  the  various  symptoms  of  erythema  multiforme. 

Medicinal  eruptions  are  apt  to  make  their  appearance  somewhat 
suddenly,  after  one  or  two  doses,  or  with  some  drugs  only  after  con- 
tinued use.  They  are  usually  highly  colored.  Upon  withdrawal  of  the 
drug  they,  with  but  few  exceptions,  as  rapidly  disappear.  Sometimes, 
however,  the  eruptive  phenomena  may  continue  for  some  time  after 
the  drug  has  been  stopped,  as  has  occasionally  been  observed  with 
bromids,  and  less  frequently  with  the  iodids,  especially  in  children.  And 
in  exceptional  instances  it  has  been  noted  that  the  first  appearance  of 
the  rash  has  not  presented  until  the  drug  had  been  withdrawn.  Excep- 
tionally, too,  the  eruption  produced  may  go  through  the  various  stages 
of  the  idiopathic  malady  which  it  simulates.  In  generalized  eruptions, 

1  General  literature:  Behrend,  "Zur  allg.  Diagnostik  der  Arzneiausschlage,"  Berlin, 
klin.  Wochenschr.,  1879,  P-  TH;  Van  Harlingen,  "Medicinal  Eruptions,"  Arch.  Derm., 
1880,  p.  337;  Morrow's  Drug  Eruptions,  1887,  and  the  same  publication  with  addi- 
tional notes  and  references  by  Colcott  Fox,  in  Selected  Monograph  on  Dermatology, 
Sydenham  Soc'y  publication,  1893;  Brooke  "On  Behrend's  Division  of  Drug  Rashes 
Into  Specific  and  Dynamic  Groups,"  Brit.  Jour.  Derm.,  1890,  p.  313;  Colcott  Fox, 
"Contribution  to  the  Study  of  Drug  Eruptions"  (especially  bearing  upon  the  question 
of  placing  eruptions  due  to  external  action  of  certain  drugs  in  the  same  category  with 
the  universal  eruptions  following  internal  use),  ibid.,  p.  327;  Stowers,  "Drug  Eruptions 
—Their  Nature  and  Varieties,"  ibid.,  1898,  p.  289  (with  discussions  thereon  by  Payne, 
Galloway,  Crocker,  and  others,  adding  personal  observations);  Caspary,  "Zur  Lehre 
von  der  Arznei-exanthemen,"  Archiv,  1894,  vol.  xxvi,  p.  n;  Jadassohn,  "Zur  Kennt- 
niss  den  medicamentosen  Dermatosen,"  Verhandl.  der  Deutschen  dermatohg.  Gcsell- 
schafl,  V.  Congress,  1895;  Hudson,  "Some  Cases  of  Drug  Eruptions,"  Atlanta  Med. 
and  Surg.  Jour.,  April,  1898;  Ryall,  "Dermatitis  Medicamentosa,"  Med.  Record,  Dec. 
24,  1894.  These  several  papers,  especially  those  of  Van  Harlingen,  Morrow,  and 
Colcott  Fox,  are  replete  with  references  and  refer  to  cases  to  date.  Fernet,  "Drug 
Eruptions,"  Brit.  Med.  Jour.,  May  16,  1903;  G.  G.  Campbell,  "Drug  Eruptions," 
Vermont  Med.  Monthly,  Oct.,  1907. 


INFLAMMATIONS 

especially  of  the  erythematous,  morbilliform,  and  scarlatiniform  types, 
there  may  be  a  variable  degree  of  constitutional  disturbance. 

Etiology. — In  the  large  majority  of  cases  the  eruption  called  forth 
is  due  to  some  peculiar  idiosyncrasy  of  the  individual  to  that  particular 
drug,  and  while  the  same  drug  produces  most  frequently,  as  a  general 
rule,  the  same  type  of  eruption  in  other  susceptible  individuals,  this  is 
by  no  means  always  the  case.  On  the  other  hand,  certain  few  drugs, 
such,  for  example,  as  the  iodids  and  bromids,  give  rise  so  often  to  pus- 
tular or  acne-like  lesions  that  such  effect  may  really  be  considered  its 
normal  or  physiologic  action.  Many  of  the  more  severe  types  of  medic- 
inal eruption  are  due  to  the  fact  that  the  medicine  is  continued  after 
the  milder  manifestation  has  shown  itself  or  has  been  administered  in 
large  dosage;  on  the  other  hand,  occasionally  profound  cutaneous  dis- 
turbance results  from  an  exceedingly  small  quantity. 

Women  and  children  seem  to  present  drug  idiosyncrasy  most  fre- 
quently, and  those  of  light  complexion  more  commonly  than  brunettes. 
Probably,  too,  those  of  a  weakened  state  of  health  and  a  neurotic 
temperament  are  more  susceptible  than  others.  Defective  kidney  elimi- 
nation is  certainly  a  factor  of  importance.  While  this  peculiar  idiosyn- 
crasy to  a  drug  usually  persists,  it  may  in  some  persons  entirely  disap- 
pear; and  in  others  small  initial  doses  with  a  very  gradual  increase  will 
sometimes  prevent  the  manifestation. 

As  illustrating  an  extreme  of  drug  idiosyncrasy,  I  have  had  under 
my  observation1  a  man  who,  upon  taking  an  ordinary  dose  of  quinin, 
was  attacked  with  an  erythematous  scarlatinoid  eruption,  of  itchy  char- 
acter, with  some  exudation,  and  which  took  several  weeks  to  run  through 
its  course,  ending  with  desquamation.  Several  years  subsequently  he 
went  into  a  drug  store  and  took  a  "calisaya  soda-water  tonic,"  with  the 
same  eruption  as  a  result.  A  few  years  later  his  family  physician  gave 
him  some  pills,  each  containing,  among  other  ingredients,  y^g-grain  dose 
of  quinin,  of  which  he  took  only  three,  with  the  development  and  course 
of  the  cutaneous  outbreak  as  before. 

Pathology. — How  are  drug  eruptions  produced?  This  is  an  in- 
teresting question,  and  as  yet  not  conclusively  settled.  Three  principal 
theories  of  their  action  have  been  advanced:  (i)  That  of  skin  elimination, 
the  drug  acting  as  an  irritant  as  it  passes  through  the  cutaneous  tissues 
or  glands;  (2)  increased  skin  elimination  due  to  defective  condition  of 
the  ordinary  eliminative  organs,  more  particularly  the  kidneys;  (3)  the 
neurotic  theory.  The  first  seems  plausible,  but  it  is  lacking  in  proof; 
in  fact,  while  it  may  seemingly  be  true  with  a  few  drugs,  the  weight  of 
investigations  made  proves  it,  upon  the  whole,  untenable.  In  its  support 
it  is  claimed  (Adamkiewitz,  Guttmann,  Giovannini)  that  the  drug — 
investigations  with  the  iodin  and  bromin  preparations — was  found  in 
the  sebaceous  glands.  This,  however,  as  Jarisch  remarks,  proves  nothing 
unless  found  in  greater  relative  quantity  than  in  other  tissues.  These 
findings,  however,  have  been  negatived  by  investigations  in  the  same 
direction  (Pellizzari,  Ducrez,  Veiel),  and  also  by  the  histologic  examina- 

1  Stelwagon,  "An  Extraordinary  Case  of  Quinin  Susceptibility,"  Jour.  Culan.  Dis., 
1902,  p.  13. 


DERMATITIS  MEDICAMENTOSA  453 

tions  (Thin,  De  Amicis,  Colcott  Fox,  Harris,  and  others),  which  show 
the  first  changes  to  be  in  the  papillary  layer,  and  not  necessarily,  except 
secondarily,  in  or  about  the  glands.  The  view  (Behrend)  that  the  pres- 
ence of  the  drug  generates  some  toxin  or  irritant  material  in  the  blood 
to  which  the  eruptive  phenomena  are  due  has  gained  no  support,  but 
Engman  and  Mook's1  investigation,  while  not  directly  in  support  of  this, 
yet  are  somewhat  confirmatory  of  such  a  hypothesis.  These  investi- 
gations show  that  in  ioderma  and  bromoderma  the  drug  circulates  in 
the  body  tissues  and  which  under  certain  conditions  acts  as  a  toxin  caus- 
ing at  points  of  past  or  present  local  disturbance  (such  as  comedones, 
acne  lesions,  seborrheic  lesions,  scars,  traumata,  scratches,  etc.)  all  the 
symptoms  of  an  inflammation,  this  inflammation  not  differing  essentially 
from  that  produced  by  other  toxic  agents ;  the  process  consisting  primarily 
of  inflammatory  changes  about  the  vessels.  As  to  the  second  view,  it  is 
known,  it  is  true,  that  the  worst  forms  of  the  iodid  eruption — carbuncular 
(anthracoid) ,  bullous,  nodular  lesions — are  seen  commonly  in  those  with 
heart  and  kidney  disease;  but  beyond  this  scanty  knowledge  as  to  the 
possible  causative  influence  of  defective  renal  elimination,  there  is  no 
clinical  evidence  in  its  favor.  The  neurotic  theory  (Morrow),  while 
somewhat  difficult  of  explanation,  still  has  had  considerable  support;  the 
action  being  either  purely  reflex,  analogous  to  urticaria  ab  ingestis,  or 
due  to  the  influence  of  the  drug  upon  the  vasomotor  centers  or  on  the 
peripheral  nerves. 

Diagnosis. — The  diagnosis  of  medicinal  eruptions  is  sometimes 
difficult,  but  the  suddenness  of  an  outbreak  should  always  excite  sus- 
picion and  inquiry  be  made.  Particularly  is  this  so  with  eruptions  of  the( 
nature  of  an  exanthem.  I  have  little  doubt  that  many  of  the  so-called 
second  attacks  of  the  various  exanthemata  have  been  instances  of  drug 
rashes.  Medicinal  eruptions  seem  often  more  violent  in  character  than 
the  eruptions  they  simulate.  As  a  rule,  except  in  some  of  the  cases  of 
generalized  erythematous  rashes,  the  constitutional  symptoms  are 
rarely  marked  in  dermatitis  medicamentosa,  and  are  not  infrequently 
wanting.  The  withdrawal  of  any  suspected  drug  and  one  or  two  days' 
observation  will  generally  clear  up  the  matter. 

Treatment. — A  medicinal  eruption  is  usually  to  be  treated  ex- 
ternally in  the  same  way  as  the  eruption  which  it  may  simulate.  The 
carbuncular  or  anthracoid  lesions  do  not  need,  as  a  rule,  any  operative 
interference;  soothing  applications  are  generally  sufficient.  With- 
drawal of  the  drug  is  the  first  step,  and  frequently,  in  the  milder  cases 
at  least,  nothing  else  is  required.  In  others  alkaline  diuretics  and  free 
drinking  of  water  should  be  prescribed.  In  graver  cases  supporting 
treatment  is  required. 

With  certain  drugs,  as,  for  instance,  the  iodid  and  bromids,  the 
coadministration  of  Fowler's  solution  (Crocker  and  others),  potassium 

1  Engman  and  Mook,  "A  Contribution  to  the  Histopathology  and  the  Theory  of 
Drug  Eruption,"  Jour.  Cut  an.  Dis.,  1906,  p.  502,  with  histologic  cuts  (study  based  upon 
iodin  and  bromin  eruptions);  Pasini,  Annalcs,  1906,  p.  i,  has  contributed  an  interesting 
original  paper  on  the  pathogeny  of  bromid  eruptions;  found  by  a  special  test  bromin  in 
the  lesions,  but  in  combination  with  the  albumin  of  the  tissues,  from  which  ordinary 
tests  could  not  separate  it. 


454 


INFLAMMA  TIONS 


bitartrate,  and  the  maintenance  of  intestinal  antisepsis  (Fere,  Eche- 
verria,  Gowers,  Duhring)  have  seemed  at  times  to  have  an  inhibitory 
action,  more  especially  with  the  pustular  eruptions  produced  by 
these  drugs.  In  fact  it  is  probable  the  administration  of  a  diuretic 
along  with  the  drug  would,  in  some  instances  at  least,  exercise  a 
preventive  influence.  Briquet  and  Lyon's1  observations  show  that 
the  sodium  iodid  gives  rise  less  frequently  than  the  potassium  salt 
to  cutaneous  manifestations,  and  my  own  experience  is  in  accord 
with  this. 

The  subject  of  dermatitis  medicamentosa  is  of  sufficient  importance 
to  warrant  a  summary  of  the  eruptive  types  provoked  by  different  drugs 
and  a  brief  consideration  of  the  possible  eruptions  which  each  individual 
drug  may  produce. 

The  following  is  the  summary  of  the  forms  of  eruption  which  may 
follow  ingestion  or  absorption.  Many  of  these  drugs  are  capable  of 
giving  rise  to  several  types  in  different  individuals  or  even  in  the  same 
individual;  many  are  only  rarely  causative;  others,  such,  for  example, 
as  the  bromids,  iodids,  quinin,  copaiba,  coal-tar  derivatives,  and  others, 
are  somewhat  frequently  etiologic.  To  a  certain  extent  the  dividing- 
line  between  some  of  the  types  here  given  is  purely  arbitrary  and  some- 
what ill-defined;  for  example,  erythematopapular  and  polymorphous 
are  closely  similar,  but  in  the  latter  are  placed  those  more  particularly 
simulative  of  erythema  multiforme.  Doubtless  many  more  drugs  will 
eventually  be  included  in  this  list. 

Bullous. — Aconite,  anacardium,  antipyrin,  boric  acid,  chloral,  bro- 
min,  copaiba,  quinin  compounds,  copaiba  and  cubebs,  copaiba,  iodin 
compounds,  iodoform,  mercury,  opium  (?),  phosphoric  acid,  and  sali- 
cylates. 

Carbuncular  (Anthracoid). — Arsenic,  chloral,  iodin  and  bromin  com- 
pounds, and  opium. 

Cyanotic. — Acetanilid,  potassium  chlorate. 

Edematous. — Aspirin,  usually  about  head;  salipyrin  and  santonin. 

Eczematous. — Boric  acid,  belladonna,  carbolic  acid,  opium  and  mor- 
phine, sodium  borate. 

Erysipelatous. — Arsenic,  belladonna,  conium,  digitalis,  ipecac,  quinin, 
and  stramonium. 

Erythematous. — Acetanilid,  antipyrin,  arsenic,  alcohol,  antitoxin, 
aspirin,  belladonna,  benzoic  acid,  boric  acid,  bromin  compounds,  cap- 
sicum, carbolic  acid,  chinolin,  chloral,  chloralamid,  cantharides,  chloro- 
form, castor  oil,  conium,  copaiba,  copaiba  and  cubebs,  cubebs,  dulca- 
mara, exalgin,  iodin  compounds,  iodoform,  guaiacum,  gurjun  oil,  hydro- 
cyanic acid,  hyoscyamus,  lead  acetate,  mercury,  opium,  pilocarpin, 
piper  methysticum,  phenacetin,  phosphoric  acid,  potassium  chlorate, 
quinin,  salicylates,  sodium  benzoate,  santonin,  sodium  borate,  stra- 
monium, sulphonal,  tannic  acid,  tar,  oil  of  turpentine,  tuberculin,  vera- 
trum  viride,  and  veronal. 

1  Lyon,  "L'lodisme,"  Gazelle  des  Hdpitaux,  July  8,  1899— a  full  abstract  in  Jour. 
mal.  cutan.,  1899,  p.  556. 


DERMATITIS  MEDICAMENTOSA 


455 


^  Erythematopapular.— Acetanilid,  antipyrin,  benzoic  acid,  copaiba 
digitalis,  gurjun  oil,  iodin  compounds,  iodoform,  phenacetin,  silver 
nitrate,  and  potassium  chlorate. 

Epitheliomatous.— Arsenic   (secondarily  to  keratoses). 
Furuncular.— Antipyrin,  arsenic,  bromin  compounds,  calx  sulphu- 
rata,  chloral,  condurango,  ergot,  mercury,  and  opiates. 

Gangrenous.  —  Arsenic, 
belladonna,  ergot,  iodin 
compounds,  quinin,  salicy- 
lates. 

Herpetic. — Arsenic,   bel- 
ladonna, iodin    compounds, 
mercury,  and  salicylates. 
Keratotic. — Arsenic. 
Morbilliform.  —  Antipy- 
rin,   antitoxin,    belladonna, 
copaiba  and  cubebs,   boric 
acid,  opium,  sodium  borate, 
sulphonal,    tar,    turpentine, 
tuberculin,  and  veronal. 

Nodular.  —  Iodin  and 
bromin  compounds. 

Papillomatous.  --  Iodin 
and  bromin  compounds. 

Papular. — Arsenic,  boric 
acid,  bromin  compounds, 
cantharides,  chloral,  conium, 
copaiba  and  cubebs,  cubebs, 
digitalis,  iodin  compounds, 
jaborandi,  oil  of  turpentine, 
mercury,  terebene,  and 
opium. 

Papulovesicular.  —  Cap- 
sicum. 

Pigmentary.  —  Arsenic, 
silver  nitrate,  and  antipyrin. 

Pruritus  (Without  Eruption). — Opium,  chloral,  copaiba,  strychnin. 
Purpuric  (Including  Petechial). — Antipyrin,  antitoxin,  arsenic,  ben- 
zoic acid,  calx  sulphurata,  chloral,  chloroform,  copaiba,  copaiba  and 
cubebs,  ergot,  hyoscyamus,  iodoform,  iodin  compounds,  lead  acetate, 
mercury,  phosphoric  acid,  potassium  chlorate,  oil  of  sandalwood,  quinin, 
salicylates,  stramonium,  and  sulphonal. 

Polymorphous  (Resembling  Erythema  Multiforme). — Antipyrin, 
antitoxin,  sodium  benzoate,  copaiba  and  cubebs,  i6din  compounds, 
iodoform,  boric  acid,  chloral,  exalgin,  coal-tar  derivatives,  opium,  potas- 
sium chlorate. 

Psoriasiform. — Sodium  borate  and  tuberculin. 

Pustular. — Aconite,  antipyrin,  arsenic,  bromin  compounds,  calx 
sulphurata,  condurango,  antimony,  hyoscyamus,  iodin  compounds, 


Fig.  113. — Dermatitis  medicamentosa  of  pus- 
tulobullous  type,  following  ingestion  of  potassium 
iodid.  Principally  upon  the  face,  with  some  pus- 
tular lesions  on  the  neck  and  shoulders.  Sub- 
sided upon  withdrawal  of  the  drug,  and  brought 
out  again  by  experimental  readministration. 


456  INFLAMMATIONS 

ergot,  mercury,  nitric  acid,  cod-liver  oil,  opium,  tanacetum,  oil  of  tur- 
pentine, salicylates,  and  veratrum  viride. 

Papulopustular. — Bromin  and  iodin  compounds. 

Scarlatiniform. — Antipyrin,  antitoxin,  belladonna,  chloral,  copaiba 
and  cubebs,  copaiba,  digitalis,  hyoscyamus,  mercury,  mix  vomica, 
opiates,  oil  of  turpentine,  pilocarpin,  rhubarb,  quinin,  strychnin,  sul- 
phonal,  salicylates,  stramonium,  tuberculin,  viburnum  prunifolium,  and 
veronal. 

Ulcerative. — Arsenic  (secondarily  to  keratoses),  bromin  compounds, 
chloral,  iodin  compounds,  and  mercury. 

Urticarial. — Alcohol,  antimony,  anacardium,  antipyrin,  antitoxin, 
arsenic,  bromin  compounds,  benzoic  acid,  chloral,  copaiba,  copaiba 
and  cubebs,  digitalis,  dulcamara,  hydrocyanic  acid,  guarana,  hyoscya- 
mus, iodin  compounds,  opium,  mercury,  pilocarpin,  phenacetin,  pimpin- 
ella,  quinin,  salicylates,  salol,  santoninum,  oil  of  turpentine,  sodium  ben- 
zoate,  tannin,  tar,  and  valerian. 

Vesicopustular. — Antimony,  antipyrin. 

Vesicular. — Aconite,  anacardium,  antimony,  antipyrin,  arsenic, 
bromin  compounds,  cannabis  indica,  calx  sulphurata,  chloral,  copaiba 
and  cubebs,  copaiba,  cod-liver  oil,  ergot,  iodin  compounds,  iodoform, 
nux  vomica,  oil  of  turpentine,  opium,  quinin,  salicylates,  and  sodium 
santonate;  veronal,  and  other  drug  erythematous  and  erythematopapular 
erruptions  sometimes  present  some  associated  vesiculation,  especially 
on  the  extremities. 

Hair  Loss. — Boric  acid  and  thallium  acetate. 

A  study  of  the  literature  of  the  various  drug  eruptions,  together 
with  personal  observation  of  many  cases,  gives  the  following  data, 
briefly  stated: 

Aconite. — Not  common ;  usually  vesicular,  exceptionally  bullous,  and 
pustular. 

Acetanilid. — Occasional;  erythematous,  and  erythematopapular;  not 
infrequently  cyanosis,  especially  of  lips,  face,  and  extremities. 

Alcohol. — Rare;  erythematous,  and  urticarial,  of  generalized  dis- 
tribution. 

Anacardium. — Rare;  urticarial,  vesicular,  and  bullous. 

Antimony — Tartar  Emetic. — Uncommon;  urticarial,  and  vesicopus- 
tular. 

Antipyrin.1 — Not  uncommon;  usually  morbilliform,  occasionally 
erythematopapular,  polymorphous,  scarlatiniform,  and  urticarial;  there 
may  be  considerable  sweating,  variable  pruritus,  and  desquamation  may 
follow;  trunk,  flexures,  and  occasionally  face  are  the  most  common  sites; 

^polant,  "  Die  Antipyrinexantheme,"  Archiv,  1898,  vol.  xlvi,  p.  345  (a  thorough 
exposition  of  the  subject,  with  brief  resume  of  the  most  important  type-cases,  and  with 
a  bibliography  of  265  references  to  date);  Fournier  (3  cases  "Verge  noire"),  Annalcx. 
1899,  p.  371;  Werhselmann,  Deutsche  med.  Wochenschr.,  1898,  No.  21,  p.  335,  and 
Archiv,  1899,  vol.  1,  p.  23;  Deas  (bullous),  Brit.  Jour.  Derm.,  1890,  p.  194;  Barthelemy 
et  Rellay  (bullous),  Annales,  1899,  p.  478;  Mibelli.  Giorn.  ital.,  1897,  fasc.  5  and  6,  pp. 
575  and  697 — abstract  in  Annales,  1898,  p.  590;  Bruck,  Berlin,  kiln.  Wochenschr., 
Oct.  17,  1910,  No.  42,  records  aphthae  developing  on  lips  and  tongue  after  a  dose  of 
antipyrin. 


DERMATITIS  MEDICAMENTOSA  457 

mouth,  hands,  and  feet  may  also  share  in  the  eruption;  exceptionally 
vesicopustular,  bullous,  furuncular,  and  purpuric.  The  erythemato- 
papular  may  leave  behind  redness  and  pigmentation  for  several  weeks. 
Exceptional  blackness  of  the  skin  of  the  penis  ('Verge  noire"  of  the 
French)  has  developed,  usually  taking  a  long  time  to  disappear. 

In  some  instances  a  tolerance  is  soon  established,  and  the  eruption 
may  fade  while  patient  still  continues  to  take  the  drug. 

Antitoxin.1 — Rather  frequent;  simple  erythema,  scarlatiniform,  mor- 
billiform,  urticarial,  and  polymorphous.  The  morbilliform  and  the 
scarlatiniform  may  or  may  not  be  followed  by  desquamation.  There 
may  be  prodromic  symptoms,  or  the  outbreak  may  be  sudden,  with 
considerable  temperature  elevation,  and  pain  and  swelling  about  the 
joints.  The  rash  may  appear  shortly  after  the  injection  is  admin- 
istered, or  not  until  several  or  more  days  later.  The  subjective  symp- 
tom of  itching  is  variable  in  the  different  cases.  The  eruption  lasts- 
usually  from  several  days  to  a  week  or  more.  Exceptionally  petechise 
are  observed. 

Arsenic.2 — Somewhat  rare;  almost  every  form  of  cutaneous  eruption 
has  resulted  from  the  internal  use  of  this  drug — erythematous,  papular, 
vesicular,  urticarial,  pustular,  petechial,  erysipelatous,  herpetic,  furun- 
cular, carbuncular  pigmentary,  keratotic,  ulcerative,  and  gangrenous. 

1Dubreuilh,  Annales,  1895,  p.  891;  Hartung,  Jahrbuchfiir  Kinderheilkunde,  Bd. 
xliii,  1897,  p.  72 — full  abstract  in  Archiv,  1900,  vol.  lii,  p.  411  (in  375  cases,  in  20  was 
local  irritation,  and  in  68  general  eruption);  Schulze,  "Die  Serumexan theme  bei  Diph- 
theric," Inaug.  Dis.,  Berlin,  1898 — brief  abstract  in  Archiv,  1900,  vol.  lii,  19,  315  (out  of 
704  cases,  144  showed  eruption;  of  these,  29  per  cent,  urticarial,  31.9  per  cent,  scarla- 
tinoid,  1 1. 1  per  cent,  morbilliform,  20  per  cent,  indeterminate,  and  remainder  not 
noted);  Berg,  Med.  Record,  June  18,  1898,  p.  865;  Bauer  (abstract  with  discussion), 
Monatshefte,  1899,  p.  450;  Rawlings,  St.  Bartholomew's  Hasp.  Jour.,  Dec.,  1898,  p.  40; 
Washbourn,  City's  Hasp.  Gaz.,  Aug.  19,  1899;  Malherbe,  Jour.  Mai.  Cutan.,  1904,  p.  499 
("verge  noire"). 

2Meneau,  "Les  dermatoses  arsenicales,"  Annales,  1897,  p.  345  (full  paper  and 
bibliography  of  124  references);  Brouardel,  "Etude  sur  1'Arsenicisme,"  These  de  Paris, 
Feb.  17,  1897  (an  exhaustive  paper);  Moreira,  "Arsenical  Affections  of  the  Skin," 
Brit.  Jour.  Derm.,  1895,  p.  378  (8  cases— various  types);  Rasch,  "Contribution  a 
1'etude  des  dermatoses  d'origine  arsenicale"  (2  cases,  i  zoster  and  i  bullous,  and  partial 
review  of  the  general  literature  of  arsenic  eruptions),  Annales,  1893,  p.  150. 

Zoster  eruption:  Gerhardt,  Charite-Annalen,  Berlin,  1894;  Nielsen,,  Monatshefte, 
1890,  vol  xi,  p.  302  (10  cases,  with  literature  references  to  others);  Bettmann,  Archiv, 
1900,  vol.  li,  p.  203  (i  case  and  bibliography) ;  see  also  under  Herpes  Zoster  for  additional 
references 

Keratosis  (palms  and  soles):  Pringle,  Brit.  Jour.  Derm.,  1891,  p.  390;  S.  Mac- 
kenzie (also  general  cutaneous  pigmentation),  ibid.,  1896,  p.  137;  Colcott  Fox,  ibid., 
1893,  p.  51;  Hardaway,  ibid.,  p.  304;  Payne,  ibid.,  1895,  p.  249;  Hamburger  (also 
cutaneous  pigmentation),  Bull.  Johns  Hopkins  Hasp.,  April,  1900,  p.  87;  Boeck, 
Monalshefle,  1893,  vol.  xvii,  p.  184;  Mibelli,  Lo  Sperimentale,  1898,  Heft  iv;  Lang, 
Annales,  1898,  p.  480;  Ullmann,  ibid.,  p.  481;  Arning,  V  erhandlungen  der  Deutsch. 
Dermatol.  Gesellschaft ,  V.  Congress,  1894,  p.  581;  and  Dubreuilh's  "  Keratose i  arsenicale 
et  Cancer  arsenical,"  report  and  review  (Annales,  Feb.,  1910,  p.  65)  of  both  arsenical 
keratosis  and  arsenical  cancer  (with  references). 

Keratosis  with  epitheliomatous  development:  Hutchinson,  J.  C.  White,  Hebra,  Jr., 
Hartzell,  Schamberg,  and  others— see  Hartzell's  paper,  "Epithehoma  as  a  bequel  ( 
Psoriasis,  and  the  Probability  of  Its  Arsenical  Origin,"  Amer.  Jour.  Sa.,  bept.,  1899; 
and  Debreuilh  (loc.  cit.),  and." Wile  (case  report,  with  review  and  resume,  and  t 
raphy)  collected  19  cases,  J-our.  Cutan.  Dis.,  1912,  p.  192. 

Pigmentation:  Pringle,  Brit.  Jour.  Derm.,  1895,  p.  52;  Schlesmger,  Wien  ktm. 
Wochenschr.,  1895,  p.  779;  Smetana,  Wien.  med.-Wochenschr.,  1897,  p.  903;  Auciry, 
Annales,  1896,  p.  1415;  Miiller,  Archiv,  1893,  vol.  xxv,  p.  165. 


458  INFLAMMATIONS 

The  genital  region,  especially  the  scrotum,  is  the  usual  site  of  the  ulcera- 
tive,  edematous,  and  gangrenous  manifestation.  Herpes  zoster  has  been 
observed  in  a  number  of  instances  to  follow  its  administration  (see  Herpes 
Zoster).  The  long-continued  use  of  the  drug,  as  in  psoriasis  and  chorea, 
is  sometimes  followed  by  extensive  pigmentation,  especially  about  the 
trunk.  As  a  rule,  it  eventually  disappears  sooner  or  later  after  the  drug 
has  been  discontinued.  Thickening  of  the  horny  part  of  the  skin  of  the 
palms  and  soles,  and  over  the  elbows  and  knuckles,  especially  of  the 
hands  and  feet,  is  occasionally  noted  in  long-continued  administration. 
The  horny  formations  may  undergo  epitheliomatous  degeneration  (re- 
ferred to  under  Psoriasis  and  Epithelioma),  and  in  a  few  instances  death 
has  finally  resulted;  in  fact,  it  is  believed  by  several  observers  that  the 
arsenic  is  directly  responsible  for  the  epitheliomatous  development — and 
is  now  sometimes  spoken  of  as  "arsenical  cancer." 


Fig.  114. — Keratosis  (palms  and  soles)  from  the  long-continued  administration  of 
arsenic.  (Another  illustration  showing  the  development  of  epithelioma,  apparently 
upon  an  arsenical  keratosis,  will  be  found  under  Epithelioma.) 

Aspirin. — Somewhat  exceptional;  erythematous,  plain  or  multiform; 
edematous  condition  of  face  and  scalp  with  rarely  edema  of  the  mouth 
and  throat  also. 

Belladonna — Atropin.1 — Not  infrequent,  especially  in  children;  scar- 
latinous type  most  usual;  patchy  erythematous  areas  or  flushings  occa- 
sional. The  eruptions  are,  as  a  rule,  upon  suspending  the  drug,  of  short 
duration.  Exceptionally  erythema  and  gangrene  of  scrotum  have  been 
observed.  Itching  is  sometimes  troublesome. 

Benzole  Acid  and  Sodium  Benzoate. — Uncommon;  from  benzoic 
acid,  erythematous,  erythematopapular,  and  urticarial,  the  last  most 
usual.  After  sodium  benzoate,  erythematous,  polymorphous,  and 
urticarial,  with  or  without  furfuraceous  desquamation. 

1  Knowles,  "  Generalized  Eruptions  of  an  Unusual  Type,  Caused  by  the  Absorption 
from  a  Belladonna  Plaster  and  from  the  Ocular  Instillation  of  Atropin,"  Amer.  Jour. 
Med.  Sci.,  July,  1911. 


DERMA  TITIS  MEDICAMENTOSA 


459 


Boric  Acid  and  Sodium  Borate.1 — Rare;  from  boric  acid,  erythema- 
tous,  papular,  and  bullous.  An  inflammatory  scaly  eruption,  eczema- 
tous  in  character,  quite  marked  on  scalp,  face,  and  neck,  with  more  or 
less  complete  loss  of  hair,  has  resulted  in  a  few  instances  after  long- 
continued  dosage ;  condition  subsided  after  discontinuance  and  hair  grew 
in  again.  From  sodium  borate,  rare,  erythematous,  morbilliform,  ec- 


Fig.  115. — Dermatitis  medicamentosa  in  a  young  child,  from  the  ingestion  of 
potassium  bromid;  the  lesions  of  a  pustulopapillomatous  character,  and  of  somewhat 
general  distribution,  but  most  numerous  and  marked  on  the  face  and  lower  extremities 
(courtesy  of  Dr.  G.  T.  Jackson). 

zematous,  and  psoriasiform  eruptions,  the  last  after  prolonged  adminis- 
tration. 

Bromin  Compounds.2 — Quite  common.  An  acne-like  papulopustu- 
lar  and  pustular,  about  the  regions  of  the  face  and  shoulders  and  back 
most  frequently;  although  the  lesions  are  usually  discrete,  several  or 

1  Wild  (boric  acid  and  sodium  borate),  Lancet,  7,  1899,  p.  23,  with  review  of  litera- 
ture; Fordyce  (boric  acid),  Jour.  Cutan.  Dis.,  1895,  p.  499;  Cowers  (sodium  borate), 
Lancet,  Oct.  24,  1884;  Evans  (boric  acid),  Brit.  Med.  Jour.,  Jan.  28,  1899. 

2  Crustaceous  and  papillomatous  eruptions:    Jackson  (2  cases  (i  child)),  Jour. 
Cutan.  Dis.,  1895,  p.  462;  Elliot  (2  cases — infants),  Trans.  Amer.  Derm.  Assoc.for  1895; 
Panichi,  Giorn.  ital.,  1897,  fasc.  5,  p.  559 — abstract  in  Annales,  1898,  p.  395;  Malherbe 
(vegetative  and  ulcerative).  La  Presse  medicale,  May  24,  1899,  p.  243;  Hallopeau  et 
Trastour  (suppurating  plaques),  Annales,  1900,  p.  883;  Feulard,  "Bromisme  Cutanee," 
ibid.,  1891,  p.  531;  Pini  (Bromoderma  nodosum  fungoides),  Archiv,  1900,  vol.  Hi,  p.  164, 
with  4  plates — 3  histologic  and  some  literature  references;  Colcott  Fox,  Brit.  Jour. 
Derm.,  1892,  p.  287;  see  also  paper  by  Van  Harlingen,  loc.  cit.;  Hall  (confluent  pustular, 
child,  with  illustration),  Quarterly  Med.  Jour.,  Nov.,  1902,  p.  138;  Myers,  Jour.  Cutan. 
Dis.,  1904,  p.  231  (with  illustration);  Hallopeau  and  Vielliard  (gangrenous),  Annales, 
1904,  p.  442;  Parkes  Weber  (granuloma-like  or  mycotic  type;  case  demonstration), 
Brit.  Jour.  Derm.,  1905,  p.  63;  Pasini,  "Sur  la  pathogenic  des  eruptions  bromiques" 
(with  review  and  bibliography),  Annales,  1906,  p.  i  (papulopustular,  discrete,  and 
confluent);  Knowles,  "Unusual  Cases  of  Bromid  Eruption  in  Childhood,"  New  York 
Med.  Jour.,  March  20,  1909  (4  cases;  brief  review  and  full  bibliography);  Jordan, 
"Ueber  Bromoderma,"  Dermatolog.  Wochenschr.,  April  13,  1912,  liv,  p.  453,  classifies 
and  describes  various  types  of  bromid-eruptions;  records  2  severe  cases,  one  tuberose- 
and  one  acne-like  and  nodular,  with  some  nodular  groups;  Halle  and  Dorlenscourt, 
Bull.  d.  la  Soc.  de  Pediat.  de  Paris,  Feb.,  1912,  No.  2,  p.  37,  report  an  instance  of  a  giant 
papulotubercular  bromid  eruption. 


460 


IN  FLAM  MA  TIOXS 


more  may  tend  to  group  and  become  in  places  confluent,  forming  a  slug- 
gish, conglomerate  patch  studded  with  pustular  points,  and  bearing  slight 
resemblance  to  a  superficial  carbuncle.  The  eruption  may  be  in  some 
instances  more  or  less  generally  distributed.  Occasionally  erythematous, 
vesicular,  papular,  urticarial,  furuncular,  and  carbuncular  eruptions 
are  observed  to  follow  its  administration.  Exceptionally  an  eruption 
somewhat  similar  to  erythema  nodosom  is  encountered.  Bullous  de- 
velopment is  rarely  observed. 

A  rather  rare  manifestation,  occurring  especially  in  children  and 
adolescents,  consists  of  one  or  several  or  more  red  or  purplish-red  ele- 
vated, papillomatous,  or  condylomaform  areas,  sometimes  crusted,  and 


Fig.  1 1 6. — Bromid  eruption  resembling  blastomycosis  and  tuberculosis  verrucosa 
produced  by  ammonium  bromid;  disappeared  slowly  after  its  discontinuance;  patient 
an  epileptic  (Stelwagon-Gaskill  Jefferson  Hospital  case). 

sometimes  presenting  numerous  points  of  pustulation;  there  may  also 
be,  in  parts  of  such  lesions,  superficial  ulceration,  but  rarely  of  marked 
character.  Such  formations  are  usually  of  sluggish  appearance,  and 
while  they  may  be  numerous  and  of  general  distribution,  there  may  be 
but  one  or  two  plaques  present,  occupying  an  area  of  several  square 
inches.  In  the  latter  the  lower  part  of  the  leg  is  the  most  common 
site;  in  the  extensive  form,  legs,  arms,  and  region  of  face  are  favorite 
situations. 

Bromin  eruptions  (bromoderma)  may  ensue  after  a  few  and  small 
doses,  but  more  commonly  after  the  drug  has  been  given  for  a  few 
weeks  or  longer  and  after  large  doses.  Bromin  eruptions  have  been 


DERMATITIS  MEDICAMENTOSA  461 

seen  in  infants  suckled  by  a  mother  taking  the  drug,  and  when  even 
herself  free  from  any  manifestation. 

Contrary  to  observation  concerning  most  drugs,  the  eruptive  dis- 
position from  bromids  may  persist,  especially  in  children,  for  several 
weeks  after  the  drug  has  been  discontinued.  The  plaque  or  condylo- 
maform  type  is  usually  slow  in  disappearing. 

Calx  Sulphurata. — Not  common;  usually  furuncular  and  pustular, 
rarely  vesicular,  and  exceptionally  petechial. 

Cannabis  Indica. — Exceptional;  vesicular,  more  or  less  general,  with 
accompanying  pruritus. 

Cantharides. — Rare;  erythematous  and  papular. 

Capsicum. — Rare;  erythematous  and  papulovesicular. 

Chinolin. — Not  infrequent;  erythematous;  observed  in  6  out  of  20 
fever  patients  to  whom  this  drug  wras  given. 

Chloral. — Not  uncommon;  scarlatinous  most  frequent  and  usually 
accompanied  with  febrile  action,  congestion  of  buccal  and  conjunctival 
mucous  membranes,  and  followed  by  desquamation.  Occasionally 
urticarial,  papular,  and  vesicular,  and  exceptionally  bullous,  furuncular, 
carbuncular,  petechial,  and  ulcerative;  and  in  children,  ulcers  of  the 
tongue  and  cornea. 

Chloralamid. — Exceptional;  punctate  erythematous,  with  vesicles, 
and  with  redness  of  nasal  and  oral  membranes,  coryza,  febrile  action, 
and  subsequent  desquamation. 

Chloroform. — Not  infrequent;  erythematous,  punctate,  or  blotchy; 
exceptionally  purpuric. 

Cod-liver  Oil. — Rare ;  vesicular  and  acneiform. 

Condurango. — Rare;  acneiform  and  furuncular. 

Conium. — Uncommon;  erythematous,  papular,  and  erysipelatous. 

Copaiba  and  Cubebs. — Not  infrequent;  usually  erythematous, 
scarlatinous,  morbilliform,  or  polymorphous;  rarely  vesicular,  papular, 
bullous,  urticarial,  and  petechial.  There  may  be  considerable 
pruritus. 

Copaiba. — Not  infrequent;  most  of  the  rashes  observed  from  the 
conjoint  administration  of  copaiba  and  cubebs  are  due  to  this  drug; 
scarlatiniform,  urticarial,  erythematous;  rarely,  vesicular,  petechial, 
and  bullous. 

Cubebs. — Rather  unusual;  erythematous  and  small  papular. 

Digitalis.— Exceptional;  scarlatiniform,  papular,  erythematopapular, 
urticarial,  and  erysipelatous  (of  face). 

Dulcamara.— Rare;  erythematous,  urticarial,  and  erythematosqua- 
mous. 

Ergot.— Rare,  and  usually  only  after  prolonged  administration. 
Vesicular,  petechial,  pustular,  furuncular,  and  gangrenous;  this  last  on 
the  extremities  and  usually  circumscribed. 

Guarana. — Rare;  urticarial. 

Guaiacum. — Exceptional ;  miliary  erythematous. 

Gurjun  Oil.— Rare;  erythematous  and  erythematopapular. 

Hyoscyamus.— Occasional;  most  commonly  erythematous  and  urti- 
carial, with  edema,  exceptionally  scarlatiniform,  pustular,  and  purpuric. 


462  INFLAMMA  TIONS 

lodin  and  its  Compounds  (Usually  the  lodid  Salts) .^Common; 
usually  the  papulopustular  and  pustular — iodid  acne,  so  called.  This 
is  generally  seen  on  face,  shoulders,  and  back,  although  it  may  be  more 
or  less  scattered;  appears  after  one  or  more  weeks'  administration,  and 
exceptionally  after  a  few  doses.  Occasionally,  in  places,  two  or  more 
lesions  may  become  confluent,  as  in  the  bromid  eruption,  and  give  rise 
to  a  papillomatous,  condylomaform,  carbuncular,  crustaceous,  or  rupial 
area;  they  are  somewhat  persistent,  disappearing  but  slowly  upon  dis- 
continuance of  the  drug. 

Exceptionally  the  iodids  may  provoke  a  multiform  or  polymorphous 
eruption  closely  simulating  erythema  multiforme  and  sometimes  ery- 


Fig.  117. — Dermatitis  medicamentosa  of  a  bullous  type,  from  the  ingestion  of 
potassium  iodid,  in  a  woman  aged  fifty.  Face,  neck,  forearms,  and  hands  involved,  and 
the  seat  of  considerable  edematous  swelling  and  variously  sized  blebs.  In  some  parts 
blebs  became  confluent,  broke,  and  uncovered  a  superficially  excoriated  surface,  as 
shown  in  cut.  Recovery  without  any  scarring  or  other  trace.  Patient  had  a  weak 
heart. 


thema    nodosum.    Urticarial    eruptions    are    also    observed;    likewise 
vesicular,   bullous,   and   purpuric,   although   these   latter  only   rarely. 

1  Recent  literature  of  the  more  severe  forms  of  iodid  eruption:  Hyde,  Arch.  Derm., 
1879,  p.  333  (bullous  types;  with  bibliography  to  date  and  analytic  table),  and  Jour. 
Cutan.  Dis.,  1886,  p.  253  (with  references);  Morrow,  ibid.,  pp.  97  and  136;  Norman 
Walker  (vegetating,  condylomatous  type),  Lancet,  May  12,  1892,  with  literature  refer- 
ences to  other  cases;  Fordyce  (nodular  i.  rupia-like  2),  Jour.  Cutan.  Dis.,  1895,  p.  496; 
Cannet  et  Barasch  (pustulonodular,  fungoidal — death),  Arch.  Gen.  de  Medicine,  Oct., 
1896,  p.  424;  Malherbe  (ulcerative) ,  La  Presse  medicate,  May  24,  1899,  p.  243;  Neu- 
mann (nodular-ulcerative,  skin  and  mucous  membrane  of  stomach — fatal  case,  uremic 
patient),  Archiv,  1899,  v°l-  xlviii,  p.  324,  with  colored  plates  of  face  and  stomach 
lesions;  Milian  (purpuric),  La  Presse  medicale,  Sept.  20,  1899,  p.  193;  Audry  (dissemi- 
nated gangrene),  Annales,  1897,  p.  1095;  O.  Rosenthal  (tuberous  and  fungoidal,  illus- 
trations), Archiv,  1901,  vol.  Ivii,  p.  3;  Hallopeau  and  Lebret  (purpuric,  bullous,  and 
sclerous),  Annales,  1903,  pp.  826  and  925;  Gottheil,  Jour.  Amer.  Med.  Assoc.,  1909, 
vol.  liii,  p.  1465  (fatal  hemorrhagic  bullous  case,  with  illustrations;  with  brief  notes  and 
references  of  the  hemorrhagic  bullous  cases  reported  by  Morrow,  Hallopeau  and  Lebret, 
and  Russell);  F.  C.  Knowles,  "Purpura  Caused  by  the  Ingestion  of  the  Iodids,"  Jour. 
Amer.  Med.  Assoc.,  July  9,  1910,  p.  100,  report  of  2  petechial  cases  with  review  and 
references  of  recorded  cases;  Howard  Fox,  Jour.  Cutan.  Dis.,  1911,  p.  93,  generalized 
bullous  case  (case  demonstration). 


DERMATITIS  MEDICAMENTOSA  463 

The  bullous  may  be  accompanied  with  considerable  erysipelatous  red- 
ness and  swelling,  and  with  more  or  less  profound  constitutional  dis- 
turbance; such  lesions  may  be  numerous,  sometimes  confluent,  and  are 
most  commonly  seen  on  the  face,  hands,  and  arms.  Ulcerations  beneath 
the  lesions  are  sometimes  observed.  The  bullous  and  more  severe  types 
of  iodin  eruptions  are  usually  seen  in  those  with  kidney  and  heart  dis- 
ease. The  bullous  and  purpuric  iodin  eruptions  are  exceptionally  of 
grave  import,  and  in  extreme  cases  a  fatal  issue,  while  not  to  be  expected, 
occasionally  results. 

As  in  bromid  eruptions,  the  eruptive  tendency  may  persist  for  some 
time  after  the  drug  is  discontinued,  more  especially  in  children,  and  rarely 
it  does  not  appear  until  after  the  cessation  of  the  drug.  lodid  eruption 
has  been  sometimes  seen  in  nursing  infants  to  whose  mothers  the  drug 
was  being  administered.  Investigations  (Briquet,  Lyon)  tend  to  show 
that  the  sodium  salt  is  least  apt  to  give  rise  to  eruption.  This  agrees 
with  my  experience. 

lodoform.1 — Uncommon;  in  addition  to  the  dermatitis  and  eczema- 
toid  eruptions  produced  directly  by  the  local  action  of  this  drug,  referred 
to  under  the  head  of  Dermatitis  venenata,  cutaneous  manifestations 
exceptionally  follow  its  absorption,  and  may  be  erythematous,  erythema- 
topapular,  and  polymorphous,  vesicular,  bullous,  and  petechial.  Serious 
constitutional  symptoms  can  also  result;  delirium,  nephritis,  and  death 
have  been  observed. 

Ipecacuanha. — Exceptional;  circumscribed  erysipelatous  patches  of 
more  or  less  general  distribution. 

Jaborandi  and  Pilocarpin. — Rare;  erythematous,  miliary,  papular, 
and  urticarial.  Active  diaphoresis. 

Mercury.2 — Not  common;  erythematous,  scarlatiniform,  papular, 
pustular,  herpetic,  bullous,  purpuric,  furuncular,  and  ulcerative. 
Almost  all,  more  especially  the  severe  forms,  usually  resulting  from 
overdosing,  and  are  scarcely  observed  at  the  present  day. 

Castor  Oil. — Rare;  erythematous,  with  pruritus. 

Opium — Morphin. — Not  uncommon;  erythematous,  of  scarlatini- 
form, morbilliform,  and  polymorphous  types,  usually  with  intense  itch- 
ing; desquamation  may  follow;  less  frequently  urticarial,  and  excep- 
tionally vesicular,  bullous,  pustular,  furuncular,  and  carbuncular. 

Piper  Methysticum.— Kava-kava,  the  fermented  juice  of  this  plant, 
gives  rise  to  erythematosquamous,  exfoliative  dermatitis. 

Phenacetin. — Not  common;  erythematous,  erythematopapular,  and 
urticarial. 

Phosphoric  Acid— Phosphorus.— Rare;  bullous  and  purpuric. 

Pimpinella. — Exceptional ;  urticarial. 

Lead— Carbonate  and  Acetate.— Rare;  erythematous  and  purpuric. 

1  Colcott  Fox,  Brit.  Jour.  Derm.,  1890,  p.  327;  Taylor,  N.  Y.  Med.  Jour.,  Oct.  i, 
1887;  Cutler,  Boston  Med.  and  Surg.  Jour.,  1886,  vol.  cxv,  p.  73!  Etienne  et  Pilon, 
"Revue  med.  de  L'Est,"  June  i,  1895,  p.  339,  abstract  in  Annales,  1896,  p.  417-       . 

2  Gottheil,  Jour.  Cutan.  Dis.,  1911,  p.  114,  records  a  case  (case  demonstration;  u 
which  intramuscular  injections  of  mercury  salicylate  was  followed  on  several  occasions 
by  an  extensive  eruption  of  a  mixed  type  of  papulovesicular  eczema  and  erythema 
multiforme;  patient  had  nephritic  symptoms. 


464  INFLAMMA  TIONS 

Potassium  Chlorate.1 — Exceptional;  erythematopapular,  polymor- 
phous, cyanotic. 

Quinin,2  Cinchona. — Occasional;  erythematous,  scarlatiniform,  with 
or  without  desquamation,  most  commonly;  less  frequently  urticarial, 
purpuric,  vesicular,  bullous,  erysipelatous,  and  gangrenous  (especially 
of  scrotum).  In  the  scarlatiniform  and  sometimes  in  other  types  of 
general  distribution  there  may  be  considerable  constitutional  disturbance, 
with  marked  febrile  action,  etc.  In  the  desquamating  cases  this  may  be 
branny,  lamellar,  or  come  off  in  sheets  or  from  the  hands  as  a  partial  or 
complete  casting.  Idiosyncrasy,  and  not  dosage,  is  the  all-important 
factor.  Itching  is  frequently  present,  sometimes  to  an  annoying  degree. 

In  doubtful  cases  of  sudden  scarlatiniform  and  similar  eruptions 
quinin  should  always  be  eliminated  as  a  possible  etiologic  factor. 

Rhubarb. — Exceptional;  scarlatiniform  desquamative  erythema. 

Salicylic  Acid — Salicylates. — Not  common;  usually  erythematous, 
scarlatiniform,  and  urticarial,  with  or  without  desquamation;  rarely 
vesicular,  bullous,  purpuric,  and  even  gangrenous. 

Salol  has  exceptionally  also  been  responsible  for  urticarial  eruptions. 

Salipyrin  has  been  credited  with  producing  edema  and  loss  of  tissue. 

Santonin  and  Sodium  Santonate. — Exceptional;  from  santonin, 
generalized  urticarial  with  desquamation  and  edema;  from  sodium 
santonate,  vesicular. 

Silver  Nitrate. — Slate-colored  and  grayish-black  pigmentation  or 
discoloration  after  prolonged  use;  exceptionally  erythematopapular 
eruption. 

Stramonium.— Not  common;  usually  erythematous  and  scarlatini- 
form; rarely  erysipelatous  and  purpuric. 

Strychnin — Nux  Vomica. — Rare;  scarlatiniform,  and  miliaria,  with 
pruritus. 

Sulphonal. — Occasional;  most  commonly  erythematous  and  scar- 
latiniform, with  desquamation  and  accompanying  pruritus;  rarely  mor- 
billiform  and  purpuric. 

Tanacetum. — Exceptional ;  varioliform. 

Tannin. — Rare;  erythematous  and  urticarial. 

Tar. — Rare;  erythematous,  morbilliform,  and  urticarial. 

Thallium  Acetate.3 — More  or  less  complete  alopecia. 

1  Stelwagon,  "An  Erythematous  Eruption  from  Chlorate  of  Potassium,"  New  York 
Med.  Record,  July  21,  1883. 

2  Morrow,  New  York  Med.  Jour.,  March,  1880  (an  analysis  of  60  cases — in  38, 
erythematous,  of  scalatiniform  or  morbilliform  type;  in  12,  urticarial,  usually  with 
edema  or  pumness  of  the  face;  in  others  papular,  vesicular,  or  petechial);  Haralamb 
(erythema  bullosum),  Annales,  Dec.,  1895,  p.  1048;  Johnston  (bullous;  with  literature 
references  to  several  other  cases),  Jour.  Ciitan.  Dis.,  1896,  p.  1266;  Allen  (acquired 
idiosyncrasy),  Med.  Record,  1895,  vol.  xlvii,  p.  97;  Heard  (generalized  erythematous, 
with  desquamation — from  i-grain  dose),  "Trans.  Acad.  Med.  of  Pittsburg,"  Philada. 
Med.  Jour.,  Oct.  28,  1899;  Simpson,  ibid,  (similar  generalized  case,  with  general  des- 
quamation, including  the  nails);  Chomatianos  (erythematovesicular  and  erythemato- 
bullous,  hands  and  penis),  La  Grece  medicate,  1899,  No.  4 — abstract  in  Amer.  Jour.  Med. 
Sci.,   Aug.,    1899,  p.    231;   D.   W.   Montgomery   (purpuric — acquired   idiosyncrasy), 
Boston  Med.  and  Surg.  Jour.,  1897,  vol.  cxxxvii,  p.  646. 

3  Jeanselme,  Annales,  1898,  p.  999;  Huchard,  Bull,  de  Acad.  de  Med.,  March  17, 
1898;  Vassaux,  These  de  Paris,  July  12,  1898 — abstract  in  Annales,  1898,  p.  813  (was 
valuable  in  sweating  of  phthisis,  but  in  34  cases  hair  loss  occurred  in  8). 


SCARLATINA  465 

Tuberculin.— Not  common;  erythematous,  scarlatiniform,  and  mor- 
billiform,  with  or  without  subsequent  desquamation ;  exceptionally, 
psoriasiform. 

Turpentine,  Terebene.— Occasional ;  erythematous,  scarlatiniform, 
and  morbilliform;  exceptionally  vesicular  and  papular,  urticarial,  and 
pustular.  Terebene,  papular,  with  pruritus. 

Valerian.— Exceptional ;  urticarial. 

Veratrum  Viride—  Rare;  erythematous  and  pustular. 

Veronal.1— Rather  uncommon;  erythematous,  morbilliform,  or  scar- 
latiniform, eczematoid,  with  sometimes  vesiculation  on  the  extremities, 
and  rarely  large  bullae  on  the  mucosa. 

Viburnum  Prunifolium.— Exceptional ;  scarlatiniform,  with  subse- 
quent desquamation. 

THE  EXANTHEMATA 

In  many  works  on  diseases  of  the  skin  the  various  eruptive  fevers, 
generally  classed  under  the  term  exanthemata,  are  accorded  no  space. 
Inasmuch,  however,  as  their  cutaneous  features  are  always  so  promi- 
nent a  factor,  and  their  differentiation  from  other  eruptive  maladies 
so  often  demanded,  they  can,  I  believe,  be  viewed  as  on  the  border-line 
between  general  medicine  and  dermatology,  and  therefore  a  presentation 
of  the  symptomatology  and  diagnosis  is  not  an  unnecessary  addition  in 
works  on  the  latter  branch.  They  are  here  thus  presented,  and  in  suffi- 
cient detail  to  be  of  value,  although  not  so  fully  considered  as  in  standard 
general  medical  treatises. 

The  several  diseases  in  this  group  present  certain  common  charac- 
teristics: they  are  of  a  specific  infectious  nature,  with  variable  febrile 
and  other  constitutional  symptoms,  of  self-limited  course,  usually  occur- 
ring in  epidemic  manner,  and  for  the  most  part  diseases  of  childhood. 
Their  skin  manifestations  differ  slightly  or  materially  both  as  to  seat 
and  intensity,  as  well  as  to  lesional  formation.  One  attack,  as  a  rule, 
confers  immunity  from  further  infection. 

SCARLATINA 

(W.  M.  WELCH) 

Synonyms. — Scarlet  fever;  Fr.,  Scarlatine;  Ger.,  Scharlachfieber;  ltd.,  Febbre 
scarlatina. 

Definition. — An  acute  infectious  disease  characterized  by  fever, 
angina  of  variable  intensity,  a  diffuse  punctiform  rash  appearing  on 
the  second  day,  and  ending  by  a  desquamation  more  or  less  copious. 

Symptoms — In  studying  the  symptomatology  of  scarlet  fever  it 
is  found  most  convenient  to  divide  the  disease  into  three  stages — namely, 
the  stage  of  invasion,  the  eruptive  stage,  and  the  stage  of  desquamation. 
The  stage  of  invasion  is  usually  sudden  in  its  onset.  It  is  seldom  ushered 
in  by  a  chill  or  chilly  sensations,  but  in  young  children  convulsions  are 
not  uncommon.  Along  with  some  indisposition,  sore  throat  and  vomit- 

1  PolHtzer,  "Veronal  Poisoning,"  Jour.Cutan.  Dis.,  April,  1912,  p.  185  (case  report, 
with  review  of  other  cases,  with  references). 
30 


466  INFLAMMA  TIONS 

ing  are  usually  the  earliest  symptoms.  The  temperature  rises  rapidly, 
often  reaching,  in  the  course  of  a  few  hours,  102°  to  104°  F.  The  skin 
is  hot  and  dry,  the  tongue  furred,  the  face  flushed,  there  is  intense  thirst, 
and  the  patient  is  restless.  Taken  together,  the  symptoms  indicate  the 
beginning  of  an  acute  illness,  the  nature  of  which,  however,  is  not  re- 
vealed until  the  rash  appears,  which  is  usually  on  the  second  day. 

It  is  very  common,  indeed,  for  the  eruption  to  appear  within  the 
first  twenty-four  hours  of  illness,  and  in  normal  cases  it  is  rarely  delayed 
longer  than  the  second  day.  Almost  always  it  is  seen  first  on  the  trunk, 
the  skin  being  slightly  reddened  on  the  chest  and  abdomen,  frequently 
in  the  region  of  the  groins.  The  redness  rapidly  increases,  and  on  the 
evening  of  the  second  day  it  may  be  distinctly  seen  on  all  parts  of  the 
trunk  and  extremities.  The  face  frequently  escapes  entirely.  The 
cheeks  may  be  more  or  less  flushed,  while  the  lips  and  alae  of  the  nose  very 
often  appear  preternaturally  pale.  Pressure  removes  the  redness 
momentarily.  By  drawing  one's  fingers  quickly  over  the  rash  the  mo- 
mentary pallor  that  is  produced  will  be  quickly  replaced  by  the  redness, 
but  presently  the  pale  lines  return  again  and  persist  for  a  minute  or  longer. 
The  rash  may  vary  very  greatly  in  its  distribution  and  intensity.  Some- 
times it  is  so  scanty  as  scarcely  to  be  recognized,  or  it  may  be  seen  in 
ill-defined  patches,  or  it  may  be  general  and  so  intense  as  to  suggest 
the  existence  of  acute  dermatitis.  In  well-marked  cases  the  efflorescence 
covers  all  parts  of  the  body,  with  perhaps  the  exception  of  the  face,  and 
on  passing  the  fingers  over  the  skin  it  may  appear  smooth,  but  there 
is  in  most  cases  a  sensation  of  minute  elevations,  which  are  due  to  promi- 
nence of  some  of  the  hair-follicles  similar  to  the  condition  known  as  cutis 
anserina.  This  condition  may  be  so  marked  on  some  parts  of  the  body 
as  to  present  a  papular  appearance  and  thus  give  rise  to  a  suspicion  of 
measles,  especially  when  there  is  normal  skin  intervening. 

While  the  rash  presents  the  general  characteristics  of  a  diffuse  efflor- 
escence, yet  on  close  inspection  it  is  found  to  be  made  up  of  innumerable 
puncta  of  more  intense  redness,  with  intervening  erythema  of  duller  hue. 
This  gives  to  the  rash  a  somewhat  variegated  appearance,  being  at  the 
same  time  diffuse  and  punctiform.  The  color  of  the  rash  is  often  de- 
scribed as  scarlet,  but  if  it  be  compared  at  the  bedside  with  a  piece  of 
scarlet  flannel,  a  wide  difference  will  be  observed,  even  when  the  rash 
presents  its  brightest  appearance.  It  is  difficult  to  describe  the  color 
exactly,  but  it  may  be  said  to  be  a  dull  red  rather  than  a  bright  red. 
When  the  rash  begins  to  fade,  it  presents  a  dusky  or  brownish-red  color. 
It  may  disappear  entirely  in  two  or  three  days,  but  it  frequently  remains 
as  long  as  six  or  eight  days,  and  sometimes  even  longer.  In  a  rash  of 
extreme  intensity  minute  hemorrhagic  puncta  may  be  seen,  which  gen- 
erally disappear  entirely  on  pressure.  In  such  cases,  as  well  as  in  many 
milder  ones,  innumerable  miliary  vesicles  appear  at  the  height  of  the 
eruption.  These  are  much  more  frequent  than  is  generally  supposed, 
being  often  overlooked  on  account  of  their  small  size.  They  are,  as  the 
name  implies,  the  size  of  a  millet  seed,  conic  in  shape,  and  contain  the 
merest  speck  of  milky  fluid.  They  are  more  frequently  seen  on  regions 
of  the  skin  in  which  the  eruption  is  most  intense,  as  upon  the  mons 


SCARLA  TINA  467 

veneris  and  anterior  axillary  folds,  yet  they  are  by  no  means  infrequently 
present  on  the  abdomen  and  chest.  A  magnifying  glass  will  often  bring 
them  into  view,  when  they  cannot  be  seen  by  the  unaided  eye.  In  certain 
atypical  cases  the  rash  may  be  so  indistinct  that  its  true  nature  cannot 
be  recognized;  or,  indeed,  it  may  be  absent  altogether.  The  only  local 
manifestation  of  the  disease  in  such  cases  is  a  slight  soreness  of  the  throat. 
It  not  infrequently  happens  during  the  prevalence  of  scarlet  fever  in  a 
family  that  one  member  will  be  affected  by  a  sore  throat,  more  or  less 
severe,  without  any  eruption  on  the  skin.  Under  such  circumstances 
the  diagnosis  is  made  of  ''scarlatina  sine  eruptione,"  which  diagnosis  is 
sometimes  confirmed  later  by  the  occurrence  of  sequelae. 

One  of  the  earliest  symptoms,  as  has  already  been  mentioned,  is 
soreness  of  the  throat.  At  first  only  slight  redness  may  be  seen  in  the 
fauces,  causing  deglutition  to  be  somewhat  painful,  and  this  condition 
often  increases  pari  passu  with  the  development  of  the  cutaneous  rash. 
In  mild  cases  the  throat  symptoms  may  be  moderate  throughout  the 
attack,  or  even  absent.  But  in  severe  cases  the  fauces  are  often  intensely 
inflamed  and  present  an  appearance  comparable  to  the  rash  on  the  skin. 
The  soft  palate  particularly  is  of  a  vivid  red  color  and  shows  punctiform 
elevations.  The  tonsils  are  swollen  and  become  partially  covered  with 
yellowish-white  exudation.  The  mucous  membrane  involvement  fre- 
quently extends  to  the  nares,  causing  an  irritating  discharge  from  the 
nose.  The  tongue  at  first  is  red  at  the  tip,  and  covered  with  yellowish  fur. 
About  the  time  the  rash  is  developimg  on  the  skin  the  papillae  on  the 
tongue  become  prominent  and  often  project  through  the  coating,  thus 
giving  the  appearance  described  as  "strawberry  tongue."  In  three  or 
four  days  the  coating  disappears  entirely,  leaving  the  tongue  red  and 
raw  looking,  with  its  papillae  very  prominent,  when  the  strawberry 
appearance  is  even  more  suggestive.  In  certain  cases  of  scarlet  fever 
the  throat  affection  is  so  severe  as  to  constitute  an  exceedingly  promi- 
nent feature  of  the  disease.  The  name  applied  to  these  cases  is  "scar- 
latina anginosa."  The  tonsils  are  greatly  swollen  and  covered  with 
membranous  exudate.  Deglutition  is  very  painful  and  sometimes 
almost  impossible  -without  regurgitation  through  the  nostrils.  The 
tissues  of  the  throat,  particularly  the  soft  palate,  may  undergo  necrosis 
and  slough  away  in  good  part.  The  breath  is  fetid,  and  constitutional 
depression  profound.  The  glands  of  the  neck  in  such  cases  are  always 
swollen,  and  there  may  occur  extensive  abscesses  in  this  region;  so  ex- 
tensive, indeed,  as  to  destroy  a  large  area  of  skin  and  the  underlying 
connective  tissue,  leaving  the  muscles  and  large  blood-vessels  exposed. 
In  these  extreme  cases  death  is  liable  to  result  either  from  toxemia  or 
exhaustion. 

The  fever,  which  is  marked  from  the  beginning,  does  not  diminish, 
but  rather  increases  after  the  appearance  of  the  eruption.  As  a  rule, 
the  temperature  ranges  high.  In  the  average  case  the  axillary  tem- 
perature is  from  102°  to  104°  during  the  progress  of  the  rash.  In  mild 
cases  it  may  not  rise  above  102°,  even  when  the  rash  is  intensely  marked. 
But  in  severe  cases  the  temperature  not  infrequently  reaches  105°,  and 
even  exceeds  this.  Hyperpyrexia  sometimes  occurs  just  before  death, 


468  INFLAMMA  TIONS 

when  the  thermometer  may  register  as  high  as  108°  or  109°.  The  pyrexia 
in  this  disease,  as  in  most  other  febrile  affections,  is  characterized  by 
morning  remissions  and  evening  exacerbations.  When  the  rash  begins 
to  fade,  the  temperature  declines,  falling  usually  by  lysis.  Should  it 
continue  high,  some  complication  probably  exists.  During  the  pyrexia 
the  skin,  of  course,  is  hot  and  dry.  The  pulse  is  always  rapid.  This 
symptom  is  perhaps  more  uniformly  marked  in  scarlatina  than  in  any 
other  infectious  fever.  In  children  the  pulse  ranges  from  120  to  160. 
The  number  of  respirations  are  usually  increased  proportionately  to  the 
height  of  the  fever.  It  is  only  in  exceptional  cases  that  the  stomach 
continues  irritable  after  the  initial  vomiting.  Anorexia,  however,  con- 
tinues throughout  the  eruptive  stage,  and  thirst  is  usually  intense.  The 
bowels  are  not  necessarily  disturbed.  Nervous  symptoms,  such  as 
headache  and  slight  muttering  in  the  sleep,  commonly  appear  with  the 
initial  fever;  and  during  the  progress  of  the  disease,  especially  when  the 
temperature  ranges  high,  there  may  be  restlessness,  jactitation,  and  insom- 
nia, or  even  active  delirium.  Slight  albuminuria  is  present  in  a  certain 
proportion  of  cases  during  the  eruptive  stage,  but  its  presence  at  this 
time  does  not  necessarily  denote  renal  disease.  This  may  occur  at  a 
later  stage  as  a  complication  or  sequela  and  will  be  considered  presently. 

The  lymphatic  glands  are  involved  in  a  large  proportion  of  cases 
of  scarlet  fever.  They  may  be  found  swollen  in  the  submaxillary  region 
at  an  early  stage  of  the  disease.  According  to  Schamberg's1  investiga- 
tion, the  inguinal  glands  are  invariably  enlarged,  and  those  in  the  sub- 
maxillary,  cervical,  and  axillary  regions  are  also  very  commonly  enlarged. 
The  glandular  intumescence  usually  bears  some  proportion  to  the  toxemic 
condition.  Suppuration  of  the  glands  of  the  neck  not  infrequently 
occurs;  but  those  located  in  other  parts  of  the  body  rarely  suppurate. 
This  process,  however,  does  not  usually  take  place  until  the  rash  has 
disappeared.  An  acute  phlegmonous  inflammation  involving  the  glands 
and  connective  tissue  of  the  neck  may  occur  and  prove  very  destructive 
to  the  parts,  and  consequently  fatal  to  the  patient. 

In  epidemics  of  scarlet  fever  some  cases  are  sure  to  develop  into  a 
malignant  type  of  the  disease.  The  tendency  to  the  occurrence  of  this 
type  varies  in  different  epidemics.  The  disease  may  be  marked  with 
unusual  severity  from  the  beginning,  presenting  such  symptoms  as  high 
temperature,  excessive  irritability  of  the  stomach,  extreme  restlessness 
and  delirium,  or  even  convulsions.  The  delirium  may  be  followed  by 
partial  coma,  a  rapid  and  feeble  pulse,  intense  fever,  and  disturbed 
respirations.  Death  sometimes  occurs  within  the  first  forty-eight  hours 
of  the  disease  as  a  result  of  the  intensity  of  the  poison.  The  disease  but 
rarely  assumes  the  hemorrhagic  form,  which  is  recognized  by  the  livid 
hue  of  the  rash,  the  presence  of  petechiae  or  purpuric  spots,  and  by  epis- 
taxis  and  hematuria.  From  this  variety  recovery  is  rare,  and  the  struggle 
usually  short. 

When  the  rash  of  scarlet  fever  begins  to  fade,  the  skin  assumes  a 
dusky  or  brownish  hue,  is  dry  and  slightly  rough,  and  begins  to  show 
signs  of  shedding  its  upper  layer.  This  process  is  known  as  desquama- 
1  Schamberg,  Annals  of  Gynecology  and  Pediatry,  Dec.,  1899. 


SCARLA  TINA  460 

tion.  In  severe  cases  it  usually  begins  before  the  rash  has  entirely  dis- 
appeared, being  first  seen  on  the  neck  and  gradually  extending  to  other 
parts  of  the  body.  Quite  frequently  it  is  noticed  first  at  the  summits 
of  the  miliary  vesicles  and  spreads  from  each  of  these  points  by  centrif- 
ugal expansion.  In  its  degree  and  extent  it  always  bears  a  very  distinct 
relation  to  the  diffuseness  and  intensity  of  the  rash.  When  the  latter 
has  been  intense,  the  desquamative  process  is  very  copious,  the  epider- 
mis being  shed  in  flakes  and  scales.  On  the  hands,  and  feet,  where  the 
horny  layer  of  the  skin  is  thicker,  casts  resembling  gloves  and  slippers 
are  sometimes  exfoliated.  The  finger-nails  may  be  shed,  but  the  hair 
rarely  falls  out.  When  the  rash  has  been  extremely  mild,  the  desquama- 
tion  is  sometimes  furfuraceous  in  character,  and  it  may  be  even  so  slight 
as  to  be  scarcely  perceptible;  but  it«is  rarely  entirely  absent,  except  per- 
haps in  cases  of  scarlatina  sine  eruptione.  It  has  been  known  to  occur 
more  than  once  in  the  same  case.  I  am  able  to  cite  one  instance  in  which 
both  the  rash  and  desquamation  recurred  twice.  The  time  required  for 
completion  of  the  process,  counting  from  the  beginning  of  illness  until 
all  parts  of  the  body,  including  the  palms  of  the  hands  and  soles  of  the 
feet,  are  perfectly  smooth,  is  from  six  to  eight  weeks,  and  sometimes 
longer. 

Certain  complications  are  liable  to  occur,  and  of  these  otitis  media 
is  perhaps  one  of  the  most  common.  It  most  frequently  appears  during 
the  second  week  of  illness.  The  earliest  symptom  is  pain  in  the  ear, 
and  this  is  soon  followed  by  a  purulent  discharge  from  the  external  mea- 
tus.  Partial  or  complete  deafness  may  result,  although  the  majority  of 
cases  recover  without  impairment  of  hearing.  In  some  cases  there  is 
suppuration  in  the  mastoid  cells,  and  even  such  serious  results  as  menin- 
gitis, thrombosis,  or  abscess  of  the  brain.  A  mild  form  of  arthritis,  com- 
monly called  rheumatoid  pains,  often  appears  during  the  subsidence  of 
the  fever.  Abscesses  of  the  neck  are  of  frequent  occurrence.  Endo- 
carditis, pericarditis,  or  myocarditis  is  not  uncommon.  Pneumonia  or 
pleurisy  occurs  occasionally  during  convalescence.  The  latter  is  some- 
times associated  with  acute  nephritis  and  a  general  dropsical  condition, 
and  the  effusion  which  takes  place  in  the  pleural  cavity  is  often  purulent. 
Affections  of  the  eye  sometimes  occur,  but  only  rarely  are  they  serious. 
I  recently  saw  a  case  of  temporary  blindness,  doubtless  caused  by  neph- 
ritis; also  two  cases  of  exophthalmos  from  infiltration  of  the  cellular 
tissue  of  the  orbit.  Both  of  the  latter  were  albuminuric,  and  death 
resulted.  I  have  also  seen  several  cases  of  sloughing  of  the  soft  palate, 
the  trouble  beginning  as  a  perforating  ulcer. 

Albuminuria  is  not  infrequent.  It  may  be  met  with  at  an  early  stage 
of  the  disease  as  the  result  of  malignancy  or  intensity  of  the  fever,  but 
far  more  frequently  does  it  occur  from  the  fourteenth  to  the  twenty-first 
day  as  the  result  of  postscarlatinal  nephritis.  One  of  the  earliest  symp- 
toms of  this  condition  is  extreme  pallor,  with  puffiness  about  the  face. 
Whether  or  not  this  symptom  is  noticed  it  is  advisable  to  examine  the 
urine  frequently  during  the  second,  third,  or  even  the  fourth  week  of 
illness.  The  presence  of  albumin  in  the  urine  does  not  always  depend 
upon  the  severity  of  the  scarlatinal  attack.  Indeed,  very  severe  forms 


of  nephritis  not  infrequently  follow  extremely  mild  attacks  of  scarlet 
fever.  The  quantity  of  albumin  present  may  vary  greatly  in  different 
cases.  It  may  be  so  scanty  as  scarcely  to  be  found,  or  so  abundant  that 
almost  the  entire  column  of  urine  in  the  test-tube  solidifies  by  boiling. 
The  amount  of  urine  secreted  is  usually  diminished.  In  very  severe 
cases  there  may  be  almost  complete  anuria,  and  the  small  quantity  that 
is  secreted  is  usually  dark,  often  bloody,  and  contains,  besides  albumin, 
tube-casts.  The  scanty  elimination  of  urea  may  cause  constant  vomit- 
ing and  repeated  convulsions,  and  death  may  result,  with  all  the  symp- 
toms of  acute  uremia.  In  cases  somewhat  less  severe  there  is  a  puffy 
appearance  of  the  face,  especially  about  the  eyelids,  and  often  general 
edema.  The  urine  is  scanty,  sometimes  bloody  or  smoky  in  appearance, 
and  contains  tube-casts.  The  dropsy  increases,  effusion  into  the  serous 
cavities  may  occur,  and  the  child,  after  suffering  for  several  days,  may 
die  from  effusion  into  the  pleura,  edema  of  the  lungs,  or  uremic  poisoning; 
or  death  may  result  suddenly  from  hydropericardium.  Fortunately, 
in  most  cases  very  much  can  be  done  by  prompt  and  judicious  treatment 
for  relief  of  the  threatening  symptoms  of  this  complication. 

Scarlet  fever  is  sometimes  complicated  with  diphtheria.  It  has  been 
found,  by  systematically  culturing  all  cases  admitted  to  the  Municipal 
Hospital,  Philadelphia,  that  the  Klebs-Loffler  bacilli  are  present  in  from 
10  to  15  per  cent.  Not  infrequently,  however,  these  organisms  are 
found  in  cases  presenting  no  clinical  evidence  of  diphtheria. 

Diagnosis. — Except  in  atypical  cases,  the  diagnosis  of  scarlet  fever 
is  not  difficult  if  attention  be  given  to  the  following  clinical  points:  The 
disease  begins  abruptly,  usually  with  vomiting,  slight  soreness  of  the 
throat,  and  rise  of  temperature.  In  twenty-four  hours  or  less  the  rash 
appears  on  the  neck,  chest,  and  abdomen,  being  rather  fine  at  first,  but 
rapidly  increases  in  intensity  and  spreads  to  all  parts  of  the  cutaneous 
surface  except  the  face,  which  often  escapes.  When  fully  formed,  it  is 
diffuse  and  punctiform  in  character.  With  the  appearance  of  the  rash 
the  fever  increases,  the  tongue  becomes  furred,  red  at  its  tip  and  edges, 
and  the  pulse  is  rapid.  The  lymphatic  glands,  especially  those  of  the 
groins,  are  almost  always  enlarged.  The  rash  is  quite  invariably  followed 
by  desquamation.  Of  the  few  diseases  which  may  be  confounded  with 
scarlet  fever,  only  three  are  deemed  worthy  of  consideration:  measles, 
erythema  scarlatinoides,  and  septicemia.  Measles  may  be  differentiated 
by  the  longer  stage  of  invasion,  and  which  is  characterized  by  catarrhal 
symptoms;  by  the  rash  first  appearing  on  the  face  and  extending  to  the 
trunk  and  extremities;  by  the  macular  character  of  the  rash  and  its  so- 
called  crescentic  arrangement;  by  the  comparative  absence  of  sore 
throat,  and  by  the  branny  character  of  the  desquamation.  Erythema 
scarlatinoides  may  be  distinguished  by  the  uniform  distribution  of  the 
efflorescence  instead  of  the  punctiform  character;  by  the  longer  duration 
of  the  efflorescence  and  its  tendency  to  recur;  by  the  absence  of  marked 
throat  symptoms;  and  sometimes,  also,  by  shedding  the  hair  and  the 
nails,  as  well  as  the  epidermis.  The  rash  of  septicemia  is  sometimes 
quite  similar  to  that  of  scarlet  fever.  But  in  this  affection  a  history  of 
sepsis  is  almost  always  obtainable,  the  temperature  usually  shows 


R  UBE  OLA  —MEASLES 


471 


greater  variation,  the  "strawberry  tongue"  is  wanting,  and  there  is  no 
desquamation. 

Drug-rashes  are  sometimes  mistaken  for  scarlet  fever.  These  are 
usually  transitory  and  rarely  generalized.  They  are  not  associated  with 
fever,  nor  with  the  train  of  symptoms  peculiar  to  scarlet  fever.  The  rash 
caused  by  belladonna,  and  less  frequently  that  by  quinin,  gives  perhaps 
the  best  simulation. 

It  must  be  admitted,  however,  that  in  every  epidemic  there  occur 
atypical  cases  about  which  there  is  much  doubt  as  to  the  diagnosis. 
This  doubt  may  sometimes  be  dispelled  by  the  occurrence  of  nephritis 
or  subsequent  well-marked  cases  of  scarlet  fever  in  the  family. 

RUBEOLA— MEASLES 

(W.  M.  WELCH) 
Synonyms.— Morbilli;  Fr.,  Rougeole;  Ger.,  Masern;  ltd.,  Rosolia. 

Definition. — An  acute,  highly  contagious  disease,  characterized 
by  fever,  marked  catarrhal  symptoms  of  the  respiratory  tract  and  the 
occurrence  of  a  macular  rash  about  the  fourth  day  of  illness,  without 
any  abatement  of  the  earlier  symptoms. 

Symptoms.- — The  disease  usually  begins  as  a  common  cold.  At 
first  a  feverish  condition  is  noticed,  and  there  may  be  slight  shivering, 
but  rarely  a  decided  chill.  Sneezing  and  coryza  are  often  the  earliest 
symptoms  observed,  and  soon  become  very  pronounced.  There  is  slight 
running  at  the  nose,  and  the  eyes  are  irritable,  reddened,  and  watery. 
More  or  less  intolerance  to  light  is  noticed.  Examination  of  the  mouth 
and  throat  will  show  a  furred  tongue  and  hyperemia  of  the  fauces. 
Toward  the  end  of  the  initial  stage  a  distinct  punctiform  rash  may  be 
seen  on  the  mucous  membrane  of  the  mouth,  with  the  exception  of  the 
tongue.  On  the  buccal  mucous  membrane  opposite  the  molar  teeth 
may  also  be  seen. in  most  cases  minute  bluish-white  specks  at  the  sum- 
mits of  small  red  spots.  These  are  known  as  Koplik's  spots. 

Subacute  laryngitis  is  commonly  present.  This  is  denoted  by  hoarse- 
ness and  a  troublesome  cough,  which  is  dry,  sonorous,  and  distressing. 
The  hyperemia  may  extend  lower  down  in  the  respiratory  tract  and  give 
rise  to  symptoms  of  bronchitis.  With  these  local  catarrhal  affections, 
which  may  vary  greatly  in  severity  in  different  cases,  there  is  usually 
proportionate  pyrexia,  the  axillary  temperature  varying  from  101°  to  104° 
F.  The  appetite  is  impaired  or  lost.  There  is  often  headache,  always 
debility  or  lassitude,  and  sometimes  nausea  and  vomiting.  Epistaxis 
is  not  uncommon.  Convulsions  may  be  seen  in  children,  but  are  not 
of  frequent  occurrence.  Spasm  of  the  glottis  or  false  croup  sometimes 
occurs  in  young  children. 

The  average  duration  of  the  initial  stage  is  about  four  days.  It  may 
be  as  short  as  two  or  three  days,  but  more  frequently  it  is  as  long  as  five 
or  six  days,  and  sometimes  even  longer. 

The  eruption  first  appears  on  the  face  and  neck.  On  the  neck, 
behind  the  angle  of  the  jaw,  it  often  assumes  its  distinctive  character 
earlier  than  anywhere  else.  It  appears  as  small  red  spots  which  increase 


472 


INFLAMMA  TIONS 


in  number  and  size,  spreading  over  the  face  first  and  rapidly  extending 
to  the  trunk  and  extremities.  The  redness  now  entirely  disappears  on 
pressure.  The  eruption  is  macular  in  character,  sometimes  becoming 
somewhat  papular  on  some  parts  of  the  body,  but  never  presenting  to 
the  touch  the  shotty  sensation  peculiar  to  variola.  When  fully  developed, 
the  eruption  arranges  itself  into  irregular  outlines  which  are  commonly 
described  as  crescentic  in  shape,  with  here  and  there  normal  skin  inter- 
vening. At  this  stage  the  face  is  slightly  swollen  and  the  lymphatic 
glands  of  the  neck  may  become  somewhat  enlarged  and  sensitive,  though 
the  latter  symptom  is  not  so  prominent  as  in  scarlet  fever.  The  cur- 
vilinear or  peculiar  shaped  character  of  the  eruption  is  usually  found 
best  marked  on  the  chest,  abdomen,  and  back.  The  eruption  reaches 
its  fullest  development  on  the  face  on  the  second  day,  and  on  the  trunk 
on  the  third  day,  when  it  begins  to  recede  on  the  face.  On  the  fourth 
day  it  is  still  seen  on  the  trunk  and  extremities,  but  presents  a  faded 
appearance.  After  the  eruption  disappears  there  remain  for  several 
days  innumerable  yellowish-brown  spots,  giving  to  the  skin  a  distinctly 
mottled  appearance. 

The  fever  and  catarrhal  symptoms,  so  prominent  in  the  initial  stage, 
do  not  abate  with  the  appearance  of  the  eruption.  On  the  contrary, 
the  fever  not  infrequently  is  highest  after  the  eruption  appears,  reaching 
often  104°  to  105°  F.  on  the  first  and  second  days.  On  the  third  or  fourth 
day  of  this  stage,  when  the  eruption  is  fading,  the  temperature  falls 
rapidly  to  normal,  and  the  catarrhal  symptoms  also  become  markedly 
mitigated.  The  fall  is  usually  by  crisis;  when  by  lysis  it  is  probably 
because  of  the  persistence  of  the  catarrhal  symptoms. 

After  the  rash  has  entirely  disappeared  a  slight  desquamation  occurs 
in  the  form  of  fine  furfuraceous  scales,  often  so  fine  as  to  be  scarcely 
noticeable.  It  is  certainly  not  to  be  compared  to  the  coarse  desquama- 
tion in  scarlet  fever.  In  the  absence  of  complications  all  symptoms  now 
rapidly  disappear,  and  convalescence  is  established. 

The  description  given  applies  to  typical  measles,  but  it  is  well  known 
that  in  epidemics  atypical  cases  are  common.  Sometimes  the  disease 
is  so  mild  and  thought  to  be  so  trivial  that  the  family  physician  is  not  sent 
for.  Every  patient,  however,  should  be  confined  to  bed.  The  stage 
of  invasion  may  be  abnormally  short,  lasting  only  thirty-six  or  forty- 
eight  hours,  and  marked  by  mild  symptoms;  or,  on  the  other  hand,  it 
may  be  prolonged  to  five  or  six  days  and  attended  by  severe  and  painful 
catarrhal  symptoms  and  extreme  systemic  depression.  The  eruption 
also  may  be  abnormal  either  in  its  mildness  or  intensity.  The  macules 
may  be  very  scanty,  or  even  quite  abundant,  and  disappear  with  re- 
markable rapidity;  or  they  may  be  so  copious  as  to  constitute  a  general 
efflorescence,  quite  like  the  redness  of  erysipelas.  A  high  temperature 
and  an  adynamic  condition  are  common  in  the  latter  form  of  the  disease. 
The  severest  and  most  dangerous  type  of  measles  is  the  hemorrhagic. 
Fortunately,  these  cases  are  not  common  in  family  practice.  They  are 
met  with  occasionally  in  crowded  institutions,  in  military  camps,  and 
in  bad  hygienic  environments.  In  this  type  of  the  disease  the  early 
symptoms  are  severe,  and  the  eruption  never  develops  properly.  The 


RUBE  OLA  —  MEASLES 


473 


spots  at  the  beginning  are  livid,  and  soon  become  petechial.  Hemor- 
rhages occur  from  the  nose  and  often  from  the  mucous  membrane  of 
other  parts.  There  is  profound  systemic  depression,  and  death  is  apt  to 
occur  early  from  disorganization  of  the  blood. 

In  measles  complications  are  not  infrequent,  especially  in  certain 
epidemics.  Those  most  commonly  met  with  are  inflammations  of  the 
respiratory  tract.  Bronchitis  and  bronchopneumonia  are  most  frequent 
and  most  dangerous,  especially  in  infancy  and  early  childhood.  These 
affections  more  often  occur  during  the  decline  of  the  eruption.  Lobar 
pneumonia  may  occur,  but  is  less  frequent  and  not  so  dangerous.  Phthi- 
sis pulmonalis  sometimes  follows  an  attack  of  measles.  Laryngitis 
of  mild  form  is  not  at  all  uncommon,  and  may  give  rise  to  symptoms  of 
spasmodic  croup.  In  severe  and  fatal  epidemics  diphtheric  laryngitis 
or  membranous  croup  not  infrequently  occurs,  requiring  for  its  relief 
intubation  or  tracheotomy.  Recovery  from  this  complication  is  very 
uncertain.  Catarrhal  inflammation  of  the  middle  ear  is  seen  sometimes, 
but  not  so  frequently  as  in  scarlet  fever.  The  mild  conjunctivitis  com- 
monly present  may  develop  into  the  purulent  form ;  so  also  it  may  become 
chronic  and  persist  as  a  sequel.  Likewise  iritis,  blepharitis,  keratitis,  and 
some  other  eye  affections  occasionally  develop  as  sequels. 

Complications  located  in  the  mouth  and  intestinal  tract  are  some- 
times met  with.  Aphthae  and  ulcerative  stomatitis  are  not  uncommon. 
Gangrenous  stomatitis  or  cancrum  oris  may  occur.  The  form  known  as 
noma  usually  progresses  rapidly  to  a  fatal  termination.  Intestinal 
catarrh  causing  troublesome  diarrhea  occurs  not  infrequently,  and  it  may 
lead  to  enterocolitis,  especially  in  very  young  children  or  debilitated 
subjects. 

Diagnosis. — In  the  diagnosis  of  measles  it  is  important  to  bear 
in  mind  the  symptoms  of  the  two  principal  stages  of  the  disease.  Usually 
it  is  quite  impossible  to  fully  recognize  its  presence  during  the  first  or 
initial  stage.  But  if  to  such  symptoms  as  persistent  sneezing,  watery 
eyes,  slight  discharge  from  the  nares,  a  hoarse,  rasping  cough,  and  rise 
of  temperature  there  can  be  added  a  history  of  exposure,  the  diagnosis 
of  measles  may  be  made  with  a  reasonable  degree  of  certainty.  Such  a 
history,  however,  can  but  rarely  be  obtained  in  isolated  cases,  and  hence 
the  diagnosis  in  the  majority  of  cases  cannot  positively  be  made  until 
the  rash  appears.  It  is  important  to  remember  that  the  rash  often  ap- 
pears first  on  the  mucous  membrane  of  the  mouth  and  fauces.  The 
presence  of  Koplik's  spots  may  help  one  to  arrive  at  an  early  diagnosis, 
but  these  are  sometimes  absent. 

The  distinguishing  feature  of  the  disease  is  the  rash,  which  appears 
after  a  catarrhal  stage  of  about  four  days.  It  is  first  seen  on  the  face, 
and  rapidly  spreads  over  the  entire  body.  The  spots  are  red,  macular 
in  character,  and  show  a  tendency,  when  fully  developed,  to  arrange 
themselves  into  irregular  shapes,  with  traces  of  normal  skin  intervening, 
giving  to  the  eruption  curvilinear  or  crescentic  outlines.  The  eruption 
is  distinguished  from  that  of  small-pox  in  that  it  is  macular  instead  of 
papular,  and  that  it  never  develops  into  vesicles  nor  pustules.  The 
disease  with  which  measles  is  more  likely  to  be  confounded  is  scarlet 


474 


INFLAMMA  TIONS 


fever.  In  the  latter  affection  the  initial  stage  is  short,  usually  not 
longer  than  twenty-four  hours,  and  the  rash  first  appears  upon  the  trunk, 
rapidly  spreading  to  all  parts  of  the  body  with  the  exception  of  the  face, 
which  is  often  not  perceptibly  involved.  It  differs  from  the  rash  of 
measles  in  that  it  is  diffuse  and  punctiform  in  character.  The  exclusion 
of  rotheln  is  at  times  most  difficult.  This  affection  may  be  differentiated 
by  the  absence  of  prodromal  symptoms,  or,  if  present,  by  their  shorter 
duration  and  by  the  milder  fever.  The  rash  may  be  discrete  or  confluent, 
but  it  seldom  assumes  the  so-called  crescentic  arrangement.  Drug- 
rashes  may  be  excluded  by  the  absence  of  fever  and  catarrh  of  the  res- 
piratory tract. 

ROTHELN 

Synonyms. — Rubella;  German  measles;  Epidemic  roseola;  Hybrid  measles; 
French  measles;  Fr.,  Roseola  epidemique. 

Definition. — Rubella,  or  rotheln,  is  a  mild,  contagious,  eruptive  dis- 
ease, with  a  slight  febrile  action,  and  usually  of  but  several  days'  duration. 

Symptoms. — The  period  of  incubation  is  somewhat  variable, 
usually,  however,  from  one  to  three  weeks;  with  a  stage  of  invasion, 
frequently  but  a  few  hours,  scarcely  ever  exceeding  one  or  two  days, 
and  characterized  by  slight  malaise,  enlargement  of  the  cervical  glands, 
and  less  frequently  the  other  lymphatic  glands,  generally  insignificant 
febrile  action,  and  sometimes  with  headache  and  pains  in  the  extremities. 
Exceptionally  there  may  be  some  symptoms  of  nervous  character. 
Very  often,  however,  constitutional  disturbance,  which  is  rarely  marked, 
is  entirely  or  apparently  wanting,  and  the  first  recognizable  sign  of  the 
malady  is  the  rash.  This  may  first  present  upon  any  part,  but  much 
more  commonly  on  the  upper  half  of  the  body,  and  frequently  on  the 
face  and  scalp,  and  extends  rapidly  downward.  Sometimes  along  with 
the  rash  slight  catarrhal  symptoms  are  also  noted,  as  mild  coryza,  injec- 
tion of  the  conjunctiva,  with  lacrimation  and  slight  redness  and  soreness 
of  the  fauces.  The  eruption  usually  consists  of  more  or  less  rounded 
rosy  spots,  varying  in  size  from  a  pin-head  to  that  of  a  lentil,  and  which 
are  made  up  of  closely  set  points,  with  trifling  but  scarcely  recognizable 
elevation,  being  macular  or  maculopapular  in  character.  The  color 
rarely  gets  beyond  a  pale  red,  never  violaceous.  Sometimes  the  tint 
extends  as  a  faint  halo  just  a  little  beyond  the  border  of  the  actual  lesion. 
The  spots  may  be  somewhat  disseminated  or  more  or  less  crowded,  the 
eruption  seldom  covering  more  than  half  the  surface;  it  not  only  spreads 
rapidly,  but  as  it  spreads  the  first  spots  are  frequently  already  disap- 
pearing. The  rash  rarely  lasts  more  than  a  few  days  from  beginning  to 
the  end.  Desquamation  is  unusual,  and  when  observed,  is  commonly 
of  an  almost  imperceptible  branny  character.  The  general  symptoms, 
if  present,  are  scarcely  ever  pronounced,  the  temperature  only  occasion- 
ally going  beyond  100°  F.,  and  very  often  it  is  normal  throughout.  In 
exceptional  instances  relapse  occurs,  either  immediately  or  after  several 
days,  but  not  later  than  two  weeks  (Emminghaus).1  The  eruption  is 

1  Quoted  by  Atkinson,  Amer.  Jour.  Med.  Sci.,  Jan.,  1887,  in  an  excellent  paper  on 
the  disease,  giving  its  history,  with  numerous  references.  Relapses  were  also  noted  in  a 
few  instances  by  Harrison,  Brit.  Jour.  Derm.,  1892,  p.  112,  and  also  by  other  writers. 


ROTHELN 


475 


not  always  a  clearly  distinctive  one,  as  it  may  resemble  both  measles 
and  scarlet  fever;  as  Crozer  Griffith1  states,  "the  eruption  is  maculo- 
papular,  pin-head  to  split-pea  size,  pale-rose,  multiform,  usually  discrete, 
sometimes  grouped  as  in  measles,  sometimes  confluent  as  in  scarlatina." 
It  undoubtedly  more  frequently  bears  decided  resemblance  to  measles, 
and  in  considering  the  points  of  difference,  Atkinson  truly  says  that  there 
is  no  feature  of  either  affection  that  may  not  be  sometimes  observed  in 
the  other,  whether  it  belong  to  the  incubative,  invasion,  eruptive,  or 
desquamative  stages. 

The  most  common  subjects  of  the  disease  are  children,  it  being  most 
frequent  between  the  ages  of  five  and  fifteen;  adults  are  only  rarely 
affected.  The  disease  is  not  thought  to  recur,  one  attack  giving  im- 
munity. It  is  usually  epidemic  in  character,  seldom  presenting  sporadic- 
ally, so  that  reported  sporadic  cases  must  be  looked  upon  with  consid- 
erable doubt,  as  the  possibilities  of  an  erroneous  diagnosis  are  naturally 
great.  The  danger  of  contagion  is  believed  to  be  greatest  during  the 
eruptive  period. 

Diagnosis. — The  malady  is  to  be  distinguished  from  measles, 
scarlet  fever,  and  the  medicinal  erythemata.  The  mildness  of  the  dis- 
ease, its  short  period  of  invasion,  often  entirely  absent;  the  rapid  develop- 
ment and  disappearance  of  the  rash,  the  slight  angina  and  conjunctival 
injection;  and,  as  a  rule,  the  absence  of  a  tendency  to  crescent  shape  or 
to  scarlatinous  confluence;  the  slight  or  lacking  febrile  action,  the  en- 
larged cervical  glands;  and  the  usually  almost  imperceptible,  often 
absent,  character  of  the  desquamation,  are  the  distinguishing  features. 
The  importance  of  the  glandular  enlargement  referred  to  has  been  em- 
phasized by  many  writers,  and  while  taken  together  with  other  factors 
is  of  great  value,  is  not  to  be  given  too  much  weight,  as  Atkinson,  Crozer 
Griffith,  and  others  have  called  attention  to  the  fact  that  it  is  very  often 
observed  in  measles  also.2  In  typical  examples  of  the  malady  there  is 
seldom  any  difficulty  in  reaching  a  correct  diagnosis,  but  in  atypical 
cases  it  is  only  by  a  careful  consideration  of  the  points  of  difference  in 
these  several  febrile  eruptive  diseases,  sometimes  supplemented  by  one 
or  two  days'  observation,  that  error  can  be  avoided.  From  the  medicinal 
rashes  there  is  rarely  much  trouble  in  distinguishing  it,  as  these  are 
usually  more  pronounced,  the  eruptions  more  vivid  or  dark  red,  with  the 
absence  of  the  other  symptoms  of  rotheln,  as  well  as  a  history  of  drug 
ingestion. 

Prognosis  and  Treatment.— The  malady  is,  as  a  rule,  a  trivial 
affair  and  is  over  in  the  course  of  several  days  or  a  week  or  so,  and  there 
are  not,  as  often  observed  in  measles  and  scarlet  fever,  any  sequelae.  It  is 
true,  as  in  any  other  disease,  complications  may  arise  in  this,  doubtless 
independently  of  the  malady  itself,  and  the  outcome  would  then  depend 
upon  the  nature  of  the  complication,  a  few  deaths  having  been  reported 
in  consequence  of  such  accident.  The  treatment  is  purely  expectant, 

1  Crozer  Griffith  (a  report  of  150  cases),  Med.  Record,  July  2  and  9,  1887  (with  full 
bibliography). 

2  Crozer  Griffith,  "The  Differential  Diagnosis  of  Rubeola  and  Rubella,  with  Espe- 
cial Reference  to. the  Enlargement  of  the  Glands  of  the  Neck,"  University  Med.  Mag., 
Philadelphia,  June,  1892. 


476  INFLAMMATIONS 

and  generally  none  is  required.    The  patient  should  be  kept  housed, 
and  if  there  is  febrile  action,  in  bed,  and  with  a  plain  diet. 


VARICELLA 

Synonyms. — Chicken-pox;  Water-pox;  Variolae  spuriae;  Fr.,  Variolette;  Ger.t 
Spitzblattern. 

Definition. — A  contagious  febrile  systemic  affection  of  benign 
type,  occurring  chiefly  in  children,  and  characterized  by  an  eruption 
of  discrete,  scattered,  superficially  seated,  thin-walled,  usually  small 
pea-sized  vesicles. 

It  seems  strange  that  even  at  this  late  date  there  should  still  exist 
physicians  who  look  upon  small-pox  and  chicken-pox  as  identical.  This 
was  the  teaching  of  the  Vienna  school  under  Hebra,  and  this  view  was 
maintained  by  Kaposi,  but  it  need  scarcely  be  said  that  those  holding 
this  opinion  to-day  are  extremely  few  and  isolated,  and  that  even  a 
suggestion  of  such  an  association  to  American  and  English  minds  is 
received  with  complete  incredulity,  and  opposed  by  all  extended  clinical 
observation  and  experience  and  the  facts  evolved  by  the  effect  of 
vaccination. 

Symptoms. — The  eruption  may  be  the  first  evidence  recognizable 
by  the  patient,  appearing  without  appreciable  systemic  disturbance. 
On  the  other  hand,  there  may  be  for  several  hours  or  one  or  two  days 
premonitory  symptoms  of  slight  malaise,  chilliness,  and  mild  febrile 
action,  which  in  average  cases  are  scarcely  sufficiently  well  marked  to 
elicit  more  than  passing  attention.  Exceptionally  however,  in  extremely 
susceptible  children  and  in  cases  in  which  the  eruption  is  extensive,  the 
prodromal  disturbance  may  be  relatively  severe.  The  eruption  makes 
its  appearance  slowly,  as  a  rule,  and  never  all  at  once,  presenting  usually 
first  upon  the  trunk  and  head,  more  especially  the  scalp.  If  seen  in 
their  earliest  formation,  or  if  the  development  of  the  later  lesions  is 
watched,  the  first  stage  is,  as  a  rule,  noted  to  be  a  small  hyperemic  spot, 
in  the  center  of  which  a  minute,  elevated,  vesicopapule  or  vesicle  appears, 
pin-point  to  pin-head  in  size,  rapidly  growing  to  small  pea-sized,  the 
pinkish  or  reddish  peripheral  portion  of  the  macule  or  spot  usually 
measurably  or  completely  subsiding  during  the  vesicular  evolution. 
New  lesions  continue  in  an  ill-defined,  crop-like  manner  or  irregularly, 
several  or  more  at  a  time  for  twenty-four  to  forty-eight  hours,  and  some- 
times slightly  longer. 

The  eruption,  when  sufficiently  developed, — usually  in  from  several 
hours  to  a  day  after  it  begins, — is  noted  to  consist  of  scattered  vesicles 
of  scanty  or  abundant  or  variable  number,  and  in  various  stages  of  forma- 
tion; usually  some  clearly  defined,  rounded,  translucent,  small  or  large 
pea-sized  vesicles,  with  practically  no  areola,  some  with  a  small  areolae 
band;  others  with  minute  beginning  vesicular  lesions  presenting  at  the 
central  point  of  small  pinkish  or  reddish  spots  or  macules.  In  short, 
various  stages  of  the  lesional  formation  can  usually  be  seen,  although 
in  some  instances  many  are  fairly  well-rounded  and  mature  pea-sized 


VARICELLA 


477 


vesicles,  many  of  which  stand  out  from  the  skin  without  surrounding 
band  of  redness;  others  are  somewhat  irregularly  shaped.  In  some  of 
the  vesicles  the  walls  are  somewhat  flaccid,  always  thin,  often  ruptured 
accidently.  In  larger  lesions,  and  especially  if  of  slow  formation,  while 
the  enlargement  from  a  pin-head-sized  vesicle  into  that  of  a  pea-sized 
is  taking  place  by  peripheral  extension,  the  central  part  has  already 
begun  to  dry,  and  is,  compared  to  the  fresher  peripheral  portion,  de- 
pressed. Umbilication,  therefore,  while  not  a  common  feature  as  thus 
described,  is  not  infrequent  in  several  or  more  marked  or  maturing 
lesions. 

As  a  rule,  the  individual  lesions  reach  full  development  in  several 
hours  to  one  or  two  days,  by  which  time  desiccation  has  already  set 
in,  drying  to  thin,  film-like  crusts.  The  contents,  at  first  clear,  soon 
become  milky,  and  later  may  be  slightly  puriform.  This  latter  probably 
results  usually  from  accidental  irritation  or  inoculation;  it  is  chiefly  in 
such  lesions,  particularly  when  scratched  and  made  more  inflammatory 
and  sometimes  impetiginous,  that  slight  scarring  results.  This  is  uncom- 
mon, however,  and  when  occurring  is  usually  in  some  lesions  on  the  face. 
Subjective  symptoms  are  rarely  complained  of,  but  occasionally  there 
is  itching,  and  in  extensive  cases,  some  tenderness.  The  eruption  is 
commonly  scanty,  and  chiefly  seated  upon  the  trunk,  more  numerous 
usually  upon  the  back;  the  scalp  also  generally  shows  some  vesicles,  but 
the  face  and  extremities  relatively  few.  Sometimes  they  are  also  ob- 
served on  the  adjoining  mucous  surfaces,  more  especially  in  the  mouth 
and  throat;  the  covering  is  soon  broken  or  rubbed  off,  and  superficial 
abrasions  result.  Exceptionally  the  eruption  may  be  quite  extensive, 
but  with  no  tendency  to  confluence,  grouping,  or  bunching;  in  such 
instances  the  constitutional  disturbance,  generally  slight,  usually  con- 
tinues until  the  height  of  the  malady  is  reached.  The  process  is,  as  a 
rule,  ended,  and  the  crusts  fallen  off  in  from  seven  to  twelve  days  after 
the  inception  of  the  disease. 

Exceptionally  the  vesicles  are  somewhat  large,  exceeding  the  size 
of  small  or  medium-sized  peas;  or  such  pemphigoid  development  is 
noticed  to  follow  the  ordinary  sized  lesions,  developing  from  the  latter 
or  arising  independently.  In  such  rare  instances,  as  doubtless  in  the 
4  cases  reported  by  Pye-Smith,1  it  seems  probable  that  the  bleb  eruption 
is  not  necessarily  a  part  of  the  varicella,  but  is  due  to  some  accidental 
and  subsequent  infection.  The  seriousness  of  this  development  or  com- 
plication would  also  support  this  belief.  To  accidental  infection  is  also 
to  be  attributed  that  condition  known  as  varicella  gangraenosa  (q.  v.), 
in  which  gangrenous  development,  in  rare  instances,  follows  upon  vari- 
cellous  and  other  eruptive  lesions. 

Btiology  and  Pathology. — The  malady  is  contagious,  and,  ac- 
cording to  Hutchinson  and  LeGendre,  it  is  inoculable,  although  Smith2 
failed  to  produce  it  in  his  experimental  attempts.  One  attack  is  usually 
protective — it  is  rarely  observed  twice  in  the  same  individual.  Nor 
does  an  attack  protect  against  small-pox,  as  would  be  the  fact  were  the 

1  Pye-Smith,  "Four  Cases  of  Bullous  Varicella,"  Brit.  Jour.  Derm.,  1897,  p.  148. 

2  J.  Lewis  Smith,  Diseases  of  Children,  1896  edition,  p.  326. 


478  1NFLAMMA  TIONS 

two  diseases  at  all  related.1  It  has  been  alleged  that  it  occurs  most 
frequently  immediately  before,  during,  and  after  small-pox  epidemics, 
but  this  will  not  bear  the  test  of  investigation.  The  period  of  incubation 
doubtless  varies  somewhat  from  ten  to  seventeen  or  eighteen  days- 
Smith's  observations  indicate  between  fifteen  and  seventeen  days. 
Young  children  are  its  usual  subjects.  In  an  analysis  by  Baader  (quoted 
by  Smith,  loc.  cit.)  of  584  cases,  382  occurred  between  the  ages  of  one  and 
five,  191  between  six  and  ten,  7  between  eleven  and  fifteen,  2  between 
sixteen  and  twenty,  and  2  between  twenty-one  and  forty.  I  have  ob- 
served an  instance  of  its  occurrence  in  a  man  past  sixty.  The  most 
common  age  is  about  three. 

The  pathologic  changes  are  superficial,  rarely  extending  below  the 
middle  layers  of  the  rete,  in  this  respect  differing  from  variola,  in  which 
the  process  is  most  pronounced  in  the  lowest  layers  and  the  papillary 
body.  The  vesicle  cavity  is,  in  the  earliest  stages  at  least,  divided  by 
septa,  as  in  the  latter  disease,  but,  according  to  Unna,2  in  varicella  the 
septa  join  on  the  covering  wall,  whereas  in  the  small-pox  lesion  at  the 
center  of  the  base.  The  cavity  proper  occupies  only  the  upper  part  of 
the  much  widened  prickle  layer.  Fibrinoid  degeneration  of  the  epithe- 
lium takes  place,  and  to  which  process  Unna  gives  the  name  of  "reticulat- 
ing colliquation,"  in  view  of  the  most  frequently  recognizable  stage  of  the 
fibrinous  reticulum. 

Diagnosis. — The  diagnostic  points  in  varicella  are  the  absence  or 
lightness  of  the  systemic  disturbance,  the  distribution  of  the  eruption, 
usually  most  pronounced  on  trunk,  and  often  on  scalp,  the  superficial 
nature  of  the  lesion,  its  thin,  easily  ruptured  wall,  and  the  irregular, 
crop-like  appearance  of  the  eruption.  The  disease  with  wrhich  it  is  most 
likely  to  be  confounded  is  small-pox,  more  especially  in  the  earlier  stage. 
Morrow3  states  that  in  an  analysis  of  38  cases  of  error  reported  to  the 
New  York  Health  Board  at  a  certain  period  for  small-pox,  17  were  cases 
of  chicken-pox.  It  is  true  that  urticaria  bullosa,  impetigo  contagiosa,  and 
a  few  other  diseases  have  occasionally  been  confounded  with  varicella, 
but  such  mistakes  are  usually  the  result  of  hasty  and  imperfect  exam- 
ination, and  readily  avoidable,  as  the  features  of  these  several  affections 
(q.  v.)  are  sufficiently  distinctive. 

The  disease  differs  from  variola  in  many  particulars,  although  the 
differences  are  much  less  recognizable  when  it  concerns  mild  cases  of 
small-pox  or  varioloid  and  severe  cases  of  chicken-pox.  The  most  im- 
portant differential  points  in  my  judgment  are  the  distribution,  the 
manner  of  appearance,  the  character  of  the  lesion  and  its  thin  covering 
or  wall,  and  the  nature  of  the  constitutional  symptoms.  In  chicken- 

1  See  a  suggestive  and,  for  the  patient,  extremely  unfortunate,  exemplification  of 
this  fact  reported  by  Dyer  "On  the  Differential  Diagnosis  of  Varicella  and  Variola," 
New  Orleans  Med.  and  Surg.  Jour.,  Jan.,  1896.     The  patient,  according  to  Dyer's 
opinion,  presented  varicella,  but  was  placed  in  the  small-pox  hospital  by  the  municipal 
authorities,  who  considered  the  case  variola;  the  patient  made  the  usual  course  of  aver- 
age varicella  and  was  discharged;  a  few  days  subsequently  he  presented  small-pox  of 
confluent  form,  was  again  taken  to  the  hospital  where  he  had  contracted  the  disease, 
and  died. 

2  Unna,  Histopathology,  p.  635. 

3  Morrow,  "On  the  Diagnosis  of  Small-pox,"  Jour.  Culan.  Dis.,  1886,  p.  72. 


VARICELLA  479 

pox  the  trunk  presents  the  most  lesions,  and  the  face,  hands,  and  ex- 
tremities are  comparatively,  or  in  some  cases  wholly,  free;  whereas  in 
variola  the  hands  and  face  and  extremities  are  generally  most  markedly 
involved.  In  chicken-pox  the  eruption  rarely,  if  ever,  comes  out  at 
once,  but  there  are  irregular  or  crop-like  outbreaks  for  two  or  three  days, 
although  the  largest  number  appear  with  the  first  outbreak;  the  lesions 
are,  therefore,  to  be  found  in  all  stages  of  evolution.  They  begin  as 
hyperemic  spots  from  the  center  of  which  a  vesicle  develops,  or  they 
begin  as  vesicles;  the  beginning  spot  or  lesion  is  never  hard  or  shotty.  In 
small-pox,  on  the  contrary,  the  lesions  usually  appear  at  one  time  or 
within  several  hours  or  a  day,  and  their  evolution  and  course  are,  there- 
fore, uniform,  although  naturally  some  lesions  may  be  larger  than  others; 
they  are  distinctly  hard  and  shotty  in  the  beginning.  The  lesions  of 
varicella  are  discrete  and  usually  scattered,  with  no  tendency  to  close 
grouping,  bunching,  or  confluence.  In  variola  closely  set  grouping  or 
crowding  together  and  confluence  are  quite  common.  The  lesion  of 
varicella  is  relatively  rapid,  often  beginning  to  crust  over  in  a  few  days, 
whereas  that  of  variola  is  slow  and  much  longer  in  its  course.  The 
character  of  the  lesions  in  the  two  diseases  is  often  strikingly  different. 
The  varicella  vesicle  is  extremely  superficial,  thin-walled,  translucent, 
often  of  irregular  or  irregularly  rounded  shape,  and  easily  broken,  acci- 
dentally or  intentionally;  whereas  that  of  variola  is  deep-seated,  often 
markedly  globular;  the  covering  is  thick  and  tough,  with  little  if  any 
tendency  to  break,  even  if  roughly  handled,  and  with  a  yellowish  cast, 
but  not  translucent,  owing  to  the  thickness  of  the  walls.  Umbilication 
is  not  an  essential  feature  of  varicella,  and  is  generally  seen  only  in  few 
lesions,  and  these  the  larger  and  usually  the  relatively  slow-developing 
vesicles,  and  it  frequently  results  from  a  beginning  desiccation  of  the 
central  or  earliest  formed  part;  the  lesions  rarely  become  pustular;  as  a 
rule,  only  slightly  cloudy  or  milky,  and  are  not  distinctly  multilocular. 
In  variola  a  sinking-in  of  the  central  part  is  a  common  feature  of  all  cases 
and  all  lesions,  and  is  observed  long  before  the  actual  desiccating  stage 
has  been  reached,  being,  in  fact,  a  part  of  the  advanced  vesicular  stage, 
the  lesions  becoming  globular  as  they  develop  into  pustules,  and  again 
slightly  umbilicated  as  desiccation  takes  place;  the  lesions  all  become 
purulent,  and  are,  except  in  the  very  latest  stage,  clearly  multilocular. 
Scarring  is  the  rule  in  variola,  and  rare  in  varicella,  and  then  usually 
due  to  accidental  irritation.  The  constitutional  disturbance  hi  varicella 
is  slight  or  wanting,  except  in  the  extensive  cases,  and  the  eruption  is 
often  the  first  evidence  of  the  malady.  Even  in  severe  cases  it  usually 
subsides  rapjdly  after  the  eruption  has  appeared  or  reached  full  develop- 
ment, and  does  not  reappear;  in  variola,  on  the  other  hand,  there  are 
almost  always  distinct  prodromal  symptoms  for  several  days — headache, 
backache,  general  rheumatic  pains,  some  gastric  uneasiness,  and  febrile 
action,  especially  developing  with  the  eruption,  upon  the  full  appearance 
of  which  it  partially  subsides,  to  become  marked  again  when  the  pustular 
stage  approaches. 

Prognosis  and  Treatment — The  disease  is  benign  and  runs  a 
quick,  favorable  course,  recovery  ensuing  in  one  to  two  weeks.     Rare 


480  INFLAMMA  TIONS 

instances  of  fatal  ending  are,  in  all  probability,  purely  accidental,  and 
due  to  some  complication  wholly  independent  of  the  varicella  exanthem. 
Treatment  is  purely  hygienic  and  expectant.  As  a  matter  of  precaution, 
the  patient  should  be  kept  housed,  and  if  the  eruption  is  at  all  extensive, 
in  bed.  A  mild  antiseptic  dusting-powder,  such  as  boric  acid,  can  be 
used  to  lessen  the  chances  of  accidental  infection.  For  the  same  reason 
scratching  should  be  cautioned  against,  and  if  there  is  sufficient  irritation 
or  itching  present  to  lead  to  this,  a  saturated  solution  of  boric  acid  with 
\  dram  (2.)  of  carbolic  acid  to  the  pint  (500.)  can  be  used. 

VARIOLA 

(W.  M.  WELCH) 
Synonyms. — Small-pox;  Fr.,  Petite- verole;  Ger.,  Blattern  or  Pocken;  Ital.,  Vajuolo. 

Definition. — Small-pox  is  an  acute  infectious  disease  character- 
ized by  an  initial  fever  of  about  three  days'  duration,  succeeded  by  an 
eruption  passing  through  the  stages  of  papule,  vesicle,  and  pustule, 
ending  in  incrustation,  and  leaving  pits  or  scars;  the  fever  either  inter- 
mitting or  remitting  in  the  papular,  and  increasing  in  the  pustular, 
stage. 

Symptoms. — The  period  of  incubation  of  small-pox  is  seldom  less 
than  eight  days  or  more  than  fourteen,  commonly  from  ten  to  twelve 
days.  The  symptoms  constituting  the  initial  stage,  or  stage  of  invasion, 
are  usually  ushered  hi  suddenly  and  often  with  considerable  violence. 
Among  the  earlier  symptoms  is  a  distinct  chill,  which  may  be  mild  or 
severe,  and  wrhich  is  immediately  followed  by  rise  of  temperature.  The 
thermometer  often  registers  103°  or  104°  F.  on  the  first  day,  and  may 
be  a  little  higher  on  the  succeeding  days.  The  pulse  and  respirations 
keep  apace  with  the  febrile  movement.  Prostration  is  often  extreme. 
Vertigo  on  assuming  the  erect  position  is  a  frequent  symptom.  At  this 
time  vomiting  and  epigastric  tenderness  are  commonly  observed.  Head- 
ache usually  begins  at  the  onset  of  the  disease,  and  continues  until  the 
appearance  of  the  eruption.  It  may  be  excruciating,  and,  when  the  fever 
is  high,  accompanied  by  delirium.  Convulsions  are  very  common  in 
children,  and  at  times  there  may  be  coma.  Pain  in  the  lumbar  and 
sacral  regions  comes  on  early,  and,  like  the  headache,  subsides  at  the 
beginning  of  the  eruptive  stage.  This  symptom  is  not  invariably  present, 
although  it  occurs  in  over  one-half  of  the  patients.  In  hemorrhagic  cases 
the  backache  is  often  violent.  A  peculiar  prodromal  rash,  varying  in 
frequency  in  different  epidemics,  often  makes  its  appearance  on  the 
second  day,  and  disappears  within  forty-eight  hours.  It  is  stated  by 
some  authors  to  be  scarlatiniform  in  character,  but  in  my  experience  it 
has  more  often  resembled  measles,  and  has  been  designated  "roseola 
variolosa."  I  have  observed  this  rash  more  frequently  in  varioloid 
than  in  severe  cases  of  variola. 

The  eruption  usually  appears  upon  the  third  day  of  illness,  mani- 
festing itself  first  upon  the  face,  particularly  about  the  forehead,  temple, 
and  mouth,  and  then  rapidly  appearing  upon  the  scalp,  neck,  ears, 
forearms,  and  hands.  In  the  course  of  twenty-four  hours  the  body  and 


VARIOLA 


481 


lower  extremities  become  involved.  The  eruption  continues  to  increase 
for  two  or  three  days  before  its  definite  limit  is  reached.  The  lesions 
consist  at  first  of  minute  red  points,  which  in  the  course  of  twenty-four 
hours  develop  into  elevated  papules  with  characteristic  shot-like  indura- 
tion. On  the  third  day  of  the  eruption  many  of  the  lesions  will  be  found 
to  contain  a  little  clear  serum,  and  by  the  fourth  or  the  fifth  day  all  the 
papules  will  have  been  converted  into  vesicles  with  cloudy  or  milky 
contents.  These  continue  to  enlarge,  attaining  their  maximum  size 
about  the  seventh  or  the  eighth  day.  Many  of  the  vesicles  will  be  seen 
to  have  the  central  depression  or  umbilication,  which  is  a  feature  of 
diagnostic  value. 


Fig.  1 1 8. — Well-marked  discrete  small-pox  on  ninth  day,  showing  lesions  in  the  stage 
of  beginning  crust-formation  (courtesy  of  Dr.  J.  F.  Schamberg). 

The  stage  of  suppuration  usually  commences  about  the  sixth  day, 
when  the  contents  of  the  vesicles  are  yellowish  and  decidedly  puriform. 
In  the  process  of  development  the  pustules  lose  their  umbilication  and 
become  large  and  globular.  The  reddish  areola,  which  at  first  surrounded 
the  lesions,  acquires  greater  breadth  and  a  more  intense  hue.  Where 
the  pustules  are  thickly  set,  as  upon  the  face,  great  swelling  and  intumes- 
cence take  place,  so  distorting  the  patient's  features  as  to  render  him 
completely  unrecognizable.  The  eyelids  are  frequently  so  edematous 
as  to  preclude  the  possibility  of  their  being  opened.  The  lips,  nose,  and 
ears  are  greatly  tumefied,  and  the  scalp  is  swollen  and  painful.  The 
mucous  membranes  are  also  attacked,  the  lesions  manifesting  themselves 
upon  the  lips,  buccal  and  nasal  mucous  membrane,  tongue,  pharynx, 
and  at  times  the  larynx. 

31 


482  INFLAMMA  TIONS 

Upon  the  appearance  of  the  eruption,  or,  more  commonly,  on  the 
second  or  the  third  day  thereafter,  the  temperature  falls,  the  head- 
ache, backache,  vertigo,  vomiting,  etc.,  cease,  and  the  patient  believes 
himself  on  the  road  to  convalescence.  The  subsidence  of  these  symptoms, 
however,  except  in  mild  cases,  is  only  temporary,  for  upon  the  commence- 
ment of  the  stage  of  suppuration  the  temperature  again  begins  to  rise 
and  continues  high  until  the  decline  of  the  suppurative  fever.  The 
height  of  the  fever  is  proportionate  to  the  extent  of  the  eruption,  the 
temperature  varying  from  102°  F.  in  mild  cases  to  104°  or  105°  F.  in 
confluent  small-pox.  Headache,  restlessness,  and  delirium  are  common 
during  this  stage,  the  patient  at  times  sinking  into  the  typhoid  state. 

During  the  stage  of  desiccation,  which  begins  about  the  eleventh 
or  twelfth  day,  the  tumefaction  subsides,  and  the  normal  contour  of 
the  features  is  gradually  restored.  The  contents  of  the  pustules  dry 
into  crusts,  which  process  is  often  accompanied  by  intense  itching. 
The  crust-formation  begins  in  the  center  of  the  pustules,  leading  to  a 
secondary  umbilication.  In  regular  cases  of  variola  vera  the  shedding 
of  the  scabs  requires  a  period  of  three  to  four  weeks,  making  the  entire 
duration  of  the  disease  about  five  or  six  weeks.  After  the  scabs  have 
fallen  the  skin  presents  a  red,  spotted  appearance,  and  is  disfigured  by 
scars  or  pits.  These  are  deepest  on  the  face,  particularly  about  the  end 
and  alae  of  the  nose.  The  hair  is  often  lost,  but  thorough  restoration 
usually  follows. 

The  clinical  history  of  small-pox  is  not  complete  without  reference 
to  other  forms  and  varieties  of  the  disease.  The  above  description 
relates  more  particularly  to  cases  in  which  the  eruption  is  either  dis- 
crete or  semiconfluent.  The  grades  of  small-pox  cover  a  wide  field  of 
variation,  from  an  eruption  consisting  of  but  a  fewT  small  pustules, 
scarcely  sufficient  to  identify  the  disease,  to  an  eruption  completely 
covering  the  entire  cutaneous  surface.  During  the  past  few  years  there 
has  appeared  in  this  country  an  epidemic  of  small-pox  so  unprecedentedly 
and  uniformly  mild  as  to  constitute  an  unwritten  chapter  in  the  history 
of  the  disease.  Its  benignancy  can  be  best  estimated  when  it  is  stated 
that  the  mortality-rate  among  many  thousand  vaccinated  and  unvac- 
cinated  cases  throughout  the  United  States  during  the  first  three  months 
of  1901  was  not  much  over  i  per  cent.  The  clinical  picture  is  that  of 
mild  varioloid,  despite  the  absence  of  any  such  modifying  influence  as 
commonly  exists  in  this  form  of  the  disease.  Therefore  a  brief  descrip- 
tion of  varioloid  will  suffice  to  portray  also  this  unusually  mild  form  of 
small-pox. 

The  prodromal  symptoms  of  varioloid  may  be  severe  or  mild;  in 
the  latter  case  it  being  possible  to  prophesy  a  sparse  eruption.  The 
duration  of  the  initial  stage  is  more  variable  than  in  variola  vera,  varying 
from  twenty-four  hours  to  five  days.  The  eruption  of  varioloid  differs 
from  that  of  variola  only  in  that  it  is  milder  in  its  course  and  shorter  in 
duration.  The  lesions  may  be  limited  to  a  very  few  on  the  face,  or  they 
may  be  semiconfluent.  In  the  milder  forms  the  lesions  may  become 
abortive  at  an  early  period;  in  the  severe  forms  the  evolution  of  the  lesions 
may  not  differ  from  unmodified  small-pox.  The  cutaneous  involvement 


PLATE  XVI. 


Variola— an  extensive  case   showing  numerous  lesions  on  trunk  as  well   as   face  and 
extremities  (courtesy  of  Dr.  G.  W.  Wende). 


VARIOLA 


483 


is  often  superficial,  being  limited  to  the  upper  layers  of  the  skin.  As 
a  result,  we  have  a  shorter  eruptive  course,  earlier  desiccation,  more 
rapid  shedding  of  the  scabs,  and  fewer  and  less  disfiguring  scars.  Occa- 
sionally the  lesions  develop  into  large,  solid  papules,  conic  in  form,  with 
vesicular  summits.  On  shedding  of  the  crusts,  instead  of  pits,  tuber- 
culated  or  warty-looking  excrescences  are  left.  These,  however,  flatten 
down  and  disappear  in  the  course  of  time.  Secondary  fever  is  either 
absent  or  trivial  in  character. 

The  eruption  of  confluent  variola  is  usually  preceded  by  severe 
prodromes,  such  as  high  fever,  intense  headache  and  backache,  vomit- 
ing, etc.  The  temperature  does  not  descend  as  low  on  the  appearance 
of  the  eruption  as  in  milder  cases,  nor  does  the  remission  continue  so 
long.  On  account  of  the  extensive  involvement  of  the  skin,  redness  and 
swelling  begin  early,  the  former  as  early  as  the  second  day.  Many  of 


Fig.  119. — Variola — moderate  case  (courtesy  of  Dr.  G.  W.  Wende). 


the  thickly  set  papules  coalesce,  and  in  the  formation  of  vesicles  the 
confluence  is  so  great  as  often  to  cover  almost  the  whole  cutaneous  sur- 
face. The  confluent  pustules  are  usually  flat,  and  sometimes  present  a 
milky  or  pasty  appearance.  At  the  height  of  the  eruption  the  patient 
is  unrecognizably  disfigured.  The  mucous  membranes  of  the  nose, 
mouth,  pharynx,  and  larynx  are  often  intensely  involved.  The  soft 
palate,  tonsils,  and  tongue  may  become  greatly  swollen,  and  edema  of 
the  glottis  may  lead  to  a  fatal  termination.  Upon  rupture  of  the  pustules 
and  decomposition  of  the  contents  the  stench  often  becomes  unbearable. 
Secondary  fever  is  usually  very  high,  and  death  frequently  occurs  at  this 
period  from  septicemia  and  exhaustion.  When  recovery  takes  place, 
convalescence  is  long  and  tedious,  and  apt  to  be  interrupted  by  the  occur- 
rence of  boils  and  abscesses. 

The  names  petechial,  purpuric,  and  hemorrhagic  variola  are  applied 
to  the  different  phases   presented  by  malignant   small-pox.    A   pete- 


484  INFLAMMA  TIONS 

chial  rash  is  sometimes  seen  at  the  close  of  the  initial  stage,  about  the 
time  the  true  eruption  appears  or  should  appear.  This  is  quickly 
followed  by  the  purpuric  or  hemorrhagic  lesions,  which  lead  rapidly 
to  a  fatal  termination.  At  other  times  petechiae  and  ecchymoses  appear 
between  the  papules  or  vesicles,  the  latter  often  filling  up  with  a  san- 
guinopumlent  fluid.  Variola  purpurica  is  the  most  malignant  form  of 
the  hemorrhagic  type.  At  the  end  of  the  initial  stage,  which  is  par- 
ticularly characterized  by  intense  backache  and  excessive  prostration, 
a  diffuse  scarlatinoid  efflorescence  appears  on  various  parts  of  the  trunk 
and  extremities.  This  gradually  assumes  a  dark-red  or  purplish  colora- 
tion, which  does  not  disappear  on  pressure.  In  addition,  petechiae, 
vibices,  and  ecchymoses  occur.  The  face  soon  becomes  involved, 
presenting  a  swollen  and  puffy  appearance.  Indistinct  sanguinolent 
vesicles,  blackish  or  leaden-gray  in  color,  may  be  seen  in  various  localities. 
As  the  disease  progresses,  the  skin  becomes  almost  black  or  a  deep  indigo 
color.  Hemorrhages  occur  from  the  various  mucous  membranes. 
Death  is  the  almost  inevitable  termination.  In  the  form  designated 
variola  hsemorthagica  pustulosa  the  vesicles,  instead  of  filling  with 
purulent  material,  contain  a  bloody  fluid.  This  condition  of  the  vesicles 
may  be  limited  to  certain  localities  or  may  be  generalized,  with  petechiae 
and  ecchymoses  interspersed.  Hemorrhages  occur  from  the  nose, 
mouth,  and  intestinal  and  urinary  tracts.  This  form  runs  a  somewhat 
longer  course  than  purpura  variolosa,  but  is  almost  as  certain  to  end 
fatally. 

Among  the  common  complications  and  sequelae  of  small-pox  may 
be  mentioned  erysipelas,  boils,  abscesses,  and  disease  of  the  eyeball, 
middle  ear,  respiratory  tract,  and  joints.  Erysipelas  occasionally 
comes  on  during  desiccation,  and  is  apt  particularly  to  involve  the  face. 
Pneumonia  sometimes  occurs.  Furuncles  and  abscesses  are  extremely 
common.  But  few  patients  pass  through  a  well-marked  attack  of  small- 
pox without  suffering  from  boils  during  the  later  stage  of  the  disease. 
Gangrene  of  the  skin,  especially  of  the  scrotum,  is  a  complication  which 
usually  leads  to  a  fatal  termination. 

Diagnosis.— In  the  initial  period  of  the  disease  great  assistance 
may  be  gained  by  determining  the  presence  or  absence  of  vaccine  marks 
and  their  number  and  character.  Furthermore,  by  ascertaining  whether 
or  not  small-pox  is  prevalent,  and  whether  the  patient  has  been  exposed 
to  the  disease.  During  the  eruptive  stage  variola  may  be  confounded 
with  varicella,  pustular  syphiloderm,  impetigo  contagiosa,  drug-rashes, 
etc. 

The  onset  of  varicella  is  very  different  from  that  of  variola.  There 
is  usually  no  distinct  febrile  stage  preceding  the  eruption.  It  is  true 
that  in  many  cases  of  extremely  modified  small-pox  no  reliable  history 
of  an  initial  stage  can  be  obtained,  so  that  in  such  cases  the  diagnosis 
must  be  made  from  the  appearance  and  behavior  of  the  exanthem  alone. 
It  is  important  to  bear  in  mind  the  following  facts:  that  the  lesions  of 
varicella  make  their  appearance  as  distinct  vesicles  containing  perfectly 
clear  serum ;  that  they  are  usually  seen  first  on  parts  of  the  body  covered 
with  clothing,  and  especially  on  the  back,  where  they  are  apt  to  be  most 


PLATE   XVII. 


Variola  on  the  seventh  day,  showing  the  usual  preponderance  of  lesions  on  the  face, 
hands,  and  wrists  (courtesy  of  Dr.  j.  F.  Schamberg). 


VARIOLA  485 

abundant;  that  they  make  their  appearance  in  successive  crops,  and 
may  be  seen  in  every  stage  of  development;  that  they  vary  very  greatly 
in  size ;  that  they  are  unilocular  and  have  an  epidermal  covering  so  deli- 
cate as  to  be  readily  broken  by  the  finger-nail;  that  they  are  rather  soft 
and  velvety  to  the  touch;  that  many  of  them  enlarge  to  a  considerable 
circumference  by  peripheral  expansion,  while  others  are  as  small  as  millet 
seeds;  that  they  are  not  umbilicated  except  by  desiccation  beginning 
in  their  centers;  that  they  run  their  course  to  the  formation  of  crusts 
in  two  to  four  days;  that  the  crusts  are  thin,  brown,  and  friable,  and 
when  they  have  fallen  off,  red  instead  of  pigmented  spots  remain;  and 
that  but  few  of  the  lesoins  are  followed  by  permanent  scars.  The  exan- 
them  of  small-pox,  on  the  other  hand  begins  in  the  form  of  papules  which 
are  firm  and  dense  to  the  touch,  feeling  somewhat  like  grains  of  sand 
buried  in  the  skin;  that  they  usually  appear  first  on  the  face  and  then 
on  other  parts  of  the  body;  that  the  papules  slowly  develop  into  vesicles 
with  milky  or  turbid  contents;  that  the  vesicles  in  well-marked  cases 
are  umbilicated;  that  they  are  multilocular  and  have  an  epidermal  cov- 
ering so  dense  as  not  to  be  easily  broken  by  the  finger-nail;  that  the 
eruption  prefers  the  exposed  parts  of  the  body,  such  as  the  face,  hands, 
and  arms,  being  often  only  sparsely  seen  on  the  trunk;  that  the  vesicles 
are  usually  quite  uniform  in  size;  that  they  change  into  pustules;  that 
the  eruption  requires  in  severe  cases  twelve  or  more  days  to  pass  through 
its  various  stages,  while  in  extremely  mild  cases  not  more  than  five  or 
six  days  are  required;  that  the  crusts  which  form  are  thick  and  very 
dark,  and  when  they  have  fallen  off,  there  remain  pigmented  spots  and 
more  or  less  pitting. 

Despite  the  above  differentiation,  it  must  be  admitted  that  small- 
pox may  occur  in  a  form  so  atypical  as  to  make  the  differential  diag- 
nosis a  matter  of  great  difficulty.  In  such  cases  the  patient  should  be 
isolated  and  carefully  watched  for  a  few  days,  when  the  nature  of  the 
disease  will,  as  a  rule,  be  easily  determined. 

The  lesions  of  the  pustular  syphiloderm  frequently  resemble  very 
closely  those  of  small-pox.  The  difficulty  of  diagnosis  is  often  increased 
from  the  fact  that  the  eruption  in  syphilis  is  not  infrequently  preceded 
by  fever  and  various  aches  and  pains,  and  that  the  lesions  begin  as 
papules  and  end  in  pustules.  Instead  of  appearing  all  at  once,  the 
eruption  of  syphilis  usually  comes  out  in  successive  crops.  Pustular 
syphiloderm,  however,  may  be  distinguished  by  the  milder  constitu- 
tional symptoms  during  the  initial  stage;  by  appearance  of  the  lesions 
in  successive  crops;  by  the  formation,  at  the  summits  of  the  papules, 
of  small  vesicles  which  later  become  pustular;  by  the  large  indurated 
base  of  each  vesicle;  by  the  absence  of  typical  umbilication ;  by  the 
tendency  to  ulceration  of  some  of  the  lesions;  by  the  slower  course  of  the 
eruption,  and  by  concomitant  symptoms  of  syphilis  and  a  history  of 
infection.  In  doubtful  cases  a  few  days'  observation  of  the  patient  will 
usually  suffice  to  determine  the  question;  and  the  examination  for 
the  spirochseta  pallida  and  the  Wassermann  test  can  now  also  be 
resorted  to. 

Impetigo  contagiosa  has  been  confounded  at  times  with  the  mild 


486  INFLAMMA  TIONS 

variola  of  recent  years.  It  may  be  easily  differentiated  by  the  absence 
of  fever,  by  the  usual  limitation  of  the  lesions  to  the  face  and  hands, 
by  the  fact  that  they  are  primarily  vesicular  or  bullous,  rapidly  becoming 
pustular  and  drying  into  flat,  ocher-colored  crusts,  and  by  the  extreme 
superficiality  of  the  process. 

VACONAL  ERUPTIONS 

Synonym. — Vaccination  rashes. 

It  is  beyond  the  scope  of  this  volume  to  go  into  the  method  and 
details  of  vaccination  more  than  briefly,  and  chiefly  as  to  the  cutaneous 
aspect  of  the  resulting  lesions,  and  the  sometimes  engendered  or  pro- 
voked more  or  less  generalized  eruptions.  Vaccinia,  or  cow-pox,  is  a 
well-known  affection  among  certain  animals,  but  more  especially  the 
cow,  and  while  never  occurring  spontaneously  in  the  human  subject, 
its  artificial  production  in  the  latter  by  inoculation,  as  strenuously  pointed 
out  by  Jenner,  affords  a  protection  against  variola. 

The  operation  of  vaccination  is  sufficiently  well  known  to  need  no 
comment.1  For  the  first  few  days  nothing  special  is  observed:  possibly 
a  little  congestion  or  irritation  from  the  procedure.  After  the  lapse  of 
forty-eight  hours  or  thereabouts  a  minute  papule  is  noticed  at  the  point 
or  points  of  inoculation,  which  in  the  course  of  two  or  three  days  more 
has  developed  into  a  vesicle.  Where  several  or  more  have  simultaneously 
arisen  at  contiguous  points  of  the  inoculation  spot  these  usually  merge, 
and  the  subsequent  course  is,  as  a  rule,  the  same  as  when  there  is  but 
one  inoculation  point,  although  in  some  instances  the  resulting  larger 
vesicle  shows  its  compound  nature.  When  several  inoculation  points 
are,  as  the  result  of  intention  or  accident,  at  some  distance  apart,  each 
develops  and  usually  goes  through  the  regulation  course,  although  some- 
times one  undergoes  full  development  and  the  others  partial.  The  vesicle 
enlarges  peripherally,  and  in  from  five  to  seven  days  after  the  operation 
is  a  somewhat  distended,  well-formed  pea-  to  finger-nail-sized,  translu- 
cent vesicle,  frequently  with  a  perceptible  or  well-marked  tendency  to 
central  depression  or  umbilication.  At  this  stage,  in  successful,  and 
usually  especially  pronounced  in  instances  of  first  vaccination,  there  is 
a  well-defined  wide  encircling  red  or  pinkish-red  areola,  with  some 
inflammatory  infiltration  or  hardness.  At  this  time — in  the  sixth  to  the 
eighth  day — constitutional  symptoms  of  variable  degree  present:  slight 
temperature  elevation,  accelerated  pulse,  general  malaise,  often  some 
gastro-intestinal  uneasiness,  and  the  axillary  or  neighboring  lymphatic 
glands  are  somewhat  enlarged  and  tender.  The  lesion  is  usually  ex- 
quisitely sensitive,  and  slight  or  intense  itchiness  may,  at  this  time,  be 

1  Hutchins,  Jour.  Amer.  Med.  Assoc.,  April  23,  1898,  advises  a  simple,  ingenious, 
painless  method,  especially  valuable  in  children,  in  whom  even  the  suggestion  of  a 
trifling  scarification  often  meets  with  opposition.  The  part  to  be  vaccinated  is  first 
cleansed,  and  a  small  piece  of  cotton  is  wet  with  liquor  potassae  and  laid  on  the  spot  for 
two  or  three  minutes;  it  is  then  removed,  and  the  soapy  mixture  thus  formed,  with  the 
epidermis  and  skin  secretion,  wiped  off,  and  the  place  gently  rubbed  with  a  piece  of 
damp  cotton;  the  epidermis,  softened  by  the  liquor  potassae,  comes  readily  away,  and  an 
excellent  bloodless  absorbent  spot  is  thus  made,  on  which  the  vaccine  is  placed  and  let 
dry  on  in  the  usual  way. 


VACCINAL  ERUPTIONS  487 

complained  of.  The  vesicular  contents  now  become  cloudy,  and  by 
the  ninth  or  tenth  day  desiccation  gradually  sets  in,  the  inflammatory 
areola  begins  to  fade,  and  the  general  symptoms  subside,  the  lesion  then 
finally,  by  the  thirteenth  to  the  fifteenth  day,  presenting  as  a  dime-  to 
silver-quarter-sized  yellowish  or  reddish-brown  crust,  with  an  encircling 
narrow  line  of  redness,  which  latter  slowly  disappears;  and  usually  in 
a  little  less  than  three  weeks  from  the  date  of  vaccination  the  crust  has 
fallen  off,  disclosing  a  pinkish  or  reddish  scar  which  slowly  becomes 
whitish  and  shows  minute  pits  or  depressions— the  sites  of  the  primary 
points  of  inoculation.  Exceptionally,  generally  in  those  cases  in  which 
healing  has  been  accidentally  delayed,  a  keloidal  tendency  has  been 
noted,  but  usually  of  slight  development. 

All  cases  are  not  regular  in  their  development  and  course:  in  some 
the  vesicle  develops  early,  in  others  it  is  retarded.     Cases  vary  con- 
siderably in  intensity,  in  some,  probably  from  accidental  complication 
or  inoculation  or  individual  peculiarity  of  the  tissues,  the  zone  of  red- 
ness presents  a  decidedly  erysipelatous  aspect,  and  may  involve  a  greater 
part  of  or  the  entire  region.    In  fact,  so  severe  may  this  erysipelatous- 
looking  inflammation  be  that  it  may  assume  a  phlegmonous  character 
and  some  sloughing  of  the  vaccinated  spot  occur,  with  associated  lym- 
phangitis and  marked  swelling  of  the  neighboring  glands.    The  con- 
stitutional symptoms  may  also  be  correspondingly  severe.     In  other 
instances  new  vaccinal  lesions  develop  in  the  neighborhood  of  the  vac- 
cinated spot,  and  even  to  some  extent  beyond,  and  while  these  may  be 
simply  a  part  of  the  disease  vaccinia,  it  is  much  more  probable  that  they 
are  the  result  of  accidental  inoculation  in  consequence  of  carrying  the 
virus  from  the  vaccine  lesion  by  means  of  the  nails  or  fingers.     General 
vaccinia  has,  however,  it  is  stated,  been  observed,  although  the  possi- 
bility of  a  coincident  impetigo  contagiosa  might  afford  an  explanation 
of  many  such  instances.    In  some  cases  of  vaccination,  usually  unsuc- 
cessful, after  a  partial  formation  of  the  vaccine  vesicle,  it  is  ruptured, 
and  granulation  tissue  of  a  raspberry-  or  strawberry-like  character  de- 
velops, and  sometimes,  if  untreated,  will  persist  for  weeks  without  show- 
ing the  slightest  tendency  to  spontaneous  disappearance;  in  some  of  its 
aspects  presenting  a  resemblance  to  granuloma  pyogenicum.    In  some 
such  instances  there  has  apparently  been  an  accidental,  but  usually  harm- 
less, inoculation  of  an  adventitious  organism  or  material,  and  which  prob- 
ably has  taken  place  subsequently  to  the  vaccine  inoculation.     It  may 
be  that  in  some  of  these  cases  the  tubercle  bacillus  is  implanted  upon 
an  unfavorable  soil  and  fails  to  gain  proper  nutritional  support,  and  dis- 
appears on  the  institution  of  almost  any  astringent  or  antiseptic  applica- 
tion. 

Malcolm  Morris,  in  his  excellent  presentation  of  the  subject,  has 
divided  the  vaccinal  rashes1  into  two  classes:  (i)  Eruptions  due  to  pure 

1  The  reader  desirous  of  pursuing  the  subject  is  referred  to  Behrend's  paper  (read 
before  Dermatologic  Section  of  International  Medical  Congress,  London,  Aug.,  1881), 
Arch.  Derm.,  1881,  p.  383  (translated  by  Alexander);  Morrow,  Jour.  Culan.  Dis., 
1883,  p.  166,  with  references;  Malcolm  Morris'  paper,  with  discussion  (read  before 
Dermatologic  Section,  British  Medical  Association,  Birmingham,  Eng.,  July,  1890), 
Brit.  Med.  Jour.,  Nov.  29,  1890 — abstract  of  paper  in  Brit.  Jour.  Derm.,  1891,  p.  26; 


488 


vaccine  inoculation,  and  (2)  eruptions  due  to  mixed  inoculation,  which 
Frank  has  slightly  enlarged  and  modified,  and  which,  with  few  immaterial 
changes,  embody  my  own  views  and  present  clearly  the  eruptive  com- 
plications: some  not  uncommon,  others  extremely  rare,  and  some  ques- 
tionable. It  is  true  that  to  some  extent  these  divisions  are  more  or  less 
arbitrary,  and  there  is  difficulty  in  placing  some  affections  as  respects 
the  exact  etiologic  local  or  general  relationship,  and  hard-and-fast  lines 
cannot  always  be  drawn;  but  the  scheme  is  about  as  satisfactory  as  can 
be  made  under  present  conditions,  and  gives  a  faily  clear  presentation  of 
the  subject. 

Local  erythema. 
Dermatitis. 
Local  vaccinia. 
Adenitis. 

More  or  less  generalized  erythema   (ery- 
thema vaccinicum,  roseola  vaccinica). 
Urticaria. 

Erythema  multiforme. 
Vaccinia  (generalized  vaccinia). 
Purpura. 

Impetigo  contagiosa. 
Furunculosis. 
Cellulitis. 
Erysipelas. 
Gangrene. 
Tuberculosis  cutis. 


i.    Due    to     vaccine 
virus. 


2.  Due  to  mixed  in- 
oculation intro- 
duced at  time  of 
vaccination  or 
subsequently. 


Local. 


Systemic. 


Local. 


Systemic. 


3.  Sequelae  of  vaccination. 


{Gangrene. 
Pyemia. 
Syphilis. 
Leprosy. 
Tuberculosis, 
f  Eczema. 

Urticaria. 

<   Pemphigoid  eruptions. 
Psoriasis. 
Furunculosis. 


The  most  frequent  and  usually  evanescent  and  harmless  of  these 
are  the  localized  or  general  erythema,  urticaria,  erythema  multiforme,  a 
regional,  vaccinia-like  eruption  (often  probably  impetigo  contagiosa), 
impetigo  contagiosa,  and  a  pseudo-erysipelatous  or  erysipelatous  in- 
flammation, or  other  accidental  dermatitis.  A  neighboring  adenitis, 
as  already  referred  to,  is  usual  to  a  moderate  degree,  but  sometimes  is 
extremely  developed.  Local  or  generalized  erythema,  erythema  multi- 
forme,  and  urticaria  may  present  at  any  time  between  the  date  of  vac- 
cination and  the  crusting  period;  erythema  multiforme  and  urticaria, 
especially  the  latter,  even  to  a  later  period.  Behrend  called  attention 
to  the  fact  that  there  seem  to  be  two  periods  for  the  occurrence  of  vac- 
cinal  eruptions — in  the  first  three  days,  or  not  until  the  eighth  or  ninth. 
While  true  in  the  main,  there  are  many  exceptions.  They  present  no 

also  Frank's  paper,  Jour.  Cutan.  Dis.,  1895,  p.  142;  and  Dyer's,  New  Orleans  Med. 
and  Surg.  Jour.,  Feb.,  1896;  Colcott  Fox,  Brit.  Med.  Jour.,  July  5,  1902;  Towle,  Boston 
Med.  and  Surg.  Jour.,  Sept.  4,  1902;  Stelwagon,  Jour.  Amer.  Med.  Assoc.,  Nov.  22, 
1902;  Pernet,  Lancet,  Jan.  10,  1903;  Corlett,  Jour.  Cutan.  Dis.,  1904,  p.  495  (with 
illustrations  and  references  to  recent  papers).  See  also  under  Pemphigus  and  Derma- 
titis herpetiformis. 


VACCINAL   ERUPTIONS  489 

special  peculiarities  from  the  ordinary  types  of  these  maladies,  but  are 
usually  of  shorter  duration.  In  erythema  multiforme  the  erythematous 
and  erythematopapular  manifestations  are  most  common,  but  the  vesic- 
ular and  bullous  lesions  may  also  occur.  The  various  other  cutaneous 
complications  are  rare.  Eczema  developing  from  the  inoculation  site 
or  elsewhere  occasionally  follows,  but  probably  only  in  those  with  a  clear 
eczematous  tendency ;  and  exceptionally  the  disappearance  of  an  existing 
chronic  eczema  is  promoted  by  the  vaccinal  operation  (see  Eczema).1 
Psoriasis  has  in  rare  instances  taken  its  start  at  the  point  of  inoculation, 
or  has  made  its  first  appearance  closely  following  this  procedure,  as 
already  referred  to  under  that  disease;  in  all  probability  vaccination 
has  no  etiologic  relationship  except  as  possibly  its  action  as  a  local  or 
general  excitant  or  its  disturbing  influence  upon  the  nervous  system. 
Indeed,  in  this  as  in  many  other  instances  of  eruption  occurring  during 
or  immediately  subsequent  to  vaccination  it  is  more  than  probable  that 
they  are  purely  coincidental  and  in  no  way  connected  with  or  due  to 
this  operation.  The  layman  and,  flagrantly,  the  antivaccinationist, 
and  sometimes,  too,  the  physician,  are  too  prone  to  consider  all  such 
eruptions  as  effects;  in  short,  it  should  be  clearly  understood  that  cuta- 
neous outbreaks  occurring  at  such  time  are  not  necessarily  vaccinal, 
although  it  is  true  many  of  them  are. 

Most  of  the  pemphigoid  eruptions  encountered,  usually  following 
one  to  several  weeks  after  the  operation,  have  doubtless  been  examples 
of  bullous  impetigo  contagiosa.  Exceptionally,  however,  pemphigus 
or  pemphigoid  lesions  have  been  observed.2  A  few  instances  of  seeming 
relationship  have  come  to  my  notice,  and  of  serious  character;  bovine 
virus  was  used.  In  this  connection  the  observations  and  study  of  the 
etiology  of  acute  pemphigus  by  Fernet  and  Bulloch3  are  of  great  interest 
(see  Pemphigus).  In  their  report  and  analysis  of  cases,  in  a  number  the 
subjects  wrere  found  to  be  butchers,  and  the  disease  to  have  originated 
from  a  small  wound  resulting  from  their  occupation;  further,  in  one  case 
a  pemphigoid  eruption  seemingly  followed  inoculation  from  a  similar 
eruption  on  the  teats  of  a  cow.  Others  are  also  mentioned  where  the 
disease  occurred  in  those  having  to  do  with  animals  or  animal  products, 
and  instances  of  the  existence  of  pemphigoid  eruptions  in  animals  are 
referred  to.  These  facts  have  suggested  the  possibility  that  the  rare 
cases  of  pemphigus,  usually  of  grave  character,  exceptionally  observed 
developing  after  vaccination,  may  thus  be  explained. 

Irrespective  of  the  usual  transitory  rashes,  it  has  been  believed, 

1  Great  care  should  be  exercised,  however,  as  to  vaccination  in  moist,  raw,  oozing 
cases  of  eczema;  as  in  a  few  instances,  in  young  children,  more  or  less  general  inocu- 
lation of  such  surfaces  has  followed.    One  such  case  was  shown  at  the  Internal.  Derm. 
Congress  in  Berlin,  Sept.,  1904. 

2  See  a  recent  interesting  paper  by  Bowen,  "Six  Cases  of  Bullous  Dermatitis  Follow- 
ing Vaccination,  and  Resembling  Dermatitis  Herpetiformis,"  Jour.  Cutan.  Dis.,  1901, 
p.  401;  and  Howe,  "Cases  of  Bullous  Dermatitis  Following  Vaccination,"  ibid.,  1903, 
p.  254.     Other  references  will  be  found  under  Dermatitis  herpetiformis. 

3  Fernet  and  Bulloch,  Brit.  Jour.  Derm.,  1896,  pp.  157  and  205.     See  also  Bowen's 
suggestive  paper,  "Acute  Infectious  Pemphigus  in  a  Butcher,  during  an  Epizootic  of 
Foot  and  Mouth  Disease,  with  a  Consideration  of  the  Possible  Relationship  of  the 
Two  Affections,"  Jour.  Cutan.  Dis.,  1904,  p.  253;  also  "Report  of  Bureau  of  Animal  In- 
dustry," abstract,  Jour.  Amer.  Med.  Assoc.,  1909,  vol.  lii,  p.  1679. 


490 


INFLAMMA  TIONS 


ever  since  the  operation  of  vaccination  has  been  advocated,  that  the 
process  is  not  without  danger  as  to  the  inoculation  of  other  more  serious 
diseases.  There  can  be  no  question  that  pure  virus  of  bovine  origin 
should  be  employed,  and  that  with  this,  as  with  any  operative  procedure, 
care,  caution,  and  cleanliness  are  essential  prerequisites  to  safety,  and 
with  proper  observance  of  which  the  operation  is  an  absolutely  harmless 
and  safe  one.  With  careless  operators  impure  virus,  and  more  especially 
uncleanly  patients,  the  accidental  inoculation  of  tuberculosis,  leprosy, 
syphilis,  and  other  affections  becomes  a  possibility.  It  is  doubtless  true 
that  in  most  of  the  serious  sequences  of  vaccination  that  neither  the 
operator  nor  virus  is  at  fault,  but  that  the  damaging  infection  takes 
place  later  as  a  result  of  carelessness,  negligence,  or  uncleanliness  on  the 
part  of  those  vaccinated.  The  possibility  of  inoculation  of  tuberculosis 
has  been  questioned,  but  suggestive  cases  are  on  record  where  localized 
tuberculosis  cutis  (q.  v.)  has  developed  at  the  point  of  vaccination,  and 
that  much  being  admitted,  general  infection  might  likewise  be  produced.1 
As  to  the  accidental  inoculation  of  leprosy,  there  has  long  been  a  belief 
that  such  has  often  occurred  (Beaven  Rake),  but  authentic  examples 
are  rare.  Daubler's2  2  cases  seem  to  show  this  possibility,  and  doubtless 
other  instances  might  be  found  upon  investigation.  Added  to  this  is 
the  fact  that  bacilli  leprae  have  been  found  in  the  vaccine  lymph  taken 
from  a  leper  (Arning).3  Examples  of  syphilis  inoculation  through  vac- 
cination are  rarely  observed  at  the  present  day,  and  then  only 
through  gross  carelessness  or  through  pure  accident  unconnected  with 
the  procedure  itself;  but  that  it  was,  while  not  frequent,  occasionally 
observed  formerly  is  attested  by  the  observations  of  Hutchinson,  Four- 
nier,  R.  W.  Taylor,  and  others. 

Vaccinal  eruptions  cannot  always  be  prevented,  referring  especially 
to  those  that  arise  through  the  vaccine  virus  itself,  but  such  are  prac- 
tically harmless  and  short-lived,  and  rarely  give  rise  to  trouble.  Even 
taking  into  consideration  the  occasional  accidental  mixed  infections, 
which  also  with  rare  exceptions  are  not  of  serious  import,  such  cases 
weigh  as  nothing  compared  to  the  benefit  bestowed  upon  mankind  by 
the  operation.  With  proper  care,  however,  on  the  part  of  the  caretakers 
of  the  cattle  from  which  the  virus  is  derived,  rigorous  inspection  of  the 
animals,  and  extreme  precaution  in  the  collection  and  preservation  of 
the  vaccine,  added  to  caution  and  cleanliness  on  the  part  of  physician 

1  A  case  under  my  own  observation,  of  development  of  lupus  at  the  site  of  vaccina- 
tion, and  immediately  following  the  same,  and  which  is  referred  to  in  discussing  that 
disease,  is  one  in  point.     This  patient  and  two  others  were  vaccinated  from  the  same 
crust;  the  reactionary  symptoms  in  all  were  severe,  in  two  quickly  followed  by  mixed 
general  symptoms  of  what  seemed,  as  described  to  me,  of  mixed  septicemic  and  tuber- 
culous character,  followed  by  death;  and  in  my  patient,  at  that  time  a  robust  young 
female  child,  followed  by  the  development  of  lupus,  which  had  persisted  and  extended 
when  I  saw  her  ten  or  twelve  years  later.   The  history  of  the  cases  was  given  me  by  a 
physician,  the  brother  of  my  patient,  but  owing  to  the  years  which  had  elapsed  and  the 
nature  of  the  accident,  further  details  could  not  be  obtained,  and  there  naturally 
remains  an  element  of  doubt  about  the  true  character  of  the  condition  which  carried 
off  the  other  patients. 

2  Daubler,  "Ueber  Lepra  und  deren  Kontagiositat,"  Monatshefte,  Feb.  i,  1889, 
p.  123. 

3  Arning,  Jour.  Lepr.  Inves.  Com.,  No.  2,  Feb.,  1891,  p.  131,  quoted  by  Dyer 
(loc.  oil.). 


VACCINAL   ERUPTIONS  491 

and  patient,  before,  at  the  time,  and  subsequently  to  the  operation  until 
complete  healing  has  taken  place,  the  occurrence  of  serious  accidents 
would  practically  be  placed  beyond  the  bounds  of  possibility.  Human 
virus  should,  of  course,  never  be  employed.  Morris,  among  other  rec- 
ommendations for  the  prevention  of  vaccinal  eruptions  and  accidents, 
urges  that  strict  antiseptic  and  protective  treatment  should  be  carried 
out  immediately  after  the  vesicles  have  developed,  and,  further,  that 
the  cases  should  be  seen  by  the  vaccinator  until  the  wounds  have  healed. 
But  little  need  be  said  about  the  treatment  of  the  various  erythem- 
atous,  urticarial,  and  other  ordinary  rashes  occasionally  observed,  as 
it  is  in  these  the  same  as  in  these  eruptions  occurring  independently 
of  the  operation.  The  rare  serious  cases,  too,  are  likewise  managed  on 
the  same  principles  laid  down  elsewhere  for  the  particular  eruption 
presenting. 


CLASS   III— HEMORRHAGES 
PURPURA 

Synonyms. — Haemorrhoea  petechialis;  Fr.,  Hemorragies  cutanees;  Gcr.,  Blutfleck- 
enkrankheit. 

Definition. — A  hemorrhagic  affection  characterized  by  the  appear- 
ance of  variously  sized,  usually  non-elevated,  smooth,  reddish  or  pur- 
plish spots  or  patches,  not  disappearing  upon  pressure,  and  generally 
accompanied  by  systemic  disturbance  of  slight  or  severe  nature. 

Various  grades  of  the  disease  are  encountered,  from  mild  and  in- 
significant to  profoundly  grave,  both  as  to  the  cutaneous  lesions  and 
the  constitutional  symptoms.  It  is  customary,  for  the  sake  of  con- 
venience, to  divide  the  cases  into  three  classes  or  varieties,  denoting 
respectively  the  mild,  moderate,  and  severe  grades:  purpura  simplex, 
purpura  rheumatica,  and  purpura  haemorrhagica.  This  division  is, 
however,  to  a  great  extent  a  purely  arbitrary  one,  as  merging  cases 
are  not  uncommon.  Insignificant  cutaneous  lesions  are  sometimes  seen 
in  association  with  more  or  less  severe  constitutional  disturbance,  and 
in  rare  instances  the  integumentary  hemorrhage  may  be  quite  profound 
and  the  systemic  involvement  relatively  slight.  Nevertheless  it  is  not 
improbable  that  the  various  grades  may  have  a  different  or  mixed  etiology. 
In  some  of  the  more  severe  cases  soreness  of  the  throat,  of  varying 
degree,  precedes  the  cutaneous  outbreak. 

The  lesions  are  variously  designated,  according  to  size,  etc.,  petechiae, 
vibices,  ecchymoses,  and  ecchymomata.  Petechiae  are  the  spots  usually 
seen  in  the  mild  type,  and  are  generally  rounded  or  ovalish  in  form,  and 
from  a  pin-point  to  a  dime  in  size;  vibices  may  be  described  as  simply 
hemorrhagic  streaks,  of  varying  length  from  a  small  fraction  of  an  inch 
to  an  inch  or  more;  ecchymoses  are  the  larger,  non-elevated  lesions,  and 
may  be  rounded  or  irregularly  shaped;  an  ecchymoma  (also  called  hema- 
toma)  is  large  in  size,  similar  to  the  last,  but  the  extravasation  of  blood 
has  been  sufficiently  great  to  produce  slight  or  pronounced  elevations 
or  tumors. 

Symptoms. — The  essential  symptom  in  purpura  is  the  cuta- 
neous hemorrhage — hemorrhage  into  the  integumentary  tissues,  and 
which  does  not  disappear  upon  pressure.  The  lesions  thus  produced 
are  pin-head,  pea-  to  bean-sized  or  larger,  appear  suddenly,  and  are 
noted  to  be  of  a  bright-red  or  purplish-red  color.  Their  brightness 
gradually  fades,  the  color  usually  changing  to  a  bluish,  bluish-green, 
bluish-  or  greenish-yellow,  dirty  yellowish,  yellowish-white,  and  finally 
disappearing.  In  the  smaller  lesions  these  changes  are  scarcely  per- 
ceptible, the  spots  becoming  fainter  and  then  fading  away;  in  the  large 

492 


PURPURA 


493 


ecchymotic  lesions  the  various  changing  tints  are  quite  pronounced, 
resembling  in  many  respects  the  changes  observed  following  a  bruise. 
As  a  rule,  the  lesions  are  not  visibly  elevated,  but  in  extreme  cases  in 
which  there  may  be  considerable  effusion,  slightly  raised  flat,  tumor-like 
formations  result.  The  most  common  sites  are  the  lower  extremities, 
and  especially  from  the  middle  of  the  thighs  downward,  although  the 
upper  part,  and  also  the  forearms,  not  infrequently  share  in  the  dis- 
tribution. In  other  cases,  and  especially  of  the  more  severe  type,  the 
lesions  may  be  seen  over  the  trunk,  and  rarely  upon  the  face  as  well. 
Exceptionally  the  trunk  is  the  seat  of  most  of  the  spots  or  patches. 

As  a  rule,  there  are  no  subjective  symptoms  in  uncomplicated  cases, 
although  occasionally  slight  soreness  is  complained  of,  and  less  frequently 
mild  itching.  In  some  instances  other  skin-lesions,  such  as  those  of 
urticaria  and  erythema  multiforme,  are  associated,  to  be  referred  to 
later.  Other  accidental  and  general  symptoms  will  be  referred  to  under 
the  particular  varieties  or  subdivisions. 

Purpura  Simplex. — This,  the  mild  grade  of  the  disease,  is  rarely 
accompanied  by  any  systemic  disturbance,  in  some  cases  possibly  slight 
malaise,  loss  of  appetite,  etc.  It  usually  manifests  itself  quite  suddenly, 
the  spots  appearing  in  numbers,  pin-point-  to  pea-  or  bean-sized,  bright 
or  dark  red  in  color,  and  most  frequently  limited  to  the  lower  extremi- 
ties, although  it  is  not  uncommon  to  see  lesions  on  the  forearms  as  well. 
In  other  cases  their  appearance  is  gradual,  coming  out  in  distinct,  crop- 
like  exacerbations.  Once  its  acme  is  reached,  they  begin  in  most  cases 
gradually  to  fade,  and  at  the  end  of  a  few  weeks  or  longer  have  entirely 
disappeared.  It  is  not  unusual,  however,  for  new  lesions  to  appear 
either  irregularly  or  in  crops  at  irregular  intervals  for  several  weeks  to 
several  months;  and  in  exceptional  instances  the  tendency  may  persist 
for  one,  two,  three,  or  more  years.  In  a  case  of  a  young  girl  under  my 
care  the  eruption  persisted  in  this  manner,  with  irregular,  but  usually 
short,  periods  of  quiescence,  for  five  years,  and  was  still  appearing  when 
the  patient  withdrew  from  my  observation  several  years  ago;  there  were 
no  subjective  or  general  symptoms,  and  the  child,  aged  about  twelve, 
was  apparently  in  good  health.  Such  extremely  prolonged  cases  are 
rare,  but  cases  lasting  in  this  irregular  manner  for  a  year  or  two  are  not,  I 
believe,  so  uncommon  as  is  generally  thought.1 

In  rare  instances  the  lesions  may  be  circinate,  with  clear  center, 
as  in  a  case  reported  by  Duhring2  and  one  by  myself;3  the  eruption  in 
my  case  was  chiefly  limited  to  the  trunk.  Subjective  symptoms  are 
scarcely  ever  noted;  in  some  instances,  however,  there  is  an  urticarial 
element,  and  it  is  noted  that  the  hemorrhagic  spots,  here  and  there, 
become  the  seat  of  wheals — purpura  urticans;  most  of  these  cases  are, 

1  Meachen,  Brit.  Jour.  Derm.,  1903,  p.  459,  showed  a  somewhat  similar  case  before 
the  Derm.  Soc'y  of  Great  Britain  and  Ireland,  a  girl  of  eighteen,  who  had  been  continu- 
ously subject  to  the  malady,  with  varying  intensity,  for  four  years,  her  general  health 
being  good;  Osier,  Jour.  Cutan.  Dis.,  1903,  p.  297  (with  colored  plate),  reports  a  case  of 
"Chronic  Purpuric  Erythema,"  lasting  eight  years,  with  pigmentation  of  the  skin  and 
enlargement  of  the  liver  and  spleen;  patient  died  of  pernicious  malaria. 

2  Duhring,  Med.  and  Surg.  Reporter,  Aug.  3,  1878. 

3  Stelwagon,  Jour.  Cutan.  Dis..  1887,  p.  370  (with  illustration). 


494 


HEMORRHA  GES 


however,  examples  of  urticaria,  with  hemorrhagic  tendency  in  the  lesions. 
Very  exceptionally  there  may  be  associated  some  irregularly  scattered 
but  scanty  efflorescences  of  erythema  multiforme;  these  are,  however, 
rare — much  more  so  than  in  cases  of  purpura  rheumatica. 

A  variety  (purpura  senilis)  of  apparently  an  entirely  different  and 
innocent  nature  is  observed  in  people  of  advancing  years,  although 
occasionally  also  in  younger  individuals;  purpuric  spots  appear  on  the 
legs,  usually  about  the  ankles  and  on  the  leg  just  above,  which  last  a 
variable  time,  sometimes  almost  indefinitely,  and  leave  behind  pigment 
stains.  New  spots  continue  to  reappear  at  irregular  intervals.  This 
condition  seems  to  be  of  purely  local  nature,  and  is  usually  observed 
in  association  with  sluggish  circulation  and  often  with  varicose  veins. 

Purpura  rheumatica  or  arthritic  purpura  presents  itself  in  several 
varieties.  The  most  common,  and  in  fact  the  usual  one,  is  that  with 
cutaneous  lesions,  as  in  purpura  simplex,  with  the  addition  of  rheumatic 
pains  and  sometimes  swellings  about  the  joints.  There  is  generally 
slight  passing,  sometimes  more  or  less  prolonged,  febrile  action,  and  the 
outbreak  is  often  ushered  in  with  the  other  usual  symptoms  of  constitu- 
tional disturbance.  Its  behavior  and  course,  although  more  severe, 
are  practically  like  average  cases  of  purpura  simplex. 

Another  variety  of  the  rheumatic  form  is  that  known  as  peliosis 
rheumatica,  or  Schonlein's  disease.  It  is  rare.  In  its  most  marked 
expression  it  may  be  said  to  be  made  up  of  a  combination  of  symp- 
toms— those  of  rheumatism,  purpura,  and  erythema  multiforme,  often 
with  here  and  there  considerable  edematous  swelling.  Occasional  urti- 
carial  lesions  are  also  associated,  and  exceptionally  some  of  the  efflores- 
cences may  become  vesicular  or  bullous.  The  disease  frequently  begins 
with  symptoms  of  sore  throat.  In  one  case  observed  by  me  there  was 
marked  edematous  swelling  of  the  legs,  with  both  purpuric  patches  and 
ecchymoses,  and  pronounced  rheumatic  symptoms  of  the  main  joints, 
together  with  hemorrhagic  lesions  and  swellings  of  the  lips  and  throat. 
Such  extreme  examples  have  been  well  termed  febrile  purpuric  edema. 
The  constitutional  symptoms  are  often  alarming,  the  temperature 
elevated,  the  urine  often  diminished,  and  occasionally  endocarditis  and 
pericarditis,  and  in  rare  instances,  as  in  2  cases  observed  by  Osier,1 
necrosis  and  sloughing  of  a  portion  of  the  uvula.  In  the  single  example 
of  this  severe  type  under  my  care  recovery  took  place.  Osier  states 
in  fact,  that  cases  usually  do  well,  and  that  a  fatal  result  is  rare.  Recur- 
rence is  noted,  in  some  instances,  at  yearly  intervals  for  several  years—- 
in this  respect  corresponding  to  erythema  multiforme. 

Somewhat  similar  to  peliosis  rheumatica  is  that  known  as  Henoch's 
purpura,  observed  principally  in  children,  in  which,  however,  the  ery- 
thema multiforme  aspect  is  more  pronounced,  and  the  purpuric  charac- 
ter, as  to  the  integument,  less  conspicuous;  edematous  swelling  is  also 
often  noted,  suggestive  of  a  combination  of  purpura  and  angioneurotic 
edema,  as  in  the  cases  reported  by  Bowen2  and  others.  In  addition 

1  Osier,  Practice  of  Medicine. 

-  Bowen.  "The  Association  of  Purpura  and  Acute  Circumscribed  Edema,"  Jour. 
Cutan.  Dis.,  1892,  p.  434  (report  of  2  cases  and  references  to  allied  literature). 


PLATE   XVIII. 


Purpura. 


PURPURA 


495 


there  are  gastric  and  intestinal  symptoms  and  hemorrhages  from  the 
mucous  membranes.  Osier1  states  its  characters  to.be:  (i)  Relapses 
or  recurrences  extending  over  several  years;  (2)  cutaneous  lesions,  which 
are  those  of  erythema  multiforme  rather  than  of  simple  purpura;  (3) 
gastro-intestinal  crises— pain,  vomiting,  and  diarrhea;  (4)  joint  pains 
or  swelling,  often  trifling;  (5)  hemorrhages  from  the  mucous  membranes. 
A  variable  amount  of  albumin  is  usually  found  in  the  urine,  while  in  the 
most  aggravated  cases  there  were  all  the  symptoms  of  acute  hemorrhagic 
nephritis.  He  further  states  that  any  one  or  two  of  these  symptoms 
may  be  absent;  the  intestinal  crises,  with  enlargement  of  the  spleen, 
may  be  present  and  recur  for  months  before  the  true  nature  of  the  trouble 
becomes  manifest.  In  61  cases  collected,  of  which  n  are  reported  by 
Osier,  there  were  13  deaths.  In  these  are  included  the  large  number 
collected  by  Dusch  and  Hoche.2  Apparently  the  dermatologist  rarely 
gets  sight  of  these  peculiar  cases,  which,  according  to  this  writer,  are 
more  common  than  generally  thought. 

Purpura  hsemorrhagica  (also  known  as  morbus  maculosus  Werlhoffi 
and  land  scurvy)  may  begin  as  a  simple  purpura  without  preceding  con- 
stitutional disturbance  or  with  mild  systemic  symptoms,  the  integ- 
umental  lesions  being  small,  scanty,  or  numerous;  and  there  may  sub- 
sequently develop  the  characteristic  symptoms  of  this  type  of  purpura, 
such  as  more  or  less  grave  constitutional  involvement,  hemorrhages 
from  the  mucous  membranes,  and  also  considerable  hemorrhagic  effusion 
into  the  skin,  producing  large  areas  or  tumor-like  ecchymoses  (ecchy- 
momata).  On  the  other  hand,  the  disease  may  begin  suddenly,  with 
severe  systemic  disturbance,  and  assume  its  serious  character  from  the 
start.  Purpuric  patches  are  usually  noted  upon  the  mucous  membrane 
of  the  mouth  and  throat.  The  cutaneous  lesions  in  this  variety  may 
appear  anywhere,  beginning  either  on  the  extremities  or  trunk.  In 
many  cases,  although  the  symptoms  are  somewhat  alarming,  recovery 
after  several  weeks  or  a  few  months  finally  results.  Extreme  cases  are 
met  with  in  which  there  is  a  combination  of  profound  cutaneous  dis- 
turbance, and  hemorrhages  from  the  mouth,  stomach  and  intestinal 
symptoms,  with  general  symptoms  of  collapse  and  a  rapidly  fatal  ending 
— purpura  fultninans. 

Etiology. — The  disease  is  not  uncommon,  and  is  met  with  in 
both  sexes  and  at  all  ages,  being  most  frequent  between  the  ages  of  ten 
and  forty.  Its  subjects,  as  regards  the  state  of  the  general  health,  vary 
from  those  in  seemingly  good  condition  to  those  profoundly  cachectic. 
No  one  cause  can,  in  the  state  of  our  present  knowledge,  be  set  down  as 
essential  in  all  cases.  Various  factors  seem  capable  of  bringing  on  that 
unknown  condition  which  results  in  hemorrhagic  effusion.  It  is  known 
that  the  ingestion  of  certain  drugs  (see  Dermatitis  medicamentosa), 

'Osier,  loc.  tit.,  and  (interesting  paper,  reporting  n  cases — 3  deaths)  in  Amer. 
Jour.  Med.  Sci.,  Dec.,  1895,  p.  816;  see  also  valuable  contribution  by  S.  Mackenzie 
(on  the  relationship  of  purpura  rheumatica  and  erythema  multiforme),  Brit.  Jour. 
Derm.,  1896,  p.  116;  and  Weber  (case  report  with  remarks  on  the  visceral  complica- 
tions of  purpura),  Brit,  Jour.  Derm.,  1900,  p.  77. 

2  Dusch  and  Hoche,  Festchrift  Eduard  Hcnoch,  Berlin,  1890,  p.  379 


496  HEMORRHAGES 

notably  potassium  iodid,  salicylates,  and  chloral,  have  provoked  it.1 
Malarial  poison  is.  not  infrequently  to  be  assigned  as  an  important  factor, 
as  in  cases  reported  by  Tyrrell2  and  others.3  Syers,4  who  has  had  ample 
opportunities  of  observing  the  disease  in  children,  is  inclined  to  consider 
it  somewhat  allied  to  scorbutus  and  due  in  many  cases  to  poor,  unhy- 
gienic life  conditions  and  insufficient  or  poor  food.  It  is  likewise  some- 
times seen  in  the  course  of  or  following  grave  systemic  disease,5  more  es- 
pecially profound  anemia,  scorbutus,  hemophilia,  variola,  pyemia,  typhus, 
syphilis,  grip,  nephritis,  etc.  Rheumatism  has  long  been  discussed  as 
etiologic,  but  the  rheumatic  symptoms  in  this  disease  are  doubtless 
merely  a  part  of  a  symptom-complex  due  to  some  unrecognized  cause. 
It  has  also  been  observed  along  with  gonorrheal  rheumatism,  in  which 
the  latter  could  scarcely  be  considered  the  exciting  factor.  Doubtless 
in  some  of  the  gonorrheal  cases  the  purpuric  manifestation  has  been  the 
result  of  drug  administration;  copaiba  has  been  known  to  produce  it. 
Nervous  disorders,  both  of  a  functional  and  organic  character,  visceral 
diseases,  and  other  similar  factors  have  all  seemed  to  be  of  etiologic 
import  in  some  instances,  the  eruption  occurring  in  association  with 
hysteria,  myelitis,  locomotor  ataxia,  etc.  It  is  probable  that  circulatory 
disturbance,  especially  when  associated  with  debility  or  cachexia,  with 
resulting  blood  impoverishment,  anaemia  etc.  may  likewise  be  occasion- 
ally responsible. 

Micro-organisms  have  been  also  looked  upon  as  causative,  at  least 
in  the  more  grave  cases,  and  have  been  found  by  Martin  de  Gimard,6 
Letzerich,7  Hanot  and  Luzet,8  Kolb,9  Burch,10  Howard,11  and  others, 
but  there  is  a  great  deal  of  diversity  in  the  findings,  and  in  some  instances, 
as  in  the  case  of  Mosse  and  Iversenc,12  several  bacterial  forms  are  to  be 

1  Knowles,  "  Purpura  Caused  by  the  Ingestion  of  the  Iodid,"  Jour.  Anter.  Med. 
Assoc.,  July,  o,  iQ10,  P-  ioo  (with  review  and  references).     Selling,  "Purpura  Hsem- 
orrhagica  Due  to  Benzol  Poisoning,"  Johns   Hopkins   Hospital  Bulletin,  Feb.,  1910 
(in  workers  where  benzol  was  used  freely;  14  cases;  3  cases  described,  2  of  which  were 
fatal,  had  all  the  symptoms  of  idiopathic  purpura). 

2  Tyrrell,  Pacific  Med.  and  Surg.  Jour.,  June,  1876. 

3  Engmann,  "Paludides,  with  the  Histopathology  of  a  Case  of  Malarial  Purpura," 
Jour.  Cutan.  Dis.,  1903,  p.  489  (with  references). 

4  Syers,  Lancet,  Feb.  12,  1898. 

8  Among  recent  cases  may  be  mentioned  that  by  Colcott  Fox,  London  Clin.  Soc'y, 
Lancet,  June  3,  1899  (developing  toward  the  end  of  Bright's  disease);  Poynton,  ibid., 
Oct.  28,  1899  (with  pernicious  acute  rheumatism);  Frankenhauser,  St.  Petersburger 
med.  Wochenschr.,  1899,  No.  4,  and  Glendenning,  Philada.  Med.  Jour.,  May  6.  1899, 
vol.  iii,  p.  968  (following  the  grip);  Londe,  abs.  in  Jour.  mat.  cutan.,  1899,  p.  770  (at 
the  decline  of  typhoid  fever) ;  see  also  interesting  and  suggestive  paper  (with  references) 
by  Graham  Little,  "Cases  of  Purpura  Ending  Fatally,  Associated  with  Hemorrhage 
into  the  Suprarenal  Capsules,"  Brit.  Med.  Jour.,  1901,  p.  445.  Rolleston  and  Molony, 
British  Jour,  of  Children's  Diseases,  Jan.  1912.  p.  i,  records  that  in  a  series  of  100 
cases  of  infective  diarrhea,  out  of  67  fata!  cases  16  developed  purpura. 

6  Jules  L.  A.  Martin  de  Gimard,  Dit  Purpura  hemorrhagique  prim-it  if,  Paris,  1888. 

Letzerich,  U  ntcrsuchungen  iiber  die  Actiohgie  unddic  Kennlniss  des  Purpura  ham- 
orrhagica,  Leipzig,  1889. 

8  Hanot  and  Luzet,  Arch,  de  med.  ex  per.,  1800,  No.  6.  ii. 

9  Kolb.  Arbeiten  aus  der  Kaiserlichen  Gesundheitsamte,  1891,  vii,  p.  60  (with  refer- 
ences, and  4  plates,  presenting  13  cuts  of  bacillus  cultures  and  inoculated  animal  tissue 
sections). 


PURPURA  497 

found,  which  may,  as  they  suggest,  mean  that  the  primitive  infection 
opens  the  door  to  secondary  infection.  The  bacillus  described  by  Kolb, 
Letzerich  and  Burch,  and  some,  others,  however,  seems  to  be  closely 
similar  or  identical.  Most  of  these  investigations  have  been  with  hem- 
orrhagic  or  grave  types.  Martin  de  Gimard,  Letzerich,  and  Kolb  all 
succeeded,  in  experimental  inoculations  in  animals  from  pure  cultures, 
in  producing  the  malady.  Microbic  infection  is,  therefore,  doubtfess 
the  causative  factor  in  some  of  the  grave  cases;  and  it  is  not  impossible 
that  the  initial  sore  throat  often  noted  indicates  the  port  of  entrance. 

Summarizing,  I  agree  with  Johnson,1  who,  from  a  careful  study, 
believes  that  the  causative  factors  may  be  divided,  in  general,  into 
several  classes — vasomotor,  toxic,  and  infectious;  and  some  of  those  of 
toxic  origin,  probably  as  Breton's2  observations  lead  him  to  conclude, 
arise  from  an  auto-intoxication  starting  from  the  intestinal  tract.  There 
seems,  too,  an  affinity  or  connection  between  certain  cases  of  erythema 
multiforme  and  some  cases  of  purpura  rheumatica,  and  Osier  is  inclined 
to  include  with  these  angioneurotic  edema  and  urticaria,  and  suggests 
the  possibility  of  as  yet  an  unknown  poison,  possibly  the  result  of  faulty 
metabolism,  which,  according  to  individual  and  dosage,  may  provoke 
one  or  the  other  of  these  several  manifestations. 

Pathology. — While  it  is  customary  to  designate  almost  all  cases 
with  hemorrhagic  cutaneous  lesions  purpura,  it  is,  nevertheless,  beyond 
question  that  this  manifestation  is  simply  a  symptom  of  probably 
widely  diverse  conditions.3  It  is  difficult  to  reconcile  the  mild,  insig- 
nificant cases  with  those  examples,  apparently  infectious  in  origin,  and 
rapidly  fatal,  except  upon  such  assumption.  It  is  probable,  too,  that 
cases  differ  somewhat  as  to  the  pathology  of  the  lesion,  whether  the 
toxic  agent  or  the  pathogenetic  factor,  whatever  it  is,  acts  primarily 
upon  the  nervous  centers,  peripheral  nerves,  on  the  blood  itself,  or  on 
the  vessel-walls.  There  may  be  simple  transudation  of  blood  coloring- 
matter,  or  the  blood  may  find  exit  through  a  rupture  of  the  vessel-wall 
or  by  diapedesis;  the  second  method  is  probably  the  most  usual.  Ac- 
cording to  Hebra,  in  the  first  formation  of  the  lesion  there  is  slight 
accompanying  hyperemia,  which  soon  disappears,  and  Kromayer4  states 
that  since  his  attention  was  called  to  this  point  he  has  found,  from  careful 
observation,  that  there  is  a  prodromal  hyperemic  spot,  sometimes  slightly 
elevated,  which  immediately  precedes  the  hemorrhage.  Excepting  these 
two,  I  believe  no  one  else  refers  to  it  or  has  confirmed  it.  Inasmuch  as 
in  most  instances  the  lesions  are  on  dependent  parts,  blood  stasis  is 
doubtless  a  contributing  factor;  thus,  in  a  case  recorded  by  Bruce  and 
Galloway,5  a  man  aged  twenty-nine,  the  purpuric  spots  on  the  legs 

Johnson,  N.   Y.  Med.  Jour.,  Oct.  7,  1890. 

2  Breton,  Jour,  des  practiciens,  1899,  No.  3. 

3T6rok,  "Les  Purpuras,"  Jour.  mal.  cutan.,  April,  1903,  forcibly  contends  that  a 
purpuras  have  a  similar  origin— some  infective  or  toxic  or  autotoxic  agent  acting  upon 
the  vascular  walls  and  reaching  the  parts  affected  by  the  blood-stream ;  these  agents  may 
be  various,  and  can  produce  the  same  clinical  and  histopathologic  picture;  clinical  dii 
ferences  are  merely  of  degree;  the  differences  in  histopathologic  findings  by  various 
investigations  are  assumed  to  be  due  to  accidental  conditions. 

4  Kromayer,  Allgemeine  Dermatologie,  Berlin,  1896,  p.  77. 

5  Bruce  and  Galloway,  Brit.  Jour.  Derm.,  1898,  p.  6. 

32 


49  8  HEMORRHA  GES 

gradually  vanished  after  rest  in  bed,  the  eruption  recurring  as  soon  as 
the  patient  was  allowed  to  get  up.  Or  there  may  be  sudden  obstruction 
of  the  vessel,  due  to  thrombosis  or  embolism,  and  in  some  of  the  grave, 
and  doubtless  infectious,  cases,  the  obstruction  may  consist  of  accumula- 
tion of  micro-organisms,  as  Cheyne,  Letzerich,  Martin  de  Gimard,  and 
others  have  found.  Most  investigations  have  been  with  hemorrhagic 
cases.  Martin  de  Gimard1  ascribes  the  disease  conjointly  to  a  mechan- 
ical obstruction  of  the  vessels  and  to  inflammation  of  the  vessel-walls 
from  the  presence  of  colonies  of  micrococci,  rupture  occurring  spon- 
taneously or  as  a  result  of  movements  on  the  part  of  the  patient.  I  have 
noted  the  effect  of  this  latter  in  many  cases;  while  the  patient  remains  at 
relative  or  complete  rest  there  is  but  little  disposition  to  the  appearance 
of  new  lesions,  but  if  at  all  active,  an  exacerbation  is  immediately 
noted;  this  is  probably  an  element  also  in  such  cases  as  that  of  Bruce 
and  Galloway,  just  referred  to.  Letzerich,  from  his  investigations, 
was  led  to  conclude  that  the  bacilli  or  their  products  exerted  a  chemical 
influence  on  the  albumin  of  the  blood,  changing  it  into  a  gelatinous 
substance,  which  produces  disturbance  of  circulation  leading  to  ex- 
travasations. The  blood  changes  have,  however,  been  found  to  be 
somewhat  varied  by  different  observers  and  in  different  cases.  In  grave 
types  there  is  usually  great  diminution  in  the  red  corpuscles;  in  2  fatal 
cases  recently  reported  by  Dziehiszek2  and  by  Cureton3  this  was  especially 
noticeable;  in  the  latter's  case  three  days  before  death  numbering 
1,680,000  and  rapidly  going  down  to  310,000.  Duke4  found  in  his  cases 
the  blood-platelet  count  was  below  10,000,  and,  as  a  rule,  below  1000. 

Anatomically  (Robinson),  the  effusion  has  its  seat  in  the  corium, 
especially  the  papillae,  and  sometimes  in  the  subcutaneous  tissue  as 
well;  the  involved  blood-vessels  are  usually  dilated  and  filled  with  red 
blood-corpuscles. 

Diagnosis. — But  little  difficulty,  as  a  rule,  need  be  experienced 
in  the  recognition  of  so  well  marked  a  symptomatology  which  most 
cases  present.  The  lesions  are  not  inflammatory,  are  purely  hemor- 
rhagic, and  do  not  disappear  under  pressure.  In  rare  instances,  it  is 
true,  the  border-line  between  purpura  and  erythema  multiforme  is 
closely  approached,  but  in  uncomplicated  purpura  there  are  no  ery- 
thematous  lesions.  In  fact,  the  disease  to  be  differentiated  is  scurvy. 
In  this  latter,  however,  the  condition  is  observed  usually  in  one  de- 
prived of  all  vegetable  food  and  fruits,  and  is  generally  preceded  or 

1  Martin  de  Gimard  (loc.  cit.},  cited  by  D.  J.  M.  Miller,  Medical  News,  Aug.  8, 
1891,  who  reports  a  fatal  case — I  have  not  been  able  to  see  the  original. 

2  Dziehiszek,  Gazette  Lekarska,   1898,  vol.  xviii,  648— abs.  in  Jour.  Cutan.  Dis., 
1898,  p.  502. 

8  Cureton,  Lancet,  Feb.  25,  1899. 

4  Duke's  ("  The  Pathogenesis  of  Purpura  Hsemorrhagica  with  Especial  Reference 
to  the  part  played  by  Blood-platelets,"  Arch.  Intern.  Afed.,  Nov.,  1912,  x,p.  445,  with 
review  and  references;  and  "  The  Behavior  of  the  Blood-platelets  in  Toxaemia  and  Hem- 
rrhagic  Diseases,"  Bull.  Johns  Hopkins  Hasp.,  May,  1912,  p.  144)  observations  and 
experiments  seem  to  indicate  that  the  malady  may  be  caused  by  any  agent  which 
reduces  the  blood-platelet  count  to  a  sufficient  degree.  He  found  in  experiments  on 
animals  that  subcutaneous  injections  of  benzol,  diphtheria  toxin,  and  tuberculin,  the 
platelet  count  was  in  some  instances  sufficiently  reduced  to  bring  about  symptoms 
of  purpura,  only,  however,  in  those  having  an  extremely  low  count. 


PURPURA  499 

accompanied  by  softening  and  sponginess  of  the  gums,  which  bleed 
easily,  and  often  loosening  of  the  teeth;  moreover,  the  hemorrhagic 
lesions  are,  as  a  rule,  limited  to  the  legs  in  almost  all  cases,  and  most 
frequently  about  the  ankles,  with  often  some  brawny  swelling  of  the 
parts  and  a  tendency  to  break  down  into  ulcerations.  The  lesions 
which  are  produced  by  flea-bites  are  often,  after  a  day  or  two,  of  slight 
purpuric  character,  but  their  origin  is  usually  recognized,  and  in  the 
beginning  they  are  encircled  by  a  slight  erythema tous  halo,  and  they 
are  not,  moreover,  usually  seen  in  numbers,  nor  do  they  appear  in  crops. 

Prognosis. — While  it  is  generally  believed  that  various  types  of 
purpura  are  of  diverse  nature  and  etiology,  nevertheless  cases  which 
appear  as  mild  in  character  after  a  time  become,  in  some  instances, 
quite  serious.  The  prognosis  should  always  be  expressed  with  a  certain 
amount  of  caution,  although  it  can  be  said  that  almost  all  those  of  mild 
or  moderate  character  terminate  favorably.  As  to  the  length  of  time 
for  such  to  come  to  pass,  however,  no  definite  statements  can  be  given. 
Most  cases  end  in  three  to  six  or  eight  weeks;  others,  even  though  mild 
in  type,  may  persist  with  remission  for  some  months.  Those  presenting 
alarming  symptoms,  especially  those  of  the  type  purpura  haemorrhagica, 
must  always  be  considered  grave,  and  a  fatal  ending  often  occurs,  some- 
times in  several  days  or  a  week.  In  cachectic  patients  the  outlook  is 
always  less  favorable.  Hyde  and  Montgomery1  state  that  in  a  case 
under  their  care  a  purpuric  eruption  was  the  first  evidence  of  hemophilia, 
which  subsequently  showed  itself. 

Treatment — Except  in  the  mildest  types  the  patient  should  be 
kept  at  absolute  rest,  and  preferably  in  bed,  in  the  horizontal  position, 
or  with  the  legs  on  a  higher,  slightly  inclined  plane;  and  in  more  severe 
cases  light  compression,  as  with  the  roller  bandage,  may  also  be  used, 
as  advised  by  Besnier.  In  the  graver  forms  occasional  disinfection  of 
the  throat  and  mouth  (possible  port  of  entrance  of  the  disease)  is  advis- 
able. Outside  of  the  use  of  several  special  remedies,  treatment  depends 
upon  the  possible  etiologic  factor.  Quinin  is  to  be  given,  and  in  full 
doses,  where  malaria  is  suspected.  The  special  remedies  which  have 
been  extolled  from  time  to  time  are  iron,  especially  the  tincture  of  the 
muriate,  ergot,  oil  of  turpentine,  oil  of  Canada  erigeron,  aromatic  sul- 
phuric acid,  and  silver  nitrate.  Poulet2  was  especially  favorable  to 
silver  nitrate,  in  dosage  of  about  \  grain  (0.0108)  two  or  three  times  daily, 
and  records  recoveries  from  its  use  in  what  appeared  to  be  grave  cases; 
he  believes  its  favorable  action  due  to  its  modifying  influence  on  the 
capillary  circulation  through  an  impression  on  the  vasomotor  nerves. 
Crocker  strongly  indorses  oil  of  turpentine,  both  internally  and  by  in- 
halation. Recently  Wright3  has  advised  a  trial  of  calcium  chlorid  in 
15-  to  30-grain  (1-2.)  doses  three  times  daily,  basing  its  possible  value 
upon  its  service  in  urticaria  and  hemophilia,  etc.,  in  which  lessened 

1  Hyde  and  Montgomery,  Diseases  of  Ike  Skin,  seventh  edit.,  p.  485-  _ 

2  Poulet,  Bull.  gen.  de  thtrapeutique,  May  3,  1889— abstract  in  Jour.  Cutan.  DlS., 

I8893  Wright  "On  the  Treatment  of  the  Hemorrhages  and  Urticarias  which  are  asso- 
ciated with  Deficient  Blood-coagulability,"  Lancet,  Jan.  18 1896 ,  p.  153;  also  papers  m 
Brit  Jour  Derm.,  1896,  p.  82;  and  (on  calcium  salts)  Bnt.  Mcd.  Jour.,  Dec.  19,  1891. 


5  Oo  HEMORRHA  GES 

blood  coagulability  had  seemed,  from  his  investigations,  to  be  the  direct 
etiologic  factor.  The  remedy  should  not  be  given,  however,  for  more 
than  several  days,  as  its  continued  use  finally  diminishes  the  coagula- 
bility. In  suspected  cases,  probably  rare,  of  syphilitic  etiology,  the 
proper  treatment  should  be  instituted;  in  a  recent  case  by  Kornreich,1 
of  moderate  but  persistent  type,  which  showed  no  improvement  under 
ordinary  remedies,  rapid  recovery  ensued  upon  the  administration  of 
potassium  iodid  and  mercury.  Frick2  commends  antirheumatic  reme- 
dies, stating  that  such  treatment  had  succeeded  in  cases  rebellious  to 
other  plans,  and  he  is  inclined  to  believe  that  this  is  suggestive  of  a  com- 
mon or  allied  cause  for  these  affections.  The  most  valuable  remedies 
in  my  experience  have  been  quinin,  iron,  and  ergot,  the  last  in  grave  forms 
by  subcutaneous  injection.  It  is  possible,  in  these  alarming  cases,  the 
injection  of  artificial  serum  might  be  of  service;  Boulloche3  had  success 
in  a  case  of  fulminating  type,  in  which  this  seemed  to  be  the  therapeutic 
agent  in  promoting  rapid  recovery — an  injection  of  120  c.c.  was  used. 
MacGowan4  highly  commends  full  doses  of  adrenalin  chlorid. 

External  treatment  is  rarely  called  for.  Duhring,  in  the  graver 
types,  thinks  well  of  ice  applied  frequently  to  the  parts.  If  there  is 
any  itchiness,  very  occasionally  noted,  the  ordinary  antipruritic  lotion 
of  carbolic  acid  can  be  prescribed. 

Purpura  Scorbutica  (Synonyms:  Scurvy;  Sea  scurvy;  Scorbutus), 
—In  its  cutaneous  symptoms  scurvy  is  closely  similar  to  purpura,  and 
by  some  writers  is  considered  of  allied  nature.  In  the  general  characters 
and  features,  however,  the  diseases  are  more  or  less  dissimilar.  Scurvy 
is  due  to  long-continued  deprivation  of  proper  food,  especially  fruits 
and  vegetables,  and  its  development  is  also  favored  by  other  bad  hygienic 
conditions.  Its  subjects  are  usually  sailors  or  others  taking  long  voy- 
ages, although  it  is  occasionally  observed  in  those  on  land,  and  both 
Starr  and  Crozer  Griffith,  as  well  as  others,  have  also  noted  it  in  im- 
properly or  insufficiently  fed  infants  and  young  children.  A  peculiar 
constitutional  state  is  developed,  characterized  by  emaciation,  general 
febrile  and  asthenic  symptoms,  sometimes  with  also  swelling  of  one  or 
more  joints,  and  a  moderately  or  markedly  swollen,  turgid  and  spongy 
and  even  gangrenous  condition  of  the  gums;  and  concomitantly,  or 
sooner  or  later,  by  the  appearance,  usually  upon  the  lower  portion  of  the 
legs  only,  of  dark-colored  hemorrhagic  patches  or  blotches.  Sometimes, 
instead  of  more  or  less  diffused  discoloration,  it  may  consist  of  a  variable 
number  of  small  or  moderately  large  spots,  in  close  proximity  or  crowded 
together;  or  these  will  be  seen  in  the  neighborhood  of  or  just  outlying 
large  or  confluent  plaques.  In  fact,  the  cutaneous  lesions  may,  as  to 
size  and  ordinary  characters,  be  essentially  similar  to  the  petechiae, 
ecchymoses,  and  ecchymomata  of  purpura,  and  these  several  grades  of 
hemorrhagic  lesion  may  exist  at  the  same  time;  but  they  never  have  the 

1  Kornreich,  Med.  Record,  Feb.  26,  1898. 

2  Frick,  "Purpura  Rheumatica,"  Kansas  City  Med.  Index,  1896,  p.  159. 

3  Boulloche,  Bull,  el  mem.  de  la  soc.  med.  d.  hop.  de  Paris,  1899,  vol.  xvi,  p.  809. 

4  MacGowan,  "The  Use  of  Adrenalin  Chlorid  in  Hemorrhages  and  Angioneurotic 
Diseases  of  the  Skin,"  Jour.  Cutan.  Dis.,  1905,  p.  72. 


PUR  PUR  A  CQI 

bright-red  color  of  the  latter  malady,  but  are  usually  dark  sluggish  red 
from  the  beginning,  and  generally  of  a  duU  purplish  hue.  While  its 
common  and  often  sole  seat  is  about  the  ankle  and  the  immediately 
adjacent  part,  it  sometimes  is  also  seen  higher  up,  and  occasionally  on 
other  parts  as  well.  The  skin  of  the  affected  region  often  becomes 
swollen,  brawny,  and  slightly  scaly,  and  not  infrequently  breaks  down 
and  ulcerates.  The  tumid  gums  in  well-marked  cases  show  a  more  or 
less  irregular  or  fungoidal  surface,  give  off  an  offensive  secretion,  and 
bleed  readily.  Indeed,  in  advanced  cases  hemorrhages  from  the  various 
mucous  surfaces,  slight  or  grave,  may  also  take  place.  Under  unfavorable 
conditions,  in  those  instances  in  which  the  same  bad  hygienic  surround- 
ings and  the  ingestion  of  improper  food  are  continued,  death  finally 
results. 

While  scurvy  can  be  said  to  be  closely  allied  to  purpura,  it  clinically 
differs  somewhat  from  the  latter,  mainly  by  the  asthenic  and  emaciated 
general  condition  and  the  peculiar  puffy,  spongy  state  of  the  gums,  as 
well  as  by  the  diffused  character  of  the  cutaneous  manifestation  and  its 
usual  limitation  to  the  ankle  region  or  lower  part  of  the  legs.  Moreover, 
unlike  many  cases  of  purpura,  scurvy  is,  as  a  rule,  readily  remediable, 
and  usually  rapidly  so,  although  in  some  instances  recovery  is  tedious. 

The  treatment  consists  in  giving  the  patient  the  advantage  of  hy- 
gienic living,  proper  food,  with  an  abundance  of  vegetables.  Lemon-  or 
lime-juice  has  always  enjoyed  a  reputation  in  the  management  of  this 
malady,  and  deservedly,  as  it  is  especially  valuable,  and  is  to  be  taken 
freely.  In  some  cases  tonics  are  also  required,  such  as  the  ferruginous 
preparations,  quinin,  strychnin,  and,  in  weak  digestion,  the  ordinary 
stomachic  bitters,  such  as  gentian.  In  grave  cases  stimulants  are  some- 
times needed.  The  tumid,  spongy,  and  possibly  ulcerated  condition 
of  the  gums  often  demands  treatment,  and  of  great  service  is  frequent 
rinsing  of  the  mouth  with  water,  first  tepid,  later  moderately  cool.  In 
addition  astringent  and  antiseptic  mouth- washes  are  to  be  employed, 
such  as  a  weak  solution  of  potassium  chlorate,  2  or  3  grains  (0.135-0.2) 
to  the  ounce  (32.),  with  5  or  10  minims  (0.35-0.65)  of  tincture  of  myrrh.1 
A  boric  acid  lotion  with  a  little  tincture  of  myrrh  is  also  useful.  The 
skin  condition  in  most  cases  requires  but  little  if  any  treatment,  but  if 
extensive,  a  roller  bandage  to  give  support  to  the  parts  may  be  used.  If 
brawny  and  scaly,  a  mild  ointment  can  also  be  applied,  and  if  ulcerations 
have  resulted,  they  are  to  be  treated  upon  general  principles — cleanliness, 
mild  antiseptic  lotions,  and  ointments,  with  the  roller  bandage  support. 

1  Coplans  (Jour.  Trap.  Mcd.,  1904,  p.  98),  who  from  observations  of  the  disease  in 
South  Africa,  believes  the  disease  of  bacterial  rather  than  of  dietary  origin,  places  the 
greatest  stress  upon  rigorous  and  frequent  mouth  antisepsis,  and  believes  that  cases  seen 
early  can  be  cured  by  this  treatment  alone. 


CLASS   IV— HYPERTROPHIES 
LENTIGO 

Synonyms.— Freckles;  Ephelides;  Fr.,  Lentilles;  Taches  de  rousseur;  Ephelide 
lentiforme  solaire;  Ger.,  Sommersprossen;  Linsenflecken. 

Definition. — Freckles  are  yellowish,  brown,  or  blackish  pig- 
mentary, circumscribed,  cutaneous  macules,  varying  in  size  from  a  pin- 
head  to  that  of  a  pea  or  larger,  and  appearing,  for  the  most  part,  and 
often  exclusively,  on  exposed  regions,  as  the  face  and  hands. 

Symptoms. — This  affection  is,  as  well  known,  characterized 
by  pigmentary  spots,  which  are  round  or  irregular  in  contour,  and  vary 
in  size  from  a  pin-head  to  a  pea,  and  in  color  from  yellow  to  yellowish- 
brown  or  black.  Their  most  usual  color  is  a  yellowish-brown.  The 
affection  is  of  frequent  occurrence,  and  not  only  shows,  as  stated,  great 
variation  in  degree  of  development,  both  as  to  size  and  color,  but  also 
as  to  number.  In  some  cases  there  may  be  only  a  few  scattered  macules, 
in  others  exist  in  greater  or  less  profusion,  and,  indeed,  a  large  area,  as 
the  face,  or  some  parts  of  it,  may  be  thickly  studded  with  them.  They 
are  usually  met  with  only  on  exposed  parts,  such  as  the  face,  especially 
on  nose  and  cheeks,  neck,  and  dorsal  surfaces  of  the  hands,  but  they 
may  also  exist  on  covered  regions  of  the  body,  more  particularly  the  upper 
part  of  the  back.  Crocker  mentions  a  case  of  a  young  woman,  in 'whom 
they  first  appeared,  and  in  some  profusion,  on  the  thighs,  and  later  on 
the  front  part  of  the  trunk,  and  only  finally,  after  several  years,  a  few 
on  the  face.  Duhring  has  seen  several  instances  in  which  they  were 
also  to  be  seen  on  the  buttocks  and  penis.  Exceptionally,  as  in  Rob- 
inson's case,  the  lesions  may  be  in  great  part  or  wholly  limited  to  one 
part  of  the  face.  While  they  are  observed  almost  at  any  time  of  life, 
they  are,  however,  rarely  met  with  before  the  fourth  year,  and  are  most 
common  between  the  ages  of  ten  and  twenty.  Their  appearance  may 
be  slow  and  insidious,  or  may  be  somewhat  rapid,  as  quite  frequently 
observed  after  continued  sun  exposure.  In  fact,  they  usually  appear 
first  on  the  approach  of  or  during  the  summer  season,  and  always  fade 
away  more  or  less  as  the  cool  weather  comes  on,  often  completely,  reap- 
pearing or  becoming  more  numerous  and  darker  upon  the  return  of  sunny 
weather.  Beyond  the  disfigurement  they  cause  they  do  not  give  rise 
to  any  trouble,  as  there  are  no  subjective  symptoms. 

Lentigo  occurs  also  as  an  early  symptom  of  that  rare  affection  of 
the  skin  known  as  xeroderma  pigmentosum,  and  is,  moreover,  observed 
in  atrophia  cutis  senilis  (old  age  of  the  skin) ;  in  the  latter  they  some- 
times become,  after  a  time,  seborrheic,  covered  with  thin  greasy  scale, 
and  later  may  undergo  slight  degenerative  change  either  directly  or 
after  first  becoming  somewhat  warty  and  elevated  (seborrheic  wart). 

502 


LENTIGO 


503 


According  to  Crocker's  observation,  they  are  occasionally  observed 
following  eczema  in  those  advanced  in  years. 

Etiology  and  Pathology.— The  affection  is  common  to  both 
sexes  and  to  all  ages,  but,  as  already  remarked,  is  generally  seen  in  its 
greatest  development  during  adolescence,  the  disposition  to  its  appear- 
ance becoming  less  marked  as  age  advances.  Those  of  light  complexion, 
and  especially  those  with  red  hair,  are  its  most  common  subjects,  and 
in  whom  it  usually  reaches  its  greatest  development.  On  the  other 
hand,  it  is  also  seen  in  brunettes,  and  even  mulattos  are  not  wholly 
exempt,  although  the  blemish  is  naturally  much  less  conspicuous  in  those 
of  dark  complexion.  Exposure  to  the  sun  or  sunlight  is  a  potent  factor, 
and  often  the  only  recognizable  cause.  This  does  not,  however,  explain 
the  lesions  upon  covered  parts.  Heat  of  any  source,  however,  and  winds 
are  also  etiologic.  For  obvious  reasons,  therefore,  freckles  are  more 
common  in  the  summer,  and  during  cold  weather  they  fade  somewhat 
or  disappear  entirely,  to  reappear  as  soon  as  the  exciting  cause  again 
becomes  operative. 

Their  occurrence  on  protected  parts  of  the  body,  sometimes  appear- 
ing and  remaining  even  in  cool  weather,  would  indicate  that  there  may 
be  also  other  causes  than  those  named,  and  of  which  we  have  no  cogni- 
zance; such  freckles  are  sometimes  spoken  of  as  "cold  freckles."  An 
inherited  tendency  is  generally  to  be  noted.  Congenital  freckles,  occa- 
sionally reported,  are  more  probably  of  the  nature  of  pigmentary  naevi, 
although  the  latter  are,  in  reality,  in  their  slightest  development  a  similar 
formation,  except,  as  a  rule,  the  pigmentary  disturbance  involves  the 
upper  part  of  the  corium  as  well. 

Freckles  consist  of  a  circumscribed  amount  of  pigment  in  the  rete 
mucosum — merely,  in  fact,  a  localized  increase  of  the  normal  pigment, 
differing  from  chloasma  only  in  the  size  and  shape  of  the  pigmentation. 

Treatment. — The  management  of  this  affection  is  practically 
the  same  as  for  chloasma,  and  ordinarily  just  about  as  unsatisfactory. 
Like  the  latter,  in  many  instances  freckles  may  be  readily,  though  often 
only  temporarily,  removed  by  treatment;  in  others,  while  this  effect 
may  be  accomplished,  the  blemishes  prove  somewhat  rebellious,  although 
their  removal  is  possible  in  all  cases.  Unfortunately,  however,  in  the 
vast  majority  of  cases  they  soon  make  their  reappearance.  Treatment 
instituted  on  the  approach  of  autumn  is  sometimes  rapidly  effective, 
and  there  may  be  no  return  until  the  following  summer. 

The  various  applications  employed  have  in  view  the  removal  of  the 
corneous  epidermis  and  upper  rete  cells,  and,  with  these,  the  contained 
pigmented  spots.  It  is  to  be  remarked,  however,  that  all  drugs  which 
exert  such  action  are  not  therapeutically  efficient,  for  some,  as  mustard, 
cantharides,  and  others,  will  often  cause  a  deposit  of  pigment.  The  most 
efficient  and  most  generally  used  remedy  for  this  purpose  is  mercuric 
chlorid,  and  this  is  the  active  ingredient  in  most  patent  freckle  and  com- 
plexion lotions.  This  is  applied  as  a  lotion,  in  the  strength  of  from  \  to 
4  grains  (0.035-0.26)  to  the  ounce  (32.)  of  water  or  alcohol  and  water; 
this  should  be  dabbed  on  two  or  three  times  daily,  and  a  mild  degree  of 
furfuraceous  desquamation  brought  about.  A  compound  lotion,  consist- 


HYPERTROPHIES 

ing  of  mercuric  chlorid  from  4  to  8  grains  (0.26-0.52),  2  drams  (8.)  of  tinc- 
ture of  benzoin,  from  20  to  40  grains  (1.33-2-65)  of  zinc  sulphate,  and 
equal  parts  of  alcohol  and  water  to  make  up  4  ounces  (128.),  acts  more 
satisfactorily.  Hydrogen  peroxid  solution,  full  strength  or  weakened, 
will  sometimes  lessen  the  discolorations,  and  occasionally  promote  their 
disappearance.  Lactic  acid,  diluted  with  from  6  to  20  parts  of  water 
and  applied  freely  and  often,  will  sometimes  prove  satisfactory,  caution 
being  exercised  at  first  that  too  vigorous  action  does  not  result,  for  with 
some  skins  this  drug  occasionally  acts  with  unexpected  energy;  or  the 
stronger  applications  may  be  made  to  the  spots  themselves.  An  oint- 
ment of  i  dram  (4.)  each  of  bismuth  subnitrate  and  white  precipitate  to 
the  ounce  (32.)  of  cold  cream,  lard,  or  petrolatum  is  effective  in  some  cases. 
When  patients  can  give  themselves  up  to  the  treatment,  a  10  to  25  per 
cent,  salicylic  acid  plaster  applied  to  the  entire  face,  worn  constantly, 
and  replaced  when  it  loosens,  for  five  to  ten  days  will  usually  produce 
active  exfoliation  and  a  disappearance  of  the  pigment.  Such  a  plaster 
is  rendered  still  more  active  with  the  addition  of  5  to  20  per  cent,  of 
resorcin.  The  so-called  peeling  paste  (see  Acne)  acts  in  like  manner. 
This  energetic  plan,  which  is  the  one  adopted  at  some  of  the  "toilet 
parlors,"  usually  provokes,  however,  a  variable  degree  of  dermatitis, 
sometimes  mild,  sometimes  quite  severe,  which  takes  several  days  or 
more  to  subside,  and  for  which  mild  soothing  lotions  or  ointments  are 
to  be  used.  It  should  not,  therefore,  be  employed  except  very  cautiously 
in  those  of  irritable  skin. 

Electrolysis  may  be  tried  when  the  spots  are  few  in  number,  pricking 
the  epidermis  superficially,  and  using  a  mild  current  (%  to  2  milliamperes) , 
scarcely  more  than  one  or  two  seconds  to  each  freckle,  in  order  that  there 
may  be  no  possibility  of  scars. 

CHLOASMA 

Synonyms. — Moth  patches  or  spots;  Liver  spots;  Fr.,  Chloasme;  Panne  hepatique; 
Tache  hepatique;  Chaleur  du  foie;  Ger.,  Pigmentflecken;  Leberflecken. 

Definition. — Chloasma  is  the  term  applied  to  increased  pigmen- 
tation of  the  skin,  occurring  as  variously  sized  and  shaped,  yellowish, 
brownish,  or  blackish  patches,  or  as  more  or  less  diffused  discoloration. 

Symptoms. — More  commonly  chloasma  appears  as  ill-defined, 
somewhat  rounded  patches;  less  frequently  as  a  diffuse  discoloration. 
Its  appearance  is  rapid  or  slowr,  although  usually  insidious  and  gradual, 
and  unattended  by  any  subjective  symptoms,  the  sole  symptom  con- 
sisting in  the  deposit  of  more  or  less  additional  pigment,  without  textural 
change.  There  is,  therefore,  no  elevation,  and  the  surface  of  the  skin 
remains  smooth,  although  in  some  of  the  localized  forms,  especially  on 
the  face,  there  may  be  a  slight  coexisting  oily  seborrhea.  The  patches 
are  rarely  numerous,  one,  several,  or  more  being  present,  and  generally 
shade  off  gradually  into  the  surrounding  normal  skin ;  sometimes  coalesc- 
ing and  forming  one  or  more  large  irregular  and  ill-defined  areas.  The 
face  is  the  usual  site  for  the  common  or  patchy  variety,  although  it  may 
also  be  found  occasionally  on  the  trunk  and  other  parts,  but  is  then,  as  a 


CHLOASMA  c0r 

rule,  the  result  of  some  external  agency.  The  diffused  discoloration  may 
occupy  a  portion  of  the  body,  or  more  or  less  of  the  entire  surface  In 
these  latter  instances  the  discoloration  is  always  deeper  in  those  parts 
which  are  normally  darker,  such  as  about  the  eyes,  neck,  axilla  geni- 
tocrural  region,  and  about  the  nipple.  The  color  is  yellowish  or  brown- 
ish, and  may  even  be  blackish;  when  the  last,  the  malady  is  more  com- 
monly designated  by  the  practically  synonymous  term,  melasma  or 
melanoderma.  Depending  upon  the  etiologic  factors,  whether  external 
or  internal,  chloasma  cases  are  usually  grouped  in  two  classes— idiopathic 
and  symptomatic. 

Idiopathic  chloasma  (chloasma  idiopathicum)  includes  all  those 
cases  in  which  the  pigmentary  increase  is  due  to  local  or  external  agents, 
such  as  the  sun's  rays,  sinapisms,  blisters,  continued  cutaneous  hyper- 
emia, or  irritation  due  to  pressure,  friction,  scratching,  parasites,  and 
like  causes.  The  increased  discoloration  following  continued  exposure 
to  the  sun  or  diffused  bright  light  is  the  result  of  the  action  of  the  chemical 
rays,  and  may  also  occur  in  prolonged  exposure  to  strong  electric  light, 
although  to  a  relatively  slight  extent.  The  heat  itself  has  also  an  in- 
fluence, although  a  minor  action  when  compared  to  chemical  rays;  it 
will,  however,  when  long  continued  and  repeated,  bring  about  some  in- 
,  crease  of  depth  in  the  skin  tint,  as  observed  in  those  whose  occupation 
demands  close  proximity  to  the  fire,  as  stokers,  etc.  The  chloasma  thus 
variously  produced  is  sometimes  also  designated  chloasma  caloricum. 
The  first  stage,  usually,  of  such  is  slight  erythema  or  hyperemia.  In  this 
connection  the  pigmentation  resulting  from  repeated  exposure  to  the 
ar-ray  may  also  be  mentioned,  following  after  erythema,  which  it  often 
produces;  the  discoloration  is  usually  slight,  and  doubtless  the  effect 
of  both  the  light  and  the  current,  although  in  what  manner  the  latter 
is  causative,  if  it  is  so,  is  not  known.  The  discoloration  resulting  from 
the  application  of  sinapisms  and  blisters,  and  from  certain  drugs,  known 
also  under  the  name  of  chloasma  toxicum,  is  an  occasional  occurrence, 
and  sometimes  it  is  quite  persistent,  as  in  an  instance  which  came  under 
my  own  observation  hi  a  young,  fashionable  woman  who  had  had  a 
mustard  plaster  applied  over  the  sternal  region,  deep  pigmentation  de- 
veloping as  the  redness  subsided,  and  lasting  for  months  as  a  sharply 
defined  area,  the  exact  shape  and  size  of  the  plaster,  making  the  wearing 
of  decollette  gowns  impossible.  It  remains  at  the  site  of  the  application, 
although  Dubreuilh1  reports  a  case  in  which,  apparently  as  a  result  of  a 
mild  spreading  dermatitis  produced,  it  extended  considerably  beyond. 

The  increased  discoloration  due  to  pressure  and  friction,  as  well  as 
other  traumatic  agents  (chloasma  traumaticum) ,  is  exemplified  in  those 
regions  against  which  a  truss  is  in  constant  contact.  To  the  same  cause 
is  doubtless  to  be  attributed  the  slight  darkening  of  the  skin  of  the  neck 
region  noticeable  in  some  individuals.  Of  especial  dermatologic  interest 
is  the  pigmentation  resulting  from  prolonged  hyperemia  and  irritation, 
as  that  observed  in  consequence  of  the  scratching  induced  by  chronic 
irritation  of  the  skin,  particularly  in  long-continued  pruritus,  dermatitis 
herpetiformis,  and  pediculosis  corporis,  as  well  as  other  lasting,  itchy, 
1  Dubreuilh,  Annales,  1891,  p.  76. 


506  HYPERTROPHIES 

cutaneous  diseases  constituting  the  pityriasis  nigra  of  Willan.     Syphilitic 
eruptions  may,  as  is  well  known,  also  leave  some  pigmentary  stain. 

In  pediculosis  it  becomes,  after  long  continuance  of  this  malady,  often 
extremely  pronounced — so  much  so  that,  exceptionally,  there  is  a  strong 
suggestion  of  Addison's  disease;  one  such  instance  came  under  my  notice 
at  the  Philadelphia  (Charity)  Hospital,  the  patient  having  been  sent 
by  the  admitting  physician  to  the  medical  ward  under  the  belief  that 
it  was  the  latter  affection.  Similar  extreme  examples  have  been  reported 
by  Greenhow.1  In  pediculosis  the  pigmentation  is  most  marked,  as  is  to 
be  expected,  on  those  situations  where  the  irritation  is  greatest,  as  across 
the  shoulders  and  upper  part  of  the  back,  around  the  waist,  over  the 
sacrum,  etc.  (see  Pediculosis).  It  is,  in  moderately  marked  cases,  some- 
what spotty,  with  also  some  small,  somewhat  whitened,  atrophic  or 
scar-like  spots  intermingled,  the  latter  the  sites  where  the  skin  has  been 
deeply  gouged  out  by  the  nails  in  scratching.  Other  parasites  in  addition 
to  lice  and  the  itch-mites  can  also  bring  about  pigmentation  or  pseudo- 
pigmentary  changes,  as  in  a  few  rare  instances  from  the  demodex  fol- 
liculorum  (q.  v.}  and  from  the  microsporon  furfur  (see  Tinea  versicolor), 
microsporon  minutissimum  (see  Erythrasma),  which  will  be  referred  to 
in  the  proper  place. 

Symptomatic  chloasma  (chloasma  symptomaticum)  is  the  more 
important  variety,  and  includes  all  forms  of  pigment  deposit  which  occur 
as  a  consequence  of  various  organic  and  systemic  diseases,  as  the  pig- 
mentation, for  example,  observed  in  association  with  tuberculosis,- 
secondary  syphilis,  sarcoma,  cancer,  malaria,  Addison's  disease,  Graves' 
disease,  and  functional  and  organic  affections  of  the  utero-ovarian  sys- 
tem. With  the  exception  of  the  pigmentation  observed  in  the  last  named, 
the  most  common  cause  of  symptomatic  chloasma,  it  is  usually  more  or 
less  diffused.  The  hyperpigmentation  bordering  the  white  depigmented 
patches  in  vitiligo  and  that  of  the  pigmentary  syphiloderm  are  consid- 
ered under  these  diseases,  and  need  not,  therefore,  be  discussed  here. 
Moreover,  the  discoloration  of  these  various  cachectic  maladies  (chloasma 
cachecticorum)  named  is  too  well  known  to  need  special  description, 
although  to  the  practised  eye  there  is  often  considerable  difference  in 
depth  and  shading  in  the  several  affections.  In  tuberculosis,  in  its 
greatest  development,  it  is  somewhat  on  the  tint  of  the  color  in  Addison's 
disease,  although  much  less  pronounced,  and  sometimes  extremely  slight.2 
The  peculiar  sallow  or  earthy  color  of  the  early  stages  of  secondary 
syphilis,  most  marked  on,  and  sometimes  practically  limited  to,  the  face, 
is  often  sufficiently  distinct  to  be  of  some  corroborative  value  in  other- 
wise doubtful  cases.  A  somewhat  similar  tint  is  frequently  seen  in 
sarcoma  and  also  in  cancer,  but  usually  with  a  trifling  lemon-yellow 
coloring.  In  malaria  there  is  generally  a  sallow  color,  with  a  brownish 
tint,  while  in  morbus  Addisoni  it  is  of  a  somewhat  slaty,  bronzed  hue. 

1  Greenhow,  "Vagabond's  Discoloration  Simulating  the  Bronzed  Skin  of  Addison's 
Disease,"  Trans.  London  Clin.  Soc'y,  1876,  vol.  ix,  p.  44. 

2W.  G.  Smith,  Brit.  Jour.  Derm.,  1892,  p.  386,  describes  an  extreme  case;  also 
Andrewes,  "Two  Cases  of  Tuberculosis  with  Unusual  Pigmentation  of  the  Skin  and 
Deposit  in  the  Suprarenals,"  St.  Barthol.  Hasp.  Rep.,  1801.  vol.  xxvii,  p.  100  (with 
remarks). 


CHLOASMA 


507 


In  Graves'  disease  there  is  also  sometimes  observed  a  brownish-yellow 
pigmentation,  either  in  freckle-like  spots,  patchy,  or,  in  rarer  instances, 
as  a  more  or  less  diffused  discoloration,  of  which  examples  are  cited  by 
Drummond,1  Mackenzie,2  Nicol,3  and  others. 

Chloasma  Uterinum. — The  most  important  form,  however,  in  the 
symptomatic  class  is  that  due  to  disturbances,  either  functional  or 
organic  in  character,  of  the  utero-ovarian  system,  known  under  the  name 
of  chloasma  uterinum.  It  appears  upon  the  face  and  is  usually  limited 
to  this  part,  the  forehead  being  the  favorite  site,  although  occasionally 
this  whole  region  shares  in  the  discoloration,  forming  almost  a  "mask." 
In  some  instances  patches  appear  also  on  the  breast,  abdomen,  and  other 


Fig.  120— Chloasma  in  a  light  mulatto  woman  aged  thirty  of  several  months 
duration;  a  rather  sharply  denned  area  on  the  central  portion  of  the  forehead,  sorr 
under  the  eyes,  small  patches  on  cheeks,  and  a  long  patch  on  upper  lip. 
utero-ovarian  disturbance,  with  irregular  menstruation. 

parts.  It  presents  sometimes  as  fairly  well-defined  patches  of  yellowish- 
brown  pigmentation,  but  much  more  commonly  the  plaques  or  areas  are 
ill  defined,  and  the  dividing-line  between  the  normal  and  pigmented  skin 
is  difficult  of  recognition.  The  pigmentation  is  more  intense  in  bru- 
nettes. The  skin  is  smooth;  occasionally  a  mild  degree  of  seborrhea 
coexists,  in  which  event  the  surface  may  be  either  oily  or  furfuraa 

i  Drummond,  "Clinical  Lecture  on  Some  of  the  Symptoms  of  Graves'  Disease," 

Brit*  He^ MacSi'e1'  'CHnSi  Lecture  on  Graves's  Disease,"  Lancet,  1890,  vol.  ii, 
pp.  5*  and  J£  (many  interesting  cases  with  pigmentation;  ^^^ 

'Nicol,  Brit.  Jour.  Derm.,  1900,  p.  56  (more  or  less  general);  see  also  Dore  s p 
"Cutaneous  Affection  Occurring  in  the  Course  of  Graves'  Disease,    *&«*.,  p.  353- 


508  HYPERTROPHIES 

scaly,  usually  the  former,  depending,  however,  upon  the  variety  of  sebor- 
rhea.  It  is  seen  in  those  between  the  ages  of  twenty-five  and  fifty; 
rarely  in  those  younger,  and  seldom  after  the  climacteric.  It  is  most 
commonly  observed  during  pregnancy  (Moasma  gravidarum) ,  but  may 
also  occur  in  connection  with  any  functional  or  organic  disease  of  the 
utero-ovarian  apparatus.  There  is  during  the  pregnant  state,  as  is 
known,  a  physiologic  tendency  to  a  pronounced  increase  of  pigmentation, 
but  more  especially  in  certain  situations,  as  along  the  linea  alba  and 
about  the  nipples.  Kaposi1  reports  a  curious  case  of  a  woman  in  whom 
increased  pigmentation  of  a  large  mole  on  her  neck  was  the  earliest  sign- 
in  the  first  month— of  pregnancy.  In  some  instances  this  pigmentary 
tendency  is  not  only  seen  in  the  face,  especially  the  forehead,  but  also 
the  neck,  and  occasionally  it  is  extensive  or  almost  universal,  as  in  the 
cases  referred  to  by  McLane,2  Wilson,3  Murphy,4  Crocker,5  Swayne,6 
and  others.  It  more  usually  appears  in  the  early  or  middle  period,  and 
may  deepen  in  shade  as  pregnancy  becomes  advanced,  disappearing, 
as  a  rule,  after  confinement.  In  McLane's  case  it  appeared  during  the 
eighth  month;  in  Swayne's,  at  the  beginning  of  the  last  three  months, 
and  in  this  instance  had  so  occurred  in  three  successive  pregnancies.  In 
Crocker's  patient  the  color  increased  with  each  pregnancy.  As  already 
remarked,  however,  various  other  conditions  may  also  occasion  it,  such 
as  ovarian  irritation,  dysmenorrhea,  etc.7 

Etiology  and  Pathology. — The  causes  which  have  in  the  main 
already  been  necessarily  mentioned  in  speaking  of  the  varieties  are,  it  is 
seen,  numerous  and  of  different  nature.  Most  cases  coming  under  ob- 
servation are  those  with  patches  on  the  face,  and  having  some  disturbance 
of  the  utero-ovarian  apparatus  as  the  etiologic  factor.  In  addition  to 
this  and  the  other  causes  named  may  also  be  mentioned  anemia  and 
chlorosis,  chronic  indigestion,  neurasthenia,  nervous  shocks,  and  similar 
agencies.  Sex  has  a  very  decided  influence.  The  malady  is  rare  in  the 
male;  occasionally,  however,  pigmentation  of  the  face  is  observed,  and 
sometimes  discoloration,  more  or  less  patchy,  is  seen  about  the  crural 
and  perineal  region.  As  already  stated,  persistent  hyperemia,  as  in 
chronic  eczema  of  the  legs,  especially  when  associated  with  varicose  veins, 
will  often  leave  more  or  less  permanent  pigmentation.  Discoloration 
is  also,  as  known,  observed  as  a  result  or  part  of  some  other  maladies, 
as  lichen  planus,  pigmented  sarcoma,  xeroderma  pigmentosum,  lepra, 

1  Kaposi,  Trans.  Berlin.  Internal.   Cong.,  1890.  vol.  iv,  Abth.  xiii,  p.  98.      The 
papers  by  Caspary,  Kaposi,  Ehrmann,  and  Jarisch  on  the  subject,  "Die  Pathogenese 
der  Pigmentirungen  und  Entfarbungen  der  Haut,"  contained  therein,  give  a  clear 
presentation  of  the  subject. 

2  McLane,  "Extraordinary  Pigmentation  of  the  Skin  in  Pregnancy,"  Amer.  Jour. 
Obstel.,  1878,  vol.  xi,  p.  792  (chiefly  on  neck,  back,  and  thighs,  patient  profoundly 
anemic). 

3  Wilson,  Lectures  on  Dermatology,  London,  1878,  p.  24  (more  or  less  general). 

4  Murphy,   "Chloasma   Uterinurn,"  Obstetrical  Gazette,  1879-80,  vol.   ii,   p.    294 
(general). 

5  Crocker,  Diseases  of  the  Skin  (chiefly  face  and  neck). 

6  Swayne,  quoted  by  Tilbury  Fox,  Diseases  of  the  Skin,  second  Amer.  edit.,  p.  402, 
and  also  by  Crocker,  loc.  cit.  (face,  arms,  hand,  and  legs — spotty). 

7  See  valuable  paper  by  Champneys,  "Pigmentation  of  the  Face  and  Other  Parts, 
Especially  in  Women,"  St.  Earth.  Hasp.  Rep.,  1879,  v°l-  *v,  p.  233  (with  review  of  the 
subject  and  report  of  8  cases). 


CHLOASMA  500 

scleroderma,  urticaria  pigmentosa,  etc.  The  staining  of  jaundice  and 
the  yellowish  color  from  the  ingestion  of  picric  acid,  as  well  as  the  dis- 
coloration produced  by  the  external  use  of  certain  drugs,  such  as  chrys- 
arobin,  need  not  be  specially  referred  to,  the  causative  factors  being 
usually  self-evident.  The  chloasma  following  prolonged  administration 
of  arsenic  is  referred  to  elsewhere  (see  Dermatitis  medicamentosa). 
Argyria,  tattooing,  and  gunpowder  stains  are  discussed  later  on. 

The  pathologic  process  of  chloasma  is,  for  the  most  part,  merely  an 
accentuation  or  increase  in  the  physiologic  pigment  function.1  It  is 
apparently  under  the  control  of  the  nervous  system.  Some  observa- 
tions, as  in  Andrewes'  cases,2  suggest  investigation  as  to  the  possibility 
of  disease  of  the  suprarenal  glands  being  occasionally  of  influence. 
Gueneau  de  Mussy3  believed  that  any  irritation  or  lesion  of  the  nerves, 
or  affiliated  nerves,  which  supplied  the  suprarenal  capsules,  from  what- 
ever part  of  the  abdomen,  will  have  an  influence  on  increase  of  pigmen- 
tation. Anatomically  the  sole  change  consists  of  an  increased  deposit 
of  pigment  having  its  seat  wholly  or  principally  in  the  mucous  layer  of 
the  epidermis.  The  malady,  in  fact,  is  pathologically  similar  to  freckles, 
except  in  the  latter  there  is  an  extremely  circumscribed  deposit,  while 
in  chloasma  it  is  patchy  or  diffused.  In  some  instances  pigment  is  also 
found  more  deeply,  as  Demieville4  and  others  since  have  observed.  In 
some  instances,  as  in  those  following  chronic  diseases  of  the  skin,  the 
pigmentation  is  due,  in  great  part  at  least,  to  the  coloring-matter  of  the 
extravasated  blood.  In  discolorations  due  to  stains,  as  in  jaundice,  for 
instance,  the  color  extends  deeply. 

Diagnosis. — The  general  pigmentary  cases  give  no  difficulty, 
nor  does,  ordinarily,  chloasma  uterinum,  the  discolorations  of  which 
are  usually  confined  to  the  face.  The  diseases  with  which  the  latter 
is  most  likely  to  be  confounded  are  tinea  versicolor,  vitiligo,  and  chromi- 
drosis.  In  tinea  versicolor  the  discoloration  is  rarely  seen  on  the  face, 
and  then  in  connection  with  extensive  eruption  on  the  trunk,  and,  more- 
over, even  then  it  only  exceptionally  gets  higher  than  the  lower  edge  of 
the  chin.  The  distribution  and  the  extent  are,  therefore,  usually  alone 
sufficient  for  the  differentiation;  but  in  addition  to  this  the  patches  of 
chloasma  are  smooth,  the  skin  otherwise  unchanged,  whereas  in  tinea 
versicolor  there  is  more  or  less  furfuraceous  scaliness,  and  the  surface 
can  readily  be  scraped  off  with  the  finger-nail,  and  with  it  the  discolora- 
tion, as  the  latter  is  due  to  the  causative  fungus,  which  is  rarely  seated 
more  deeply  than  the  superficial  horny  layer.  The  microscope  could,  of 

1  See  "pigment"  of  the  skin  and  the  extremely  valuable  contributions  by  Ehrmann, 
"Untersuchungen  iiber  die  Physiologic  und  Pathologic  des  Hautpigmerites ,     Arcftiv, 
1885,  p.  507,  and  1886,  p.  57  (a  classic  paper,  with  references  and  n  colored  histolop 
cuts),  and  also  his  still  more  elaborate  paper,  "Das  Melanotische  Pigment,     etc., 

*   .  *      -w^.     ••    TT          •     _  o  _  £.     lii.    -  «    ^x"»1j-* «*£w-l  t-*lo  t*»c  r-f\r\\  n  inino1    mil  II V 


Bibliotheca  Medica,  Abth.  D.  ii,  H.  vi,  1896,  with  12  colored  plates  containing  many 
cuts  (Fisher  and  Co.,  Cassel);  also  "Das  Pigment  der  Haul,  by  Lima,  Monatsftejte, 
1880,  vol.  viii,  p.  366  (with  review  and  references);  also  Piersol  s  paper,  Develop- 
ment of  Pigment  within  the  Epidermis,"  University  Magazine,  1890,  p.  571  (with  ci 


and  references). 

2  Andrewes,  loc.  cit.  ,        .. 

3  Gueneau  de  Mussv,  Revue,  Med.,  Feb.,  1879,  quoted  by  Murphy,  he.  at. 

«  Demieville,  "Ueber  Pigmentflecke  der  Haut,"  Vtrchow's  Archiv  1880,  vol .  Ixxxi, 
p.  333  (based  chiefly  upon  a  study  of  lentigo,  with  3  histologic  cuts  and  references). 


5io 


HYPER  TR  OPHIES 


course,  be  resorted  to  if  necessary,  but  such  a  contingency  could  rarely 
happen.  Vitiligo,  as  is  known,  consists  of  depigmented  or  whitened 
spots  or  patches  with  surrounding  increased  pigmentation,  totally  dif- 
ferent from  chloasma,  and  this  can  readily  be  recognized  unless  hastily 
and  carelessly  examined;  but  the  possibility  of  mistake  is  in  the  fact 
that  the  white  areas  may  be  considered  the  normal  color,  in  which  event 
the  surrounding  pigmentation  would  be  misinterpreted.  The  patch 
of  chloasma  always  has,  however,  somewhat  rounded,  convex  borders, 
whereas  in  the  pigmentation  of  vitiligo  inclosing  a  more  or  less  rounded 
area  of  white  skin  the  border,  of  one  side  at  least,  would  be  just  reversed 
— concave. 

In  chromidrosis  (q.  ».)  the  discoloration  is  in  the  exuded  secretion, 
and  it  can  be  washed  or  rubbed  off,  although  sometimes  with  considerable 
difficulty,  but  usually  readily  with  ether  or  chloroform;  this  moist  or  oily 
condition  of  the  surface,  moreover,  is  unusual  in  chloasma,  and  when 
rubbed,  the  exudation  taken  up  by  the  rubbing  finger  shows  the  dis- 
coloration also.  In  view  of  the  observations  of  De  Amicis,  Majocchi,  and 
Dubreuilh,  indicating  that  exceptionally  pigmentation  results  from  the 
presence  of  a  profusion  of  the  parasite,  demodex  folliculorum  (q.  v.), 
this  factor  should  not  be  lost  sight  of,  especially  in  those  instances 
seemingly  obscure  etiologically.  Nor  is  the  possibility  in  obscure  cases 
of  the  discoloration  being  due  to  some  drug  or  other  stain  medicinally 
or  intentionally  employed  to  be  forgotten,  which,  if  such  suspicion  is 
aroused,  can,  as  a  rule,  readily  be  determined.  It  is  to  be  remembered, 
also,  that  the  continued  administration  of  arsenic  sometimes  produces 
a  more  or  less  general  pigmentation. 

Prognosis. — Chloasma  uterinum  is  usually  persistent  and  rebel- 
lious, generally  disappearing  as  the  cause — pregnancy  or  other  dis- 
turbance of  the  generative  organs — subsides.  In  persistent  cases,  in 
which  no  evident  factor  seems  present,  ovarian  irritation  or  some  disease 
of  the  uterus  is  to  be  suspected,  and  such  possibility  substantiated  or 
disproved  by  gynecologic  examination.  Cases  depending  upon  anemia, 
chlorosis,  and  similar  removable  agencies  are  usually  of  favorable  out- 
come. It  is  true,  without  disappearance  of  the  underlying  cause,  the 
discoloration  can  generally  be  removed  by  local  applications,  but  the 
effect  is,  as  a  rule,  only  temporary.  The  remediability  of  the  more  or 
less  generalized  pigmentation  of  tuberculosis,  cancer,  etc.,  is  dependent 
upon  the  prognosis  of  the  disease  in  question.  The  pigmentation  conse- 
quent upon  irritation  and  inflammatory  diseases  usually  subsides  sooner 
or  later  after  discontinuance  of  the  cause,  but  in  some  cases  some  months 
or  a  year  or  more  may  elapse  before  it  has  entirely  disappeared;  that  from 
chronic  eczema  of  the  leg,  if  in  people  of  advanced  years,  is  usually  per- 
manent, though  it  becomes  somewhat  less  marked.  That  following 
syphilitic  eruptions  is  rarely  persistent. 

Treatment. — Chloasma  requires  for  its  removal  a  careful  study 
of  the  exciting  and  predisposing  causes.  The  digestion,  the  tone  of  the 
general  health,  and  the  utero-ovarian  organs  should  receive  attention 
as  possible  factors.  If  anemia  or  chlorosis  is  present,  the  proper  measures 
should  be  accordingly  instituted.  In  fact,  the  constitutional  treatment 


CHLOASMA  tjn 

is  to  be  prescribed  upon  general  principles,  as  there  are  no  specific  reme- 
dies. As  in  some  instances  it  is  difficult  or  impossible  to  discover  any 
faulty  condition  of  the  general  system,  in  such  reliance  must  be  placed 
upon  local  treatment;  and,  in  fact,  this  latter  is  to  be  employed  in  all  cases, 
although,  unless  a  removal  of  the  exciting  or  predisposing  cause  is  pos- 
sible or  has  ceased  to  persist,  the  relief  furnished  is  commonly  but  tempo- 
rary. 

The  cases  applying  for  treatment  are  usually  those  in  which  the 
face  is  the  site  of  the  blemish, — other  cases  being  relatively  rare, — and 
for  the  most  part  these  are  examples  of  chloasma  uterinum.  The  external 
treatment  has  in  view  a  twofold  action — a  removal  of  the  epidermic 
corneous  layer  and  upper  rete  cells,  and  with  these  the  pigmentation 
contained  therein,  and  a  stimulation  of  the  absorbents.  Occasionally 
the  action  must  also  take  in  the  lower  rete  cells.  The  external  treatment 
is,  in  fact,  similar  to  that  employed  in  the  removal  of  freckles,  to  which 
the  reader  is  referred  for  the  method  of  application  of  the  remedies — 
corrosive  sublimate,  lactic  acid,  hydrogen  peroxid,  the  ointment  of 
bismuth  subnitrate  and  white  precipitate,  and  the  peeling  pastes.  As 
a  rule,  however,  in  chloasma  the  stronger  applications  are  necessary, 
and  sometimes  actual  blistering  is  required.  It  should  be  noted,  more- 
over, that  certain  remedies  which  produce  active  exfoliation  or  blistering, 
instead  of  removing  the  pigment,  may  tend  to  increase  it,  such  as,  for 
instance,  mustard  and  cantharides,  and  these  are  to  be  avoided.  The 
application  selected  should  be  employed  in  the  weaker  strength  at  first, 
in  order  to  test  the  sensitiveness  of  the  skin;  it  is  to  be  made  several 
times  daily  when  possible,  and  as  soon  as  branny  exfoliation  begins  to 
show  itself  or  active  irritation  supervenes,  it  should  be  discontinued 
until  such  symptoms  have  subsided.  When  the  temporary  disfigure- 
ment is  not  objected  to,  treatment  can  be  more  energetic,  pushing  it  to 
the  point  of  more  decided  exfoliation,  after  which  a  mild  soothing  salve, 
such  as  cold  cream,  can  be  applied  for  a  day  or  two  until  the  surface  is 
smooth  again,  and  then,  if  pigment  still  remains,  as  it  commonly  does, 
although  usually  less  marked,  active  treatment  is  resumed,  and  so  on 
until  it  is  entirely  removed;  or  if  the  selected  remedy  is  unsuccessful, 
then  changing  to  another.  Hydrogen  peroxid  acts  more  through 
its  bleaching  property,  and  occasionally  satisfactorily  without  push- 
ing it  in  greater  strength  to  the  point  of  producing  a  mild  exfoliative 
dermatitis. 

My  own  experience  would  indicate  that  the  most  valuable  applica- 
tions are,  in  the  order  named,  corrosive  sublimate  solution,  lactic  acid, 
salicylic  acid,  the  peeling  pastes,  and  hydrogen  peroxid. 

Argyria  is  the  term  applied  to  the  discoloration  which  follows  the 
prolonged  administration  of  silver  nitrate,  a  rare  occurrence  at  the 
present  day,  but  not  infrequent  at  the  period  when  this  drug  was  the 
chief  remedy  in  the  treatment  of  epilepsy.  It  has  also  been  stated  to 
follow  the  repeated  applications  to  the  throat,  and  Crocker  (toe.  ctt.) 
"met  with  a  case  in  which  the  blueness  did  not  develop  for  many  years 
after  the  topical  application  had  ceased  to  be  made."  In  an  instance 


512 


H  YPER  TR  OP  HIES 


observed  by  Neumann1  in  the  case  of  a  physician,  who  for  gastric  ulcer 
was  in  the  habit  of  injecting  into  his  stomach  daily,  through  an  esopha- 
geal  tube,  two  or  three  syringefuls  of  a  solution  containing  24  grains  (1.5) 
of  silver  nitrate  to  3  ounces  (96.)  of  water,  and  in  whom,  after  the  twelfth 
injection,  according  to  the  patient's  statement,  the  discoloration  began 
to  appear.  In  the  instance  reported  by  Riemer,2  the  first  sign  appeared 
after  about  280  grains  had  been  taken.  Koelsch3  has  observed  two  cases 
of  generalized  argyria  in  women  handling  silver  leaf.  According  to 
Branson,  confirmed  by  Pepper,4  the  earliest  indication  of  the  development 
of  the  discoloration  is  the  occurrence  of  a  dark-blue  line  on  the  edges  of  the 
gums,  very  similar  to  that  produced  by  lead,  but  somewhat  darker.  The 
color  of  the  skin  resulting,  as  well  known,  is  of  a  bluish-gray  or  slate  color, 
and  when  once  established,  is  permanent.  It  is  general  over  the  surface 
and  also  on  the  adjoining  mucous  membranes,  but  is  most  pronounced 
on  those  parts  exposed  to  the  light,  as  the  face  and  hands.  The  hair 
and  nails  also  share  in  the  discoloration,  the  hair  having  a  faint  reddish 
tinge.  According  to  the  investigations  of  Riemer  and  Neumann,5  the 
pigment  is  found  in  the  form  of  reduced  silver,  and  in  all  parts  of  the 
skin  except  the  rete  cells  and  the  glandular  epithelium,  and  also  in  the 
subcutaneous  connective  tissue.  The  greatest  deposition  is  just  below 
the  rete,  in  the  uppermost  papillary  layers  of  the  corium,  where  it  ap- 
pears as  a  sharply  denned  blackish  border,  and  it  is  also  abundant  in 
the  membranae  propriae  of  the  sweat-glands.  A  deposit  is  likewise 
found  in  the  internal  organs,  with  the  exception  (quoting  Lesser)6  of 
the  central  nervous  system. 

When  the  discoloration  is  once  established,  it  is  permanent,  although 
Neumann7  records  an  instance  in  which  there  occurred  some  lessening 
of  the  intensity  in  the  course  of  several  years;  and  Yandell8  reported  2 
such  patients  (epileptics)  who  contracted  syphilis,  for  which  the  adminis- 
tration of  potassium  iodid  was  conjoined  with  mercurial  vapor-baths, 
and  during  which  treatment  there  was  gradual  disappearance  of  the 
discoloration — in  one  completely,  in  the  other  practically  so.  Others, 
however,  who  have  since  tried  this  plan  have  not  been  so  fortunate. 

Tattoo-marks. — Tattooing,  or  the  mechanical  introduction  of  pig- 
ments into  the  skin,  is  a  well-known  process.  The  coloring-matter  used 
consists  of  carbon,  cinnabar,  carmin,  and  indigo,  and  when  once  thor- 
oughly imbedded,  is  permanent.  The  chief  interest  dermatologically 
lies  in  the  attempts  at  successful  removal,  an  end  exceedingly  difficult, 
and  without  excision  or  destructive  action  almost,  if  not  wholly,  im- 

1  Neumann,  "Ueber  Argyria,"  Medidnische  Jahrbucher'iST?,  p.  369  (with  resume, 
several  histologic  cuts,  and  references). 

2  Riemer,  Archiv  dcr  Heilkunde,  1875,  PP-  296  and  385. 

3  Koelsch,  Mttnchen,  Med.  Wochenschr.,  Feb  6,  191 2,  p.  304  (professional  argyria, 
etiology,  and  prophylaxis). 

4  Branson,  Pepper,  cited  in  United  States  Dispensatory. 

5  Neumann,  Lehrbuch  der  Hautkrankheiten. 

4  Lesser,  Ziemssen's  Handbook  of  Skin  Diseases,  p.  455. 

7  Neumann,  Medidnische  Jahrbiicher,  1877,  p.  382,  also  cited  by  Lesser,  Ziemssen's 
Handbook  of  Skin  Diseases,  p.  455. 

8  Yandell,  Amer.  Practitioner,  1872,  vol.  v,  p.  329. 


CHLOASMA 


513 


possible  of  attainment.  Various  methods  have  been  extolled  fronvftimV 
to  time,  having  usually  as  a  basis  the  production  of  a  reactive  destructive^' 
inflammation  which  results  in  crusting,  the  crust  dropping  off,  and^ii  - 
successful  instances  the  pigment  cast  off  with  it,  leaving  a  superficial- 
or  pronounced  scar,  according  to  the  particular  plan  employed.  The"' 
French  methods,  which  seem  to  have  the  most  support,  excepting  excision 
or  cauterization,  are  the  plans  advocated  by  Brault1  and  by  Variot,2 
with  neither  of  which  I  have  had  any  personal  experience.  Brault's 
method  consists,  after  thorough  cleansing  of  the  surface,  of  tattooing  hi 
of  a  solution  of  30  parts  of  zinc  chlorid  in  40  parts  of  water;  mild  in- 
flammatory reaction  ensues,  but  usually  slight,  a  crust  forms,  and  after 
some  days  falls  off,  leaving  a  scar;  a  repetition  is  sometimes  necessary. 
Variot's  plan  is  first  to  put  on  the  mark  a  concentrated  solution  of  tannin, 
which  is  then  tattooed  in,  making  punctures  close  together:  he  then  rubs 
the  silver  nitrate  stick  firmly  over  the  surface,  allows  it  to  remain  for 
several  minutes,  and  then  wipes  it  off.  There  is  a  slight  inflammatory 
reaction,  occasionally  trifling  suppuration;  the  part  blackens,  a  super- 
ficial crust  or  eschar  forms,  which  in  one  or  two  weeks  drops  off,  leaving 
an  insignificant  scar  which  becomes  scarcely  noticeable.  Dubreuilh3 
has  warmly  extolled  "shaving"  off  the  involved  skin,  supplementing  by 
skin-grafting  if  necessary. 


O 
Fig.  121.  —  Cutaneous  punch  or  trephine. 

In  recent  years  Ohmann-Dumesnil,4  Nelson,5  and  Skillern6  have 
reported  success  in  their  removal  by  tattooing  in,  after  first  rendering 
the  surface  aseptic,  of  glycerol  of  papoid  spread  upon  the  surface. 
Others,7  including  myself,  have  not,  however,  been  successful  with  this 
method. 

The  methods  which  I  have  chiefly  employed  are  those  of  electrolysis, 
the  cutaneous  trephine,  and  excision.  Electrolysis  is  successful  only 
with  small  spots.  The  needle  is  introduced,  as  a  rule,  from  the  edge, 
slantingly  toward  the  center—  as  if  to  undermine  it;  the  whole  border 
is  thus  gone  around,  the  punctures  being  about  one-eighth  inch,  apart. 
The  strength  of  current  varies  from  i  to  4  or  5  milliamperes,  and  with 
each  introduction  allowed  to  act  from  one-half  to  one  minute  or  a  trifle 
longer.  It  is  in  reality  a  destructive  method,  reaction  taking  place,  a 
thin  eschar  or  crust  forming,  and  finally  cast  off,  leaving  a  supei 

1  Brault,  Annales,  1895.  p.  33- 

2  Variot.  Compt.-Rend.  Soc.  de  Biol.,  1888,  p.  636. 

•'Dubreuilh,  "Detatoage  par  decortication,"  Annales   1907,  p.  307. 
<Ohmann-Dumesnil,  New  York  Med.  Jour.   1893,  vo  .  lvn>    " 


mann-umesn,      ew  .          .  ,       .  i  p    6 

Med.  and  Surg.  Jour,  (tattoo-marks   and  powder-stains),  1900    vol.  be  vn    P    6* 
Later,  ibid.,  Oct.,  1908,  this  same  writer  states  that  caroid  is  super 
^fNeS;  New  York  Med.  Jour.,  1894,  vol.  lix.,  p  .272  (chiefly  as  to  powder-stains). 

«  Skillern,  Philada.  Med.  Jour.,  1898,  vol.  i,  p.  1166. 

'  Cantrell  and  Stout,  Bangs  and  Hardaway's  Amer.  Text-book,  p.  94Q- 


33 


5 !  4  #  r/>£  je  TR  OPH-IES 

scar.  If  any  remains,  that  part  is  to  be  gone  over  again.  The  cutaneous 
trephine  or  punch  can  be  used  in  two  ways:  if  the  spot  is  very  small,  it 
can  be  "punched,"  and  the  projecting  disc  cut  off,  and  a  slightly  larger 
disc  of  healthy  skin  made  by  a  larger  trephine  transplanted;  if  the  area 
is  greater,  then  a  small  or  moderate  sized  punch  can  be  used  on  several 
parts  of  its  surface,  the  discs  cut  off,  and  the  denuded  places  dressed  with 
an  antiseptic  powder,  such  as  i  part  of  acetanilid  and  7  parts  of  boric 
acid.  After  these  have  healed,  new  places  can  be  treated  in  the  same 
manner  until  it  is  entirely  removed.  With  care  and  trouble  transplanta- 
tion could  also  be  practised  in  such  larger  areas.  When  the  mark  is  on 
soft  yielding  parts,  excision  is  a  good  plan,  the  skin  at  the  edges  being 
dissected  under  and  drawn  together.  At  my  service  at  the  Jefferson 
Medical  College  Hospital  we  have  recently  tried  applications  of  carbon- 
dioxid  snow,  with  moderate  success,  when  the  pigment  is  not  too  deeply 
imbedded. 

Powder-stains  are  practically  similar  to  tattoo-marks.  If  the  case 
comes  under  observation  shortly  after  the  accident,  many  of  the  marks 
can  be  picked  out.  Later  this  same  plan  may  prove  of  service,  but  much 
better  is  the  method  of  removal  by  a  cutaneous  trephine  of  extremely 
small  caliber,  as  originally  suggested  by  Watson1  and  subsequently 
brought  into  more  general  use  through  the  paper  by  Keyes.2  The  punch 
is  placed  over  the  powder  speck  and  given  a  slight  rotary  motion,  pressing 
firmly,  but  not  going  down  to  unnecessary  depth;  the  little  disc  of  skin 
tends  to  jut  out,  can  be  snipped  off,  and  the  minute  cavity  rilled  with 
powdered  subsulphate  of  iron  or  with  a  paste  of  tincture  of  benzoin 
and  boric  acid,  or  with  the  compound  powder  of  boric  acid  and  acetanilid 
mentioned  under  tattoo-marks.  With  care  and  skill,  not  cutting  too 
deeply,  the  little  scars  left  become  practically  unnoticeable.  More 
recently  the  application  of  hydrogen  dioxid  has  received  favorable  com- 
ment, Crile,3  Rhoads,4  and  Clark3  reporting  satisfactory  and  rapid 
results.  It  is  applied  in  full  strength,  freely  and  often,  and  if  not  irri- 
tating, it  can  be  kept  constantly  applied  on  lint,  wetting  this  from  time 
to  time.  Crile  used  a  "concentrated  solution,"  which  was  applied  until 
a  white  zone  had  appeared  around  and  under  the  grains,  and  until  bub- 
bling, which  was  also  produced,  had  fully  ceased,  after  which  they  may  be 
readily  removed  with  a  pointed  instrument.  Clark  used  a  solution  of 
i  part  glycerin  and  3  parts  hydrogen  dioxid,  and  applied  freely,  on 
lint,  if  not  irritating,  and  the  stains  disappeared.  In  addition  to  these 
several  methods  the  tattooing  in  of  the  glycerol  of  papoid  or  caroid 
has  also  been  commended,  employed  as  in  tattoo-marks. 

Blue  stains,6  or  pigmentation,  are  not  infrequently  seen  at  and  about 

1  Watson,  "Discotome,"   Med.  Record.,  1878,  vol.   xiv,  p.  78;  and  "Gunpowder 
Disfigurements,"  St.  Louis  Med.  and  Surg.  Jour.,  1876,  vol.  xxxv,  p.  145. 

2  Keyes,  "The  Cutaneous  Punch,"  Jour.  Cutan.  Dis.,  1887,  p.  99;  Busch,  Berlin, 
khn.  Wochenschr.,  1884,  vol.  xxi,  p.  306,  originally  suggested  a  similar,  but  larger, 
trephine  for  the  removal  of  small  growths. 

3  Crile,  Cleveland  Med.  Gazette,  1896-97,  vol.  xii,  p.  183. 

4  J.  N.  Rhoads,  "Powder-Stains,"  American  Medicine,  1901,  vol.  i,  p.  16. 

5  Clark,  ibid.,  June  i,  1901,  p.  384. 

4  Gottheil,  "Blue  Atrophy  of  the  Skin  from  Cocain  Injection."  Jour.  Cutan.  Dis., 
1912,  p.  .1,  with  resume1  of  other  cases  (Thibierge,  Horand,  GaillardJ  with  references. 


PIGMENTOSUS 

the  sites  of  hypodermic  injections,  and  exceptionally  the  pigmentation 
may  be  associated  with  slight  atrophic  changes;  the  stains  are  thought  to 
be  due  partly,  directly  or  indirectly,  to  the  needles  and  possibly  also  to 
adulteration  of  the  injected  material. 

NAEVUS  PIGMENTOSUS 

Synonyms—  Pigmentary  mole;  Mole;  Mother's  mark;  Fr.,  Nsevus  pigmentaire- 
Tache  pigmentaire;  Ger.,  Pigmentnaevus;  Fleckenmal;  Pigmentmal;  Linsenmal. 

Definition.— Naevus  pigmentosus,  or  mole,  may  be  defined  as  a 
circumscribed  increase  in  the  pigment  of  the  skin,  usually  associated 
with  hypertrophy  of  one  or  all  the  cutaneous  structures,  especially  of 
the  connective  tissue  and  hair. 

Symptoms.— Moles  are  of  various  kinds  and  degrees,1  and  accord- 
ing to  the  predominance  of  one  or-  other  feature  are  divided  into  the 
several  varieties,  naevus  spilus,  naevus  pilosus,  naevus  verrucosus,  and 
nsevus  lipomatodes. 

Naevus  spilus  is  the  simple  pigmented  smooth  spot,  consisting  of  a 
pea-  to  bean-sized  or  much  larger  area,  usually  deeply  colored  from  a 
light  brown  to  a  black,  and  scarcely,  if  at  all,  elevated.  Sometimes, 
however,  there  is  slight  connective  tissue  increase  with  this,  and  when 
so,  the  patch  is  slightly  raised  above  the  surrounding  surface.  One, 
several,  or  more  may  be  present.  The  face,  neck,  and  back  are  favorite 
situations.  Naevus  pilosus  is  the  hairy  mole,  which  in  addition  to  the 
features  of  the  common  smooth  naevus,  just  described,  presents  an 
abnormal  growth  of  hair,  slight  or  excessive,  light  in  color  or  deeply 
pigmented,  and  usually  coarse  and  of  considerable  length.  There  is 
often  added  a  somewhat  irregular  surface  and  a  variable  connective- 
tissue  hypertrophy.  They  may  be  single  or  multiple,  and  may  occur 
upon  any  part  of  the  body,  and  while  ordinarily  not  larger  than  a  bean, 
may  be  of  much  greater  area,  and  in  extreme  instances  cover  a  portion 
of  or  a  complete  region.  The  "bathing-trunk"  or  "bathing  drawers," 
pigmented  and  hairy  naevus,  covering  the  region  indicated  by  its  name, 
is  an  example  of  the  extensive  type.2 

Naevus  verrucosus,  as  the  name  signifies,  is  the  mammillated  or 
warty  pigmented  naevus,  with  a  rough,  sometimes  hard,  •sometimes  soft, 
irregular  surface,  and  usually  with  variable,  but  often  considerable, 
increase  of  all  the  skin  tissues,  and  with,  often,  marked  hypertrophy  of 
the  papillae,  this  last  feature  giving  rise  to  the  furrowed  and  uneven 
surface.  There  may  be  but  slight  development  in  the  hair  of  the  part, 
but,  as  a  rule,  there  is  considerable  growth.  The  naevus  lipomatodes 
is  the  type  in  which  there  is  an  excessive  fat  and  connective-tissue  hyper- 
trophy,3 producing  sometimes  formations  of  considerable  dimensions  and 

1  The  different  forms  are  discussed  in  full,  with  bibliography,  by  Moller,  Archiv, 
1902,  vol.  Ixii,  pp.  55  and  371,  and  Riecke,  ibid.,  1903,  vol.  Ixv,  p.  65. 

2  Howard  Fox  (Jour.  Amer.  Med.  Assoc.,  April  20,  1912,  p.  1190)  records  a  typical 
case   and   gives  a  brief   review  of  26  similar  cases  reported,  with   references;  Dore 
(Brit.  Jour.   Dem.,  1912,  p.  194,  case  demonstrated)  also  records  a  typical  example 
with  illustration. 

3  Jackson  reports  a  good  case,  with  illustration,  in  Jour.  Cuian.  Dts.,  1895,  p.  00. 


ij  j  6  HYPER  TR  OPHJES 

elevation,  being  soft  and  loose  in  texture,  or  somewhat  verrucous  and 
hard,  with  or  without  hair  hypertrophy.  The  surface  is  either  smooth 
or  irregular  and  warty,  and  sometimes  the  growth  shows  loosely  or  closely 
packed  folds  and  deep  furrows,  occasionally  having  a  mollusciform  as- 
pect. As  already  stated  the  more  common  or  ordinary  moles  are  found 
most  frequently  upon  the  face,  neck,  and  upper  part  of  the  trunk, 
although  they  may  occur  upon  any  part  of  the  surface.  The  extensive 
hairy,  verrucous,  and  lipomatous  moles  sometimes  cover  a  considerable 
area,  in  extreme  cases  a  great  part  of  the  trunk,  and  especially  the  lower 
trunk  and  the  ischiof emoral  regions  are  partially  or  completely  enveloped.1 


i-\  J 


Fig.  122. — Naevus  pigmentosus,  congenital  and  of  extensive  distribution;  except  the 
large  irregular  and  clefted  area  on  the  back,  they  are  nearly  all  small,  smooth,  and  flat; 
here  and  there,  especially  on  those  of  the  right  shoulder  and  buttock,  a  growth  of  hair. 
A  slight  secretion  from  the  clefts  of  the  large  growth  and  of  an  offensive  odor.  This 
growth  has  spread  slightly  during  past  few  years,  with  the  suggestion  of  possible  ma- 
lignant change.  Patient  a  Swede,  aged  twenty-one  (courtesy  of  Dr.  Burnside  Foster). 

While  there  is  in  most  cases  no  special  distribution  or  configuration, 
hi  exceptional  instances  of  apparently  the  same  disease  the  lesions  are 
arranged  in  narrow  bands,  sometimes  zosteriform,  as  in  the  De  Amicis 
and  Hyde  cases.  These  cases,  usually  limited  to  one  side  of  the  body, 
have  a  peculiar  form  which  has  been  described  under  the  various  names 
of  linear  naevus,  naevus  unius  lateralis,  naevus  nervosus,  naevus  lichenoide, 
ichthyosis  linearis  neuropathica,  papilloma  lineare,  papilloma  neuro- 

1  Remarkable  cases,  with  illustrations,  have  been  recorded  in  recent  years  by  Michel- 
son,  Ziemssen's  Handbook  of  Skin  Diseases,  p.  405;  Hyde,  Jour.  Cutan.  Dis.,  1885,  p. 
193  (with  references  to  other  cases);  Joseph,  Lehrbuch  der  Hautkrankheiten,  third  edit., 
p.  181;  Lesser  (Baerensprung's  case),  Lehrbuch  der  Hautkrankheiten,  tenth  edit.,  pp. 
234  and  235;  Burnside  Foster,  Jour.  Cutan.  Dis.,  1899,  P-  I32  (concerning  the  case 
herein  illustrated). 


PIGMENTOSUS  ^7 

pathicum  unilaterale,  etc.1  Cases  vary  to  a  slight  degree,  but  only  in 
minor  details,  more  especially  as  to  extent,  location,  and  width  of  the 
band-like  strips.  The  characters  of  the  formation  vary  somewhat, 
however,  in  different  cases;  most  cases  probably  corresponding  to  a  some- 
what hard  naevus,  with  some  accumulation  of  the  horny  layer,  giving  it 
slight  scaliness,  and  of  a  light  or  dark  brownish  color;  or  it  may  consist 
of  contiguous  and  distinctly  small  papillary  growths.  In  other  cases 
the  component  lesions  may  be  comparatively  smooth  and  soft,  with 
variable  pigmentation.  Occasionally,  as  in  the  3  cases,  apparently  of 
this  disease  and  of  closely  similar  nature,  reported  by  Thibierge,2  Sel- 
horst,3  and  DaCosta,4  there  is  associated  a  comedo-like  plugging  of  the 
sebaceous  ducts.  In  some  cases,  as  in  Morrow's,  there  is  some  itching. 
Etiology  and  Pathology.— Moles  are  seen  in  both  sexes,  and 
are  usually  congenital,  sometimes  being  small  and  insignificant  at  birth, 
and  undergoing  variable  development  later.  Duhring  and  some  others 
believe  that  many  of  the  flat,  smooth,  pigmentary  naevi  without  hair, 
which  are  seen  so  commonly  upon  the  trunk,  are  not  congenital,  but 
appear  subsequently.  Duhring  states  that  they  "are  almost  invariably 
acquired  during  the  life  of  the  individual."  There  is  no  doubt  of  this 
in  some  instances  according  to  my  own  observations,  although  it  is 

1  A  full  list  of  the  numerous  names  under  which  this  peculiar  form  has  been  de- 
scribed is  given  in  D.  W.  Montgomery's  paper,  "The  Cause  of  the  Streaks  in  Naevus 
Linearis,"  Jour.  Cutan.  Dis.,  1901,  p.  455  (with  report  of  a  case,  with  illustration). 

Among  the  various  case  reports  and  contributions  on  this  subject  (linear  naevus), 
several  with  references  and  resume  of  other  cases,  may  be  mentioned:  Hyde,  "Rare 
Form  of  Congenital,  Multiple,  and  Monolateral  Pigmentary  Naevus,  Having  the  Dis- 
position of  Zoster  Corporis,"  Chicago  Med.  Jour,  and  Exam.,  1877,  vol.  xxxv,  p.  377; 
S.  Mackenzie,  "On  Neuropathic  Papillomata,"  Illust.  Med.  News,  1888,  vol.  i,  p.  123 
(several  cases  with  illustrations);  Spietschka,  "Ueber  Sogenannte  Nerven  Naevi," 
Archill,  1894,  vol.  xxvii,  p.  27  (report  of  3  cases,  with  illustrations,  review  of  the  sub- 
ject, and  references);  Werner  and  Jadassohn,  "Zur  Kenntniss  der  'systematisirten 
Naevi,'  "  Ibid.,  1895,  vol.  xxxiii,  p.  341;  and  Jadassohn  (second  paper),  "Bemerkungen 
zur  Histologie  die  systematisirten  Nasvi,"  ibid.,  p.  355,  and  Jadassohn  (third  paper), 
"Zur  Localisation  der  systematisirten  Naevi,"  ibid.,  p.  373  (3  extremely  valuable 
papers  and  report  of  9  cases,  case  illustrations,  histologic  cuts,  and  full  resume  of  the 
disease,  with  bibliography). 

Among  other  important  papers:  Hallopeau  and  Weil,  Neeoi  systematizes  metamer- 
iques,  1897,  p.  483  (with  some  references);  Morrow,  "Linear  Naevus,  with  Remarks  on 
its  Nature  and  Nomenclature  (2  cases),"  N.  Y.Med.  Jour.,  1898,  vol.  lxvii,p.  i  (with 
2  colored  plates) ;  Ransom,  "An  Unusual  Case  of  Naevus  Unius  Lateris,"  Jour.  Cutan. 
Dis.,  1896,  p.  141  (with  case  illustration,  and  histologic  cut  by  Fordyce);  Philippson, 
"Ichthyosis  cornea  (hystrix)  partialis,  etc.,"  Monatshcfte,  1890,  vol;  xi,  p.  337  (2  cases 
and  5  similar  cases  from  literature — critically  discussed;  illustrations);  Cutler,  "Ich- 
thyosis Linearis  Neuropathica,"  Jour.  Cutan.  Dis.,  1890,  p.  139  (case  demonstration); 
Peterson,  "Ichthyosis  Linearis  Neuropathica,"  ibid.,  p.  57  (with  illustration  and  some 
literature  references);  Miiller,  "Fin  Fall  von  Naevus  verrucosus  unius  lateris,  Archtv, 
1892,  vol.  xxiv,  p.  21  (with  2  illustrations);  Colcott  Fox,  Brit.  Jour.  Derm.,  1897, 
p.  446  (case  demonstration).  Heidingsfeld,  Jour.  Amer.  Med.  Assoc.,  Aug.  27^,  1904  (3 
cases,  with  review  and  references);  Hodara,  Jo-ur.  Mai.  Cutan.,  1905,  p.  61  (histologic, 
with  review  and  bibliography);  Adamson  (histologic),  Brit.  Jour.  Derm.,  1906,  p. 
235;  Schalek,  Jour.  Cutan.  Dis.,  1908,  p.  562  (case  report,  with  illustration) ;  blowers, 
Brit.  Jour.  Derm.,  1908,  p.  i  (a  case,  not  unilateral,  chiefly  left  side;  several  plates). 

2  Thibierge,  "Nsevus  acneique  unilateral  en  bandes  et  en  plaques,"  Annales,  1896, 
p.  1298  (case  demonstration).  .  , 

3  Selhorst,  "Na?vus  Acneiformis  Unilateralis,"  Brit.  Jour.  Derm.,  1896,  p.  419 
case  illustration). 

'Mendes  DaCosta,  "A  Case  of  Sebaceous  Naevi"— abs.  in  Brit,  Jour.  Derm., 
1897,  p.  207;  original  paper  in  Nederlandsch  Tijdschrift  wor  Geneeskunde,  D 
7,  1897. 


H  YPER  TR  OPHIES 

possible,  as  has  been  suggested,  that  there  may  have  been  previously 
small,  insignificant,  unnoticed  lesions  from  which  their  development 
may  have  sprung.  That  a  naevus  may  sometimes  undergo  variable 
extension  is  a  matter  of  observation,  but  much  more  commonly,  however, 
the  only  change  in  many  instances  is  increase  in  the  growth  of  hair. 

Pathologically,  an  ordinary  pigmented  naevus  is  similar  to  a  freckle,1 
except  that  it  is  larger,  and  with  usually,  but  not  always,  a  variable, 
though  often  slight,  connective-tissue  hypertrophy,  and  commonly 
with  the  pigment  extending  more  deeply;  and  with  peculiar  cells,  usually 
called  "naevus  cells,"  suggestive  of  embryonic  epithelium.  The  condi- 


Fig.  123.  —  Linear  naevus. 


tions  in  the  other  forms  vary:  there  may  be  hypertrophy  of  all  parts  of 
the  cutaneous  structures,  or  a  predominance  of  one  or  more  over  other 
components.  Their  origin  is  somewhat  obscure.  Unna,  speaking 
jointly  of  angiomatous  and  pigmentary  naevi,  believes  that  they  have  a 
hereditary  basis  or  have  their  foundations  laid  in  embryonic  life,  and 
become  evident  at  different  periods  later,  developing  slowly.  This 


,  ("Multiple  Areas  of  Pigmentation,"  etc.,  Jour.Cutan.  Dis.,  1912,  p. 
83,  with  review  of  similar  cases  and  conditions,  with  case  and  histologic  illustrations, 
and  bibliography)  investigation  would  indicate  that  doubtless  many  of  the  thin, 
superficial  pigmented  cases,  heretofore  considered  as  in  the  nsevus  class,  really  belong 
pathologically  to  ephilis. 


N&VUS  PIGMENTOSUS 


519 


practically  corresponds  to  Kaposi's  view,  that  they  are  the  result  of  an 
embryonic  impulse  in  one  or  more  of  the  tissues,  which  continues  beyond 
the  usual  normal  limit.  The  cells  of  which  a  mole  is  chiefly  composed 
have  generally  been  thought  by  pathologists,  following  Virchow's  view, 
to  be  of  connective-tissue  or  endothelial  origin,  and  their  endothelial 
origin  has  recently  been  maintained  by  Johnston,1  but  Unna,  Gilchrist, 
Whitfield,2  and  others  have,  in  following  out  the  histogenesis  of  these 
growths,  reached  the  conclusion  that  they  are  not  of  dermal,  but  of  epi- 
dermal, origin.  W.  S.  Fox,3  while  largely  sharing  this  latter  opinion, 
believes,  from  his  investigations,  there  is  also  a  rare  variety  of  soft  moles 
whose  cells  are  probably  derived  from  the  mesoblast. 


Fig.  124. — Linear  naevus  (lesions  in  this  case  were  very  much  like  those  of  lichen  planus). 

The  position  of  linear  naevus  is  somewhat  problematic.  Unna  con- 
siders that  provisionally  they  might  remain  with  the  proliferative  tumors. 
Histologically,  however,  in  the  main,  the  characters  are  similar  to  those 
of  the  other  forms  of  naevi  presenting  like  clinical  features.  Both  Peter- 

1  Johnston,  "Melanoma,"  Jour.  Culan.  Dis.,  Jan.  and  Feb.,  1905.     (An  elaborate 
paper  with  numerous  histologic  cuts  (two  colored)  and  complete  bibliography  to  date.) 
Among  others  of  the  important  recent  papers  on  the  pigmented  moles  are  those  of  Fick 
(included  in  Johnston's  bibliography),  Sachs,   Archiv,  1903,  vol.  Ixvi,  p.  101  (with 
bibliography),  and  Migliorini,  ibid.,  1904,  vol.  Ixx,  p.  413. 

2  Gilchrist,   Trans.  Amer.  Derm.  Assoc.  for  1898,   p.  30;   Whitfield,  Brit.  Jour. 
Derm.,  1900,  p.  268  (with  bibliography  and  histologic  cuts). 

3  W.  S.  Fox,  "Researches  into  the  Origin  and  Structure  of  Moles  and  their  Relation 
to  Malignancy,"  Brit.  Jour.  Derm.,  1906,  pp.  i,  47,  and  83  (with  review  and  bibliog- 
raphy);  Ziegler's  investigations  ("Beitrage   zur   pathologischen  Anatomic   und   zur 
allgemeinen  Pathologic,"  1906,  vol.  xxxix)  show  that  in  some  instances  the  growth  takes 
its  origin  from  the  covering  epithelium  ("Deckepithelium")  and  not  from  the  naevus 
cells  themselves;   Fich,  "Ueber  weiche  Naevi,"  Monatshefte,  1909,  vol.  iv,  pp.  397  and 
443,  discusses  the  soft  naevi  at  length,  reviewing  the  literature  in  detail,  with  a  full 
bibliography. 


-2Q  HYPERTROPHIES 

sen1  and  Elliot2  found  adenomatous  involvement  of  the  sweat-glands; 
the  latter,  however,  believing  this  finding  to  be  an  entirely  secondary 
and  accidental  one. 

The  origin  of  this  linear  nsevus  formation  and  distribution  has  been 
the  subject  of  much  discussion.  D.  W.  Montgomery's  study  of  the 
literature  shows  that  the  various  theories  advanced  are:  (i)  The  streak 
or  bands  follow  the  course  of  the  cutaneous  nerves;  (2)  run  along  what 
are  called  Voight's  lines;  (3)  follow  the  lines  of  cleavage  of  the  skin;  (4) 
follow  the  course  of  the  blood-vessels;  (5)  run  in  the  metameres  or  seg- 
ments of  the  body;  (6)  lie  along  the  embryonic  sutures  and  follow  the 
trend  of  growth  of  the  tissues.  The  last,  according  to  this  writer, 
more  nearly  explains  the  curious  band  distribution.  Balzer  and  Alquier,3 
in  a  recent  study,  conclude  that  the  readiest  explanation  is  upon  the  basis 
of  the  Voight  lines,  and  that  the  occasional  divergence  probably  depends 
upon  embryonic  malformation. 

Prognosis. — Pigmentary  naevi  are  permanent,4  but,  as  a  rule, 
when  once  established,  do  not  tend  to  grow  larger,  although  in  many, 
even  of  the  ordinary,  moles,  later  in  life  there  is  a  disposition  sometimes 
noticed  toward  increased  growth  of  the  down  or  hair  of  the  patch. 
Beyond  the  disfigurement,  however,  the  blemish  is  a  benign  one, 
unless  constantly  irritated,  under  the  influence  of  which,  especially  in 
advancing  years,  degenerative  changes  set  in  and  a  malignant  char- 
acter is  occasionally  noted.  In  some  instances,  it  is  true,  apparently 
without  known  irritation  or  traumatism,  a  naevus  has  been  the  starting- 
point  of  more  or  less  general  malignant  growths  (see  also  Sarcoma), 
as  noted  by  several  observers,  among  whom,  most  recently,  Green,5 
Gilchrist,6  and  Waelsch.7 

Treatment. — There  are  several  methods  of  removing  moles — by 
electrolysis,  caustics,  and  excision.  Soft,  pigmented  fleshy  moles, 
those  which  have  a  peculiar  tendency  to  lead  to  degeneration  and 
general  carcinomatous  (or  sarcomatous)  invasion,  should  be  freely 
excised,  going  well  beyond  the  limits  of  the  growth.  Circumscribed 
or  even  large  hypertrophic  moles  can  also  be  satisfactorily  treated  with 
this  method,  but  usually  with  variable  disfigurement.  Flat  freckle-like 
moles  may  also  be  removed  satisfactorily  with  shaving  over  the  skin, 
just  going  deeply  enough  for  the  pigment — it  is  similar  to  the  method 
of  procuring  skin-graft. 

1  Petersen,  "Ein  Fall  von  multiplen  Knaueldriisengeschwiilsten  unter  dem  Bilde 
eines  Naevus  verrucosus  lateris,"  Archiv,  1892,  vol.  xxiv,  p.  919. 

2  Elliot,  "Adeno-cystoma  Intracanaliculaire  Occurring  in  a  Naevus  Unius  Lateris," 
Jour.  Cutan.  Dis.,  1893,  P-  J68  (with  histologic  cuts). 

3  Balzer  and  Alquier,  "Les  dermatoses  lineares — Etude  clinique  et  pathogenique," 
Arch.  gen.  de  Med.,  1901,  vol.  clxxxvii,  p.  717  (19  illustrations). 

4  Spitzer,  Dermatolog.  Zeiischr.,  1905,  p.  34,  describes  a  case  of  verrucous  naevus 
which  underwent  spontaneous  involution,  and  also  refers  to  a  similar  one  reported  by 
Lassar. 

5  Ledham  Green,  "Ueber  Naevi  pigmentosi  und  deren  Beziehung  zum  Melanosar- 
com,"  Virchow's  Archiv,  1893,  vol.  cxxxiv,  p.  331. 

6  Gilchrist.  "Are  Malignant  Growths  Arising  from  Pigmented  Moles  of  a  Carcino- 
matous or  Sarcomatous  Nature?"  etc.,  Joe.  tit.  (with  histologic  cuts  and  bibliography). 

7  Waelsch,  "Ueber  die  ausweichen  Nsevus,  enstandenen  bosartigen  Geschwulste," 
Archiv,  1899,  vol.  xlix,  p.  249  (with  histologic  cuts  and  bibliography). 


ACANTHOSIS  NIGRICANS  521 

In  the  ordinary  surface  non-hairy  moles  application  of  the  "electric 
needle"  to  several  or  more  points,  and  but  superficially  inserted,  not 
going  more  deeply  than  the  upper  part  of  the  corium,  will  sometimes 
remove  the  blemish,  especially  after  several  repetitions,  without  leaving 
much  of  a  scar,  and  occasionally  with  scarcely  any  trace.  With  hairy 
moles  the  hairs  should  be  removed  first  by  the  ordinary  electrolytic 
method,  and  in  some  cases,  when  this  is  done,  the  pigment  will  have 
almost  completely  disappeared,  although,  as  a  rule,  supplementary 
treatment,  as  just  described,  will  be  necessary.  The  elevated  and  ver- 
rucous  growths,  if  not  too  large,  can  also  be  treated  in  like  manner,  the 
hairs,  if  present,  being  first  removed.  If  the  case  is  at  all  extensive, 
this  method  is  tedious,  but  much  can  be  accomplished  in  the  way  of  a 
good  result.1  The  strength  of  current  employed  varies,  according  to 
the  character  and  nature  of  the  growth,  from  one-half,  in  the  superficial, 
freckle-like  lesions,  to  several  or  more  milliamperes  in  the  thicker  and 
hypertrophic  varieties. 

In  recent  years,  however,  the  favorite  treatment  for  an  average  or 
moderate  case  is  by  caustic  refrigeration,  as  previously  endorsed  by  Dade 
and  Trimble,2  and  later  by  Pusey,  Zeisler,  Bunch,  and  many  others, 
including  myself.  Liquid  air,  originally  employed  for  this  purpose, 
has  given  way  to  the  easily  procurable  carbon-dioxid  snow.  The  method 
of  using  is  described  in  the  preliminary  chapter  on  Treatment. 

The  superficial  moles  can  also  frequently  be  satisfactorily  removed 
by  mild  chemical  caustics  carefully  and  scantily  used,  such  as  trichlor- 
acetic  acid,  glacial  acetic  acid,  and  nitric  acid,  applied  by  stippling  or  by 
a  thin  coating  to  the  surface;  the  deeper  growths,  by  the  same  caustics 
more  energetically  and  repeatedly  applied. 

Linear  nasvus  can  in  some  instances  be  successfully  treated  by  the 
various  methods  described,  but  ordinarily  the  readiest  plan  is  that  by 
excision.  Ransom,  in  his  case,  after  trying  many  methods  found 
that  the  most  satisfactory  procedure  consisted  in  picking  the  skin  up 
between  the  thumb  and  fingers,  snipping  off  the  top  of  the  ridge  thus 
made  by  flat-pointed  scissors,  the  cut  being  superficial  and  extending 
not  quite  through  the  skin  proper. 

ACANTHOSIS  NIGRICANS 

Under  this  title  Pollitrf  and  Janovsky*  reported  and  described 
minutely  in  tSoo  each  a  case  of  an  obscure  and  a  practically  unknown 
r±£££d  giave  malady  characterized  in  the  mam  by  more  or  less 
general  pigmentation,  associated  with,  especially  onTtcertai";e^wS;vtehre 
development  of  verrucous  nsevus-like  growths  It  seems,  however 
that  a  case  with  apparently  similar  symptomatology  had  pn 

i  See  report  of  a  successful  case,  with  illustration,  by  G.  H.  Fox,  Jour.  Cntan.  Dis., 
3* '£in£le,  Mea.  Record,  July  8,  IQoS;  and  (second  paper)  /_.  O*m.  Dis.,  W, 
4?Wer,  Internat.  Atlas  Rare  Skin  Diseases,  1890,  plate  x  (female,  a 
Janovsky,  ibid.,  plate  xi  (male,  aged  forty-two). 


522 


HYPER  TR  OPHIES 


been  recorded  by  Crocker1  in  1881.  Since  the  report  by  Pollitzer  and 
Janovsky  other  examples  of  the  disease  have  been  noted  by  various 
observers,  among  whom  are  Darier,2  Hallopeau,3  Morris,4  Kuznitzky,5 
Neumann,6  Spietschka,7  Boeck,8  Roberts,9  Syer,10  and  several  others,11 
so  that  now  the  detailed  description  of  more  than  50  cases  is  on  record 

(C.  J.  White). 

The  onset  of  the  malady  is  slow  or  rapid.  The  pigmentation  varies 
somewhat  in  intensity  in  different  cases,  being  a  sallow  yellowish, 
such  as  observed  in  some  instances  of  cancerous  cachexia,  in  others,  a 
bronze  tint,  and  in  still  others  various  shades  of  a  darkish  or  dirty  brown. 
It  is  more  or  less  general,  but  usually  more  pronounced  about  the  flexures 
and  other  sites  of  the  papillomatous  growths.  Concomitantly  with 
pigmentary  changes  or  following  it  papillary  hypertrophy  is  noted, 
which  to  a  great  extent  goes  into  distinct  verrucous  elevations.  The 
verrucosity  is  often  limited  to  or  most  developed  on  certain  parts, 
especially  the  axillary,  genitocrural,  anal,  and  abdominal  regions.  The 
neck,  face,  lips,  and  mouth  are  also  favorite  situations,  and  to  a  variable 
extent  share  in  the  papillomatous  development.  The  skin,  in  places  at 

1  Crocker,  "General  Bronzing  without  Constitutional  Symptoms,"  London  Clinical 
Soc'y  Trans.,  1881,  vol.  xiv,  p.  152  (with  histology — male,  aged   twenty- two),  and 
second  case,  Brit.  Jour.  Derm.,  1899,  P-  IJ6  (case  demonstration— male,  aged  fifty). 

2  Darier,  "Dystrophie  papillaire  et  pigmentaire,"  Bull.  Soc.  Derm,  et  Syph.,  1893, 
p.  421,  and  Anndes,  1893,  p.  865  (female,  aged  thirty-four),  and  ibid.,  1895,  p.  97  (male, 
aged  thirty). 

3  Hallopeau,  Jeanselme,  and  Meslay,  ibid.,  1893,  p.  876  (female,  aged  seventy-two), 
and  Hallopeau,  ibid.,  1896,  p.  737  (doubtful  case). 

4  Malcolm  Morris,  London  Med.  Chirurg.  Soc'y  Trans.,  1894,  vol.  Ixxvii,  p.  305 
(female,  aged  thirty-five). 

5  Kuznitzky,  Archiv,  1896,  vol.  xxxv,  p.  3  (with  a  colored  illustration  and  histologic 
cuts — female,  aged  forty-one). 

8  Neumann  (case  demonstration),  ibid.,  1896,  vol.  xxxiv,  p.  145  (female,  aged 
seventeen — case  demonstration). 

7  Spietschka,   Archiv,  1898,  vol.  xliv,  p.  247  (3  cases — 2  females,  aged  fifteen  and 
twenty;  male,  forty-four — with  histologic  review). 

8  Boeck,  Norsk.  Mag.f.  Laegev.,  No.  3,  1897 — abstract  in  Jour.  Cutan.  Dis.,  1897, 
p.  588  (female,  aged  fifty-two). 

9  Roberts,  "Melanosis  Accompanied  by  Moderate  Acanthosis"  (acanthosis  nigri- 
cans?)  (male,  aged  fifty-eight),  Brit.  Jour.  Derm.,  1897,  p.  184  (histologic  cut). 

10  Dyer,  "A  Case  of  Keratosis  Nigricans,"  New  Orleans  Med.  and  Surg.  Jour.,  1898, 
vol.  li,  p.  201  (male,  aged  seventeen). 

11  Burmeister,  Archiv,  1899,  vol.  xlvii,  p.  343  (reports  a  case — male,  aged   thirty- 
six — and  gives  a  resume  and  analysis  of  19  reported  cases) ;  Couillaud's  paper,  "Dys- 
trophie papillaire  et  pigmentaire;  ses  relations  avec  la  carcinose  abdominale,"  These  de 
Paris,  1896,  and  Gaz.  des  Hdpitaux,  1897,  p.  413,  gives  a  review  of  the  subject  and 
literature  to  date.     An  abstract  review  of  the  cases  and  papers  by  Boeck,  Couillaud, 
Roberts,  Kuznitzky,  Rasch,  Collan,  in  Jour.  Cutan.  Dis.,  1897,  p.  588,  and  those  by 
Barsky,  Dyer,  and  Spietschka,  in  same  journal,  1899,  p.  07;  Rille,  Wien.  med.  Wochen- 
schr.,  1897,  p.  1019,  and  Gaucher,  Medical  Week,  1897,  p.  411,  give  good  descriptive 
accounts;  M.  Hodara,  Monatshefte,  1905,  vol.  xl,  p.  629  (following  a  breast  cancer); 
Wild,  Brit.  Med.  Jour.,  Aug.  28,  1909  (i  case);  St.  George  and  Melville,  ibid,  (i  case, 
with  detailed  review  of  literature);  Janovsky,  Mracek's  Handbook,  vol.  iii,  p.  97  (with 
literature  references);  Grouven  and  Fischer,  Archiv,  1904,  vol.  Ixx,  p.  237  (with  litera- 
ture references);  Bogrow,  ibid.,  1908,  vol.  xciv.  p.  297  (with  literature  references); 
Pribram,  Deutsch.  Archiv  f.  kiln.  Med.,  1909,  p.  407;  Pollitzer  ("Acanthosis  Nigricans: 
A  Symptom  of  a  Disorder  of  the  Abdominal  Sympathetic,")  Jour.  Amer.  Med.  Assoc., 
Oct.  23,  1909,  p.  1369  (review  and  analysis  of  published  and  two  unpublished  cases); 
C.  J.  White,  Jour.  Culan.  Dis.,  April  1912,  p.  179  (i  case,  girl  fourteen,  beginning  when 
aged  four;   case  illustration  and  histologic  cut);    Schalek,  Jour.  Cutan.  Dis.,  1912, 
p.  660  (woman  aged  fifty-eight,  extensive  and  well  marked  case;  abdominal  tumors 
of  unknown  character;  no  operation  and  no  autopsy,  case  illustration). 


ACANTHOSIS  NIGRICANS  523 

least,  and  especially  on  those  parts  most  affected,  often  presents  accen- 
tuation of  the  natural  lines,  in  some  instances  amounting  to  superficial 
furrowing,  and  is  hypertrophied.  Palmar  and  plantar  keratosis  is 
commonly  present,  and  partial  or  complete  loss  of  hair,  especially  of  the 
hair  of  the  scalp  and  eyebrows,  and  dystrophic  nail-changes  are  quite 
frequently  noted.  In  the  region  of  the  flexures  the  warty  growths  are 
often  so  numerous  and  crowded  that  practical  coalescence  ensues,  re- 
sulting in  the  formation  of  masses  of  a  papillomatous  and  vegetating 
aspect.  These,  like  the  skin,  vary  in  intensity  of  pigmentation  from  a 
grayish  yellow  to  almost  black,  and  are  usually  seen  in  all  stages  of  growth 
—  some  minute,  others  distinctly  verrucous.  Scaliness  is  not  a  usual 
feature.  Darier  has  noted  also  the  development  of  nsevi,  freckle-like 
spots,  and  seborrheic  warts;  and  in  a  few  instances  epitheliomatous 
degeneration  in  some  of  the  lesions  has  been  observed.  The  lesions  on 
the  mucous  membrane,  especially  the  mouth,  are  not  present  in  every 
instance,  but  more  or  less  involvement  is  the  rule;  they  consist  of  furrows, 
discrete  or  crowded  papillomatous  formations,  which  may  be  sessile  or 
slightly  pedunculated,  or  the  mucous  surface  may  be  more  or  less  granu- 
lar-looking. 

The  course  of  the  malady  is  slow  or  somewhat  rapid,  with  some 
exceptions  cases  ending,  after  some  months  or  several  years,  fatally. 
A  cancerous  cachexia  is  commonly  developed,  and  in  the  majority  of 
instances  sooner  or  later  carcinomatous  disease  of  one  of  the  abdominal 
organs  is  recognized—  usually  the  stomach,  but  occasionally  it  is  the 
uterus,  and  in  exceptional  cases  it  is  more  or  less  general,  sometimes 
secondarily  to  cancer  of  the  breast. 

Etiology  and  Pathology.—  The  cause  of  the  disease  is  not 
definitely  known,  but  the  frequent  association  of  carcinoma,  usually 
affecting  the  organs  of  the  abdominal  cavity,  would  appear  to  make  it 
in  the  majority  of  cases  at  least,  dependent  upon  the  latter  malady, 
Darier,  Pollitzer,  and  others  believing  that  the  interference  with  the 
functions  of  the  abdominal  sympathetic  thus  engendered  has  a  causative 
relationship  with  the  cutaneous  manifestations.  Internal  malignancy 
has  not  been  noted,  however,  in  the  cases  under  the  age  of  nineteen. 
It  may  occur  at  almost  any  age  but  it  is  rare  in  childhood.2  According 
to  Burmeister's  analysis  of  this  point,  in  14  cases  i  case  was  observec 
under  the  age  of  twenty  years;  i  between  twenty  and  thirty;  3  between 
thirty  and  forty;  5  between  forty  and  fifty;  2  between  fifty  and  sixty; 
i  between  sixty  and  seventy;  and  i  between  seventy  and  eighty  As 
to  sex,  women  seem  slightly  more  prone  to  it,  according  to  Burrne  ster  * 
analysis  furnishing  60  per  cent,  of  the  cases.  Couillaud  ™ 

contribution  was  prepared  under  the  supervision  of  Darier 


".?wis?,  b^^Ms." 

1  •  Quoted  from  abstract  in  Jour.  Cvtan.  Dis.,  loc.  cit. 


524  HYPERTROPHIES 

by:  (i)  a  papillary  hypertrophy  and  a  cutaneous  pigmentation  having 
an  essentially  regional  character;  (2)  a  papillary  hypertrophy  of  the 
mucous  membrane;  (3)  a  dystrophy  of  the  hair  and  nails;  (4)  absence 
of  desquamation;  (5)  existence  of  a  cachexia;  (II)  from  a  pathologic 
standpoint,  by  carcinomatous  degeneration  of  the  abdominal  organs; 
(III)  histologically,  by  lesions  of  hypertrophy  and  pigmentation  in  the 
rete  and  corium."  Histologic  examinations  show  that  the  horny  layer 
is  thickened,  the  rete  cells,  more  especially  the  prickle-cells,  enlarged, 
the  corium  infiltrated  and  exhibiting  some  mast-cells;  and  both  rete  and 
corium  filled  to  a  variable  degree  with  pigment  granules,  irregularly 
distributed  or  in  masses,  partly  intracellular  and  partly  extracellular. 

Prognosis  and  Treatment. — When  no  carcinomatous  disease 
is  present,  the  course  of  the  malady  is  slow  and  its  outcome  uncertain; 
when,  as  in  most  cases,  however,  there  is  underlying  carcinoma,  a  fatal 
result  is  but  a  matter  of  months  or  a  few  years.  Treatment,  unfortu- 
nately, is  purely  expectant,  with  scarcely  a  possibility  of  influencing 
the  course  of  the  disease.  Boeck  thought  that  in  his  case  life  was  pro- 
longed by  the  administration  of  suprarenal  extract.  C.  J.  White's 
case  showed  some  improvement  under  thyroid  medication. 

CLAVUS 

Synonyms. — Corn;  Fr.,  Cor;  Tylosis  gompheux;  Oeil  de  perdrix;  Ger.,  Leichdorn; 
Huhnerauge. 

Definition. — Clavus,  or  corn,  is  a  small,  circumscribed,  conic, 
deep-seated,  horny  formation  or  callosity,  usually  seated  about  the  toes, 
with  the  small  end  of  the  growth  pressing  down  upon  the  corium. 

A  corn  resembles  a  callosity,  the  epidermis  being  thickened,  pol- 
ished, and  horny.  It  differs,  however,  from  callosity  in  being  smaller 
and  circumscribed,  averaging  a  pea  in  size,  and  in  being  provided  with 
a  central  prolongation  or  horny  peg,  shaped  like  the  head  of  a  nail, 
known  as  the  core.  The  base  of  the  corn  is  directed  upward  and  the 
apex  downward,  the  latter  by  its  pressure  on  the  nerve  filaments  giving 
rise  to  pain.  Two  varieties  of  clavus  are  recognized — the  hard  and  the 
soft.  The  former  is  the  common  one,  and  generally  occurs  on  the  dorsal 
surface  of  the  toes  or  on  the  plantar  aspect  of  the  foot;  although  they 
may,  however,  appear  on  any  other  part  which  is  subjected  to  pressure 
or  friction  long  continued.  One,  several,  or  more  may  be  present.  A 
soft  corn  is  generally  seen  between  the  toes;  it  is  depressed  in  the  center, 
and  of  a  grayish  color,  and,  owing  to  the  constant  heat  and  moisture  of 
the  parts,  it  becomes  soft.  Not  infrequently,  when  improperly  treated, 
corns  are  the  starting-point  of  erysipelas  and  suppuration,  and  even 
ulceration  may  occur.  From  accidental  causes  or  as  the  result  of  con- 
stant pressure  or  from  some  unknown  factor  a  corn  exceptionally  be- 
comes the  seat  of  inflammatory  and  suppurative  action  which  may  be 
more  or  less  persistent — suppurating  corn.  They  are  prone  to  become 
quite  sensitive  during  climatic  changes,  and  are  usually  at  all  times 
painful  when  pressed  upon,  and  sometimes  spontaneously  so.  On  the 
sole  of  the  foot,  when  well  developed,  they  may  give  rise  to  considerable 


CLA  VUS 


525 


discomfort,  making  locomotion  or  standing  painful;  doubtless  some  of 
these  latter  cases  more  properly  belong  under  verruca  plantaris  (q.  z>.). 
Etiology  and  Pathology.— A  corn  results  from  pressure 
with  counterpressure  and  friction,  attributable  generally  to  tight  or 
badly  fitting  shoes.  It  appears,  however,  that  apparently  similar 
formations  may  occur  spontaneously  independently  of  pressure,  as  in 
the  cases  of  Davies-Colley,  quoted  by  Crocker,  in  which  the  palms  and 
plantar  surfaces  of  a  Hindoo  were  the  seat  of  numerous  clavi.  Primarily 
the  growth  is,  as  in  callositas,  an  attempt  to  protect  a  part  pressed  upon, 
but  its  subsequent  peculiar  development  is  difficult  to  understand.  It 
consists  of  a  circumscribed  hyperplasia  of  the  epidermis,  of  conic  shape, 
with  the  base  external,  variously  elevated,  and  with  the  apex  directed 
downward  and  pressing  upon  the  papillae.  It  is,  in  fact,  a  peculiarly 
shaped  callosity,  the  central  portion  and  apex  being  dense  and  horny, 
forming  the  so-called  core.  The  corium  beneath  the  down-pressing  apex 
is  thinned,  and  the  papillae  are  usually  atrophied,  although  occasionally 
hypertrophied.  There  is,  Robinson  states,  more  or  less  hypertrophy  of 
the  papillae  at  the  circumference.  Unna  noted  "well-preserved  condi- 
tion of  the  sweat-glands,  and  even  those  glands  whose  pores  disappear 
in  the  core  do  not  atrophy."  Minute  hemorrhages  frequently  occur 
beneath  the  thickened  epidermis,  due  to  rupture  of  capillary  vessels  of 
the  papillae.  Structurally,  the  growth  is  made  up  of  closely  packed 
epidermic  cells  arranged  in  concentric  layers. 

Treatment — Removal  of  the  cause  and  the  wearing  of  properly 
fitting  shoes  are  a  sine  qua  non  of  successful  treatment.  In  fact,  if 
pressure  is  removed,  corns  will  in  most  instances  disappear  sponta- 
neously. In  an  affection  so  common,  the  plans  of  treatment  recom- 
mended, as  is  to  be  expected,  are  almost  innumerable.  A  simple  and 
popular  method  of  treatment  consists  in  shaving  off,  after  a  preliminary 
hot-water  soaking,  the  surface  portion  by  means  of  a  razor  or  sharp 
knife,  and  then  applying  a  ring  of  felt  wadding  or  like  material  having 
an  adhesive  side,  to  be  found  in  the  shops,  over  the  region  of  the  corn, 
with  the  hollow  part  directly  over  the  site  of  the  core.  This  should 
be  worn  for  some  time— usually  several  weeks— thus  relieving  the 
growth  of  all  pressure  and  friction;  and  if  well  carried  out,  this  plan 
quite  frequently  will  bring  a  good  result.  Another  method  is  to  pare 
off,  as  before,  the  thickened  broad  surface,  and  then  carefully  to  dissect 
out  the  core;  in  some  instances,  after  thorough  soaking  and  surface 
removal,  this  can  be  extracted  with  the  forceps.  Chiropodists  have 
become  quite  expert  in  their  removal,  often  dissecting  them  out  without 
previous  softening,  and  with  scarcely  any  pain  and  rarely  any  bleed- 
ing. In  manipulations  of  this  character  it  is  absolutely  imperative  that 
the  instruments  employed  should  be  aseptic,  as  unpleasant  comphc 
tions  or  consequences  have  occasionally  been  noted.  In  some  cases 
touching  the  base  of  the  cavity  left  by  the  removal  of  the  corn  with  a 
droplet  of  a  solution  of  caustic  potash  will  prevent  a  return;  but 
application  must  be  made  with  care,  and  with  a  solution  of  not  rnor 
than  5  per  cent,  strength,  and  its  action  almost  immediately  n 
with  vinegar  or  dilute  acetic  acid. 


526  HYPERTROPHIES 

A  safe  and  conservative  plan,  sometimes  successful,  consists  in  the 
repeated  application  of  a  solution  of  salicylic  acid  in  collodion,  for  which 
the  common  formula  is:  Salicylic  acid,  gr.  xxx-xl  (2-2.65)',  ext-  cannabis 
indica,  gr.  x  (0.65);  collodion  and  flexible  collodion,  aa  f3ij  (8.). — M. 
This  is  to  be  painted  on  the  corn  night  and  morning  for  several  days, 
at  the  end  of  which  time  the  parts  are  soaked  in  hot  water,  and  the  horny 
mass,  or  a  greater  part  of  it,  will,  as  a  rule,  come  readily  away  with  a 
little  rubbing  or  scraping.  If  it  is  then  at  all  tender,  treatment  is  to  be 
discontinued  for  a  few  days,  and  the  paintings  resumed.  Several  repe- 
titions are  usually  necessary.  After  apparent  relief  the  wearing  of  a  ring- 
pad,  as  already  referred  to,  for  a  few  weeks,  is  to  be  advised.  Salicylic 
acid  has  the  peculiar  property,  especially  when  so  applied,  and  also  in 
the  form  of  a  plaster,  of  softening  and  removing  the  horny 'layer  of  the 
epidermis,  and  this  drug  is  the  active  principle  in  most  of  the  adver- 
tised corn-cures.  The  various  caustics  are  also  occasionally  employed, 
but  their  use  requires  care  and  caution.  Of  the  milder  caustics,  lactic 
acid  may  sometimes  be  applied,  in  minute  quantity,  with  benefit,  weak- 
ened or  full  strength. 

In  soft  corns  the  same  mild  plans  mentioned  may  also  be  employed. 
Nitrate  of  silver  is  useful  in  these  cases,  the  outer  surface  first  being  re- 
moved by  salicylic  acid  or  weak  solution  of  caustic  potash.  The  essen- 
tial measure  is  the  prevention  of  friction  and  maceration  by  keeping  the 
toes  slightly  separated  with  a  piece  of  soft  lint  or  absorbent  cotton, 
changing  frequently.  When  extremely  sensitive,  dilute  lead-water  is  a 
soothing  application. 

CALLOSITAS 

Synonyms. — Tyioma;  Tylosis;  Keratoma;  Callus;  Callosity;  Fr.,  Durillon;  Ger., 
Verhartung. 

Definition. — Callositas  is  a  hard,  horny,  thickened  epidermic 
patch,  due  to  hyperplasia  of  the  stratum  corneum,  and  occurring  for  the 
most  part  on  the  hands  and  feet. 

Symptoms. — Callosities  are  acquired  formations.  They  consist 
of  small  or  large  patches  of  yellowish,  grayish,  or  brownish,  hard,  horny, 
slight  or  excessive  epidermic  accumulations,  which  are  generally  seen 
on  parts  subjected  to  pressure  or  friction.  Hardening  and  slight  thick- 
ening are  also  sometimes  caused  by  chemical  irritants.  The  palms, 
soles,  fingers,  and  toes  are  favorite  locations.  They  are  somewhat 
elevated,  are  quite  thick,  especially  at  the  central  portion,  less  so  at  the 
edge,  and  gradually  merging  into  the  sound,  unaffected  skin;  they  are 
very  hard,  dry,  and  horn-like  and  occasionally  brittle.  The  natural 
surface  lines  of  the  affected  part  are  obliterated,  the  patches  generally 
being  smooth.  When  the  thickening  is  markedly  developed,  it  interferes 
with  delicacy  of  touch,  and  may  impair  the  finer  movements  somewhat. 
As  callosities  are  usually  the  effort  of  nature  to  protect  underlying  parts 
constantly  rubbed  or  pressed  upon,  they  are  necessarily  very  frequently 
observed  on  the  hands  of  mechanics,  as  tinsmiths,  blacksmiths,  carpen- 
ters, shoemakers,  tailors,  workers  in  metals,  etc.  They  are  also  not  in- 
frequently seen  on  the  fingers  of  zither-players,  violinists,  and  harpists. 


CALLOSITAS 


527 


About  the  soles  and  sides  of  the  feet  they  most  commonly  occur  in  those 
whose  occupation  requires  constant  walking  or  standing,  and  more 
especially  if  roughly  and  heavily  made  or  tight  shoes  are  worn.  The 
ball  of  the  great  toe  and  lateral  surface  of  the  little  toe  and  the  heel  are 
favorite  locations.  They  are  also  obseved  in  those  who  go  barefooted. 
Long-continued  pressure  kept  up  by  surgical  appliances  for  the  correc- 
tion of  some  deformity  or  the  wearing  of  a  truss  may  bring  about  callosi- 
ties in  the  parts  pressed  upon.  Callous  thickening  over  the  ischial 
tuberosities  are  usually  formed  in  those  who  sit  much  upon  hard  chairs 
or  benches.  They  are  also  thought  to  arise  spontaneously  at  times,  but 
such  cases  are  mostly  examples  of  inherited  and  usually  symmetric 
callosities — keratosis  palmaris  et  plantaris  (q.  ».).  As  a  rule,  inflam- 
matory symptoms  do  not  make  their  appearance  in  these  growths, 
although  occasionally,  from  accidental  injury,  the  subjacent  corium  may 
become  inflamed  and  suppurates,  and  the  thickened  mass  be  cast  off.1 
They  usually  disappear  spontaneously  when  pressure  and  other  external 
irritation  which  may  have  produced  them  are  removed.  A  variable 
callous  condition  or  horny  thickening  is,  as  well  known,  sometimes 
observed  in  several  of  the  chronic  cutaneous  diseases,  as  in  some  forms 
of  eczema,  in  ichthyosis,  lichen  planus,  psoriasis,  and  a  few  other  maladies, 
but  in  such  it  is  merely  a  part  of  the  pathologic  process;  sometimes, 
however,  the  callous  development  remains  after  the  disease  has  dis- 
appeared. Palmar  and  plantar  keratoses  are  also  not  infrequently  the 
result  of  prolonged  arsenical  administration  (see  dermatitis  medicamen- 
tosa).  Anatomically,  the  growths  consist  of  thickened  upper  epidermic 
layers;  the  deeper  underlying  strata  of  the  epidermis  and  corium  remain, 
as  a  rule,  except  when  involved  by  accidental  inflammatory  action, 
unaffected. 

Treatment. — Quite  frequently  treatment  is  not  required,  as  the 
accumulation  may  be  a  naturally  formed  protective  against  the  constant 
pressure  and  friction  incident  to  the  patient's  occupation.  Occasionally, 
however,  the  formation  is  excessive  and  unsightly,  and  gives  rise  to  dis- 
comfort. In  such  instances  and  in  others  in  which  removal  or  at  least 
thinning  down  is  deemed  advisable,  this  object  can  be  accomplished  in 
several  ways.  The  callus  can  be  softened  in  hot  water  containing  one- 
half  to  an  ounce  (i6.~32.)  of  an  alkaline  carbonate,  such  as  sodium  carbo- 
nate or  bicarbonate,  potassium  carbonate,  or  sodium  borate,  to  the  gal- 
lon. The  parts  can  also  be  softened  by  poultices.  After  a  soaking  of 
some  minutes  the  outer  surface  is  sufficiently  softened  to  be  readily 
pared  down,  and  this  may  be  repeated  until  the  thickening  is  sufficiently 
reduced.  The  same  result  can  be  obtained  by  painting  on  a  solution  of 
caustic  potash— in  mild  cases,  the  liquor  potassae,  in  hard  and  much 
thickened  areas  a  solution  several  times  stronger;  care  should  be  exer- 
cised with  the  latter.  Several  such  paintings  can  be  made  within  a 
few  minutes  of  one  another,  and  then  the  softened  part  scraped  or  shaved 

i  Morrison,  Jour.  Cutan.  Dis.,  1886,  p.  5,  reported  a  curious  case  in  a  negro,  a  fire- 
man for  ten  years  on  a  steamer,  in  whom  the  friction  of  the  handle  of  the  shovel  an 
the  exposure  to  intense  heat  brought  about  markedly  thickened  layered  callosities 
under  which  later  suppuration,  ulceration,  and  necrosis  developed. 


528  HYPERTROPHIES 

away.  According  to  circumstances  it  can  again  be  repeated  immediately, 
or  if  any  irritation  has  been  produced,  a  day  or  two  later.  Lactic  acid, 
weakened  or  full  strength,  will  also  soften  such  epidermic  accumulations. 
Another  satisfactory  method  is  by  the  continuous  application  of  a  10 
to  25  per  cent,  salicylic  acid  rubber  plaster  or  plaster-mull  for  several 
days  or  a  week;  on  removal  it  is  followed  by  hot- water  soaking,  and  the 
mass  can,  in  great  part,  at  least,  be  rubbed  or  scraped  away.  The  action 
of  the  plaster  may  have  been  sufficient  to  permit  the  rubbing  or  scraping 
away  of  the  callus  without  the  supplementary  soaking.  According  to 
the  degree  of  thickening  this  application  may  need  to  be  repeated  once 
or  several  times.  The  salicylic  acid  collodion  paint,  often  used  in  clavus 
(q.  v.},  can  be  employed  in  place  of  the  plaster,  but  is  generally  not  so 
efficient,  although  it  is  not  so  inconvenient.  In  moderate  cases  envel- 
oping the  parts  at  night  with  a  compound  salicylated  soap-plaster, 
advised  in  some  cases  of  eczema,  will  usually  keep  the  thickened  accumu- 
lation from  getting  stiff,  hard,  and  inelastic. 

KERATOSIS  PALMARIS  ET  PLANTARIS 

Synonyms. — Tylosis  palmae  et  plantar,  Ichthyosis  palmaris  et  plantaris;  Keratoma; 
Keratoma  palmare  et  plantare  hasreditarium;  Symmetric  keratodermia;  Fr.,  Kera- 
todermie  plantaire  et  palmaire. 

Definition. — Hypertrophy  of  the  corneous  layer  of  the  palms 
and  soles,  usually  of  a  more  or  less  horny  and  plate-like  character. 

Symptoms. — The  features  of  this  somewhat  uncommon  malady, 
to  which  the  contributions  of  Unna1  and  Hyde2  first  directed  special 
attention,  are  in  their  essential  character  analogous  to  those  of  cal- 
lositas,  but  the  hardening  and  thickening  arise  spontaneously  with- 
out necessarily  having  any  external  factor,  such  as  pressure,  friction, 
etc.,  as  in  the  latter  malady,  and  is,  furthermore,  symmetric,  and  usually 
on  palms  and  soles.  Moreover,  it  is,  as  a  rule,  congenital  or  a  hereditary 
condition.  The  degree  of  development  varies  somewhat  both  as  to 
thickness  and  uniformity.  In  the  typical  cases  the  whole  palmar  and 
plantar  regions  are  the  seat  of  a  thickened,  usually  smooth,  hardened, 
and  sometimes  seemingly  translucent,  yellowish,  brownish-yellow,  or 
yellowish-gray  calloused  epidermic  plate.  It  is  of  a  hard,  leathery  con- 
sistence, not  infrequently  being  almost  horny  in  character.  While 
it  is  commonly  limited  to  the  palmar  and  plantar  aspects,  occasionally 
it  extends  somewhat  beyond  on  to  the  side,  and  exceptionally  slightly 
on  to  the  dorsal  surface.  Much  more  frequently,  however,  the  only 
parts  calloused  over,  in  addition  to  the  usual  sites,  are  several  or  more  of 
the  knuckles.  It  is  common  to  find  the  nails  more  or  less  affected,  and 
tilted  slightly  or  moderately  upward  by  the  collection  of  hardened  and 

1  Unna,  "Ueber  das  Keratoma  palmare  et  plantare  hereditarium,"  Archill,  1883,  p. 
231  (2  cases,  with  illustration). 

2  Hyde,  "Observations  in  Three  Cases  of  Symmetrical  Hand  and  Foot  Disease," 
Med.  News,  1887,  vol.  li,  p.  416  (3  cases,  bibliography).      The  subject  is  well  gone  over 
in  the  papers  and  discussion  in  Trans,  of  Third  Internal.  Dermatolog.  Congress,  Lon- 
don, i8q6.     The  clinical  appearances  of  the  malady  are  well  shown  in  the  plate  in 
Mracek's  Hand-Atlas  of  Skin  Diseases,  and  also  in  the  colored  illustration  in  Crocker's 
paper,  "Tylosis  Palm.-e  et  Plants,"  in  Brit.  Jour.  Derm.,  1891,  p.  169. 


KERATOS1S  PALMARIS  ET  PLANTARIS  529 

thickened  epidermis  under  their  free  borders.  At  the  edge  of  the  plate- 
like  thickening  there  is  generally  a  narrow  pinkish  or  reddish  halo  or 
zone,  apparently  passive  in  character,  and  not  due,  as  a  rule,  to  inflam- 
mation, this  latter,  with  few  anomalous  exceptions,  being  observed  onlv 
as  an  occasional  accidental  factor.  In  some  instances  there  is  associated 
hypendrosis  of  the  parts,  in  which  event  the  epidermic  mass  is  not  so 
hard  or  horny,  and  although  still  tough,  may  have  a  slightly  sodden 


The  condition  is  a  persistent  one,  although  in  some  cases,  from 
time  to  time,  there  is  a  partial  or  almost  complete  casting  off  of  the 
hardened  plate,  and  a  variable  intermission  of  at  least  comparative 
freedom.  While  the  surface  is  usually  smooth  or  not  conspicuously 


Fig.  125. — From  a  case  of  symmetric  keratosis  of  palms  and  soles  (has  occurred  in 

three  generations). 

rough,  sometimes  it  is  somewhat  irregular,  and  in  occasional  instances 
it  has  a  slightly  worm-eaten  appearance.  The  thickness  of  the  plate 
varies,  averaging  almost  \  of  an  inch,  and  sometimes  much  more  over 
parts  subjected  to  pressure.  The  conditions  are  practically  the 
same  on  both  palms  and  soles,  although  on  the  latter  the  hollow  of  the 
foot  usually  escapes  completely  or  is  but  relatively  slightly  affected. 
There  are  variations,  however,  from  the  malady  as  described,  and  it 
may  not  involve  the  entire  parts  uniformly.  Brocq1  has  described  a  case 
in  which  the  calloused  formation  was  of  a  more  or  less  band-like  char- 
acter and  of  a  longitudinal  direction,  running  along  and  corresponding 
to  the  middle  of  the  anterior  aspect  of  the  fingers.  In  other  instances 
the  chief  thickening  is  over  the  joint  prominences.  In  some,  moreover, 

1  Brocq,  Traitcment  dcs  Maladies  de  Ic  Peau,  second  ed.,  p.  378. 
34 


530  HYPERTROPHIES 

the  keratosis  consists,  primarily  at  least,  of  small  rounded  or  conic  cal- 
losities, with  but  slight  or  moderate  thickening  of  the  intervening  skin. 
A  case  somewhat  similar  to  the  last,  with  a  slight  erythematous  or  in- 
flammatory halo  or  zone  surrounding  the  callosities,  has  been  noted  by 
Besnier.1  Brooke2  has  also  called  attention  to  a  peculiar  erythematous 
condition  (erythema  keratodes  of  palms  and  soles),  seemingly  allied  to 
the  malady  under  consideration,  but  in  which  there  was  some  under- 
lying erythema,  giving  the  slightly  thickened  epidermis  an  orange-gray 
color  and  a  quite  pronounced  inflammatory  halo;  the  inflammation  was 
of  a  mild  or  moderate  grade,  although  the  outer  edges  were  somewhat 
swollen  and  tense  and  hot  to  the  touch.  There  was,  in  addition,  ery- 
thematous horny  papules  over  the  joints  on  the  dorsal  surface  of  the 
fingers.  The  malady  was  less  marked  on  the  soles.  It  responded  to 
treatment,  but  was  prone  to  recur. 

There  are  no  subjective  symptoms — occasionally  slight  tenderness 
around  the  edges  and  over  the  joints.  There  is  interference  with  free 
mobility  of  the  parts,  and  sometimes  fissures  are  to  be  seen,  and  these 
are  usually  quite  painful.  Exceptionally,  from  accidental  irritation  or 
as  a  result  of  occupation,  an  eczematous  element  may  be  superadded. 
Ordinarily,  however,  the  condition,  beyond  its  unsightliness  and  incon- 
venience, gives  rise  to  no  trouble.  Hyde3  mentions  that  in  these  patients 
"the  pulse  is  sometimes  exceedingly  slow,  running  in  adults  from  50 
to  55  beats  a  minute,  without  other  manifest  impairment  of  the  general 
health." 

Etiology  and  Pathology.— Beyond  the  fact  of  the  malady 
being  congenital  and  often  hereditary,  but  little  is  known  as  to  its 
causes.  Exceptionally  it  has  been  acquired.  A  history  of  its  occur- 
rence in  two  or  more  generations  is  sometimes  obtainable  (Thost,  Unna, 
Date,  Crocker,  Sherwell,  Heuss,  Neumann,  Pendred),4  and  not  infre- 
quently two  or  more  members  of  the  same  generation,  as  in  several  re- 
ported by  those  just  named.  It  has  also  been  stated  that  it  tends 
to  affect  only  one  sex  in  the  family,  but  this  is  not  borne  out  by  an  analy- 
sis of  the  cases.  In  some  instances  pressure  and  friction  have  seemed 
to  be  exciting,  or  at  all  events  aggravating,  causes.  The  malady  is  not, 

1  Besnier,  "Keratodermia  symmetrica  erythematosa,"  Internal.  Atlas  Rare  Skin 
Diseases,  1889,  plate  v. 

2  Brooke,  Brit.  Jour.  Derm.,  1891,  p.  335,  with  colored  plate;  also  "Notes  on  Some 
Keratoses  of  the  Palms  and  Soles,"  ibid.,  p.  19;  Dubreuilh,  ibid.,  1892,  p.  185,  reports  a 
somewhat  similar  case. 

3  Hyde,  Morrow's  System,  vol.  iii  (Dermatology),  p.  405. 

4  Thost,  Ueber  erbliche  Icythyosis  palmaris  el  plantar  is,  Heidelberg,  1880,  quoted  by 
Unna  (4  generations);  Unna,  loc.  cit.  (i  case,  2  and  i  case,  3  generations);  Date,  "He- 
reditary Ichthyosis,"  Brit.   Med.  Jour.,  1887,  ii,  p.  718  (5  generations;  brief  note); 
Crocker,  loc.  cit.  (one  instance  5,  and  another  2,  generations);  Sherwell,  Jour.  Cutan. 
Dis.,  1898,  p.  451  (case  demonstration — 2  generations);  Heuss,  "Keratoma  palmare  et 
plantare  hereditarium,"  Monatshefte,  1896,  vol.  xxii,  p.  405  (3  generations);  Neumann, 
''Ueber  Keratoma  hereditarium,"  Archiv,  1898,  vol.  xlii,  p.  163  (7  plates,  2  generations) ; 
Pendred,  Brit.  Med.  Jour.,  1898,  i,  p.  1132  (3  members  of  family;  disease  appeared 
in  unbroken  succession — 5  generations — for  at  least  one  hundred  and  fifty  years  in  the 
same  family,  principally  through  the  female  line);  Vorner  (Archiv,  1901,  vol.  Iv,  p.  i, 
with  bibliography),  Pasini  (Giorn.  ital.,  1902,  vol.  xxxvii,  p.  318,  with  bibliography), 
Decroo  (Jour.  d.  sci.  med.  de  Lille,  July  4,  1903— abs.  in  Brit.  Jour.  Derm.,  1903,  p. 
377),  and  Bohn  (Dermatofog.  Centralbl.,  1904,  March,  p.  162)  also  report  instances  of 
the  malady  through  several  generations. 


KERATOSIS  PALMARIS  ET  PLANTARIS  531 

however,  to  be  confounded  with  the  keratosis,  often  of  similar  general 
aspect,  such  as  the  callosities  resulting  from  occupation  and  that  noted 
in  connection  with  eczema,  pityriasis  rubra  pilaris,  and  other  chronic 
diseases;  nor  that  due  to  the  continued  ingestion  of  arsenic  (see  dermatitis 
medicamentosa),  although  this  latter  might  readily  be  considered  as  an 
acquired  or  accidental  example  of  the  same  malady  due  to  a  definite 
etiologic  factor.  It  is  not  improbable  that  there  are  several  distinct 
varieties,  as  indicated  by  the  unusual  types  referred  to,  and  that  the 
etiologic  factors  are  somewhat  varied.  Besnier  divided  the  cases  into 
four  classes:  (i)  The  ordinary  symmetric  congenital  and  hereditary  form; 
(2)  the  symmetric  keratodermia  developing  in  childhood,  of  an  erythem- 
atous  and  irritable  character,  and  probably  connected  with  some  neu- 
rosis; (3)  symmetric  keratodermia,  especially  of  the  feet,  developing 
primarily  in  isolate  foci,  and  probably  of  central  origin;  (4)  accidental 
keratodermias,  distinct  from  ordinary  callositas,  occurring  at  any  age, 
and  provoked  by  some  unusual  occupation  or  work. 

While  the  malady  may  be  seen  in  any  station  of  life,  it  is  usually 
observed  in  the  poorer  and  working-classes.  It  is  met  with  in  both 
sexes.  The  condition,  or  an  analogous  affection,  seems  to  be  endemic 
on  the  island  of  Meleda,  off  the  coast  of  Dalmatia,  and  is  known  as 
the  "mal  de  Meleda";  Hovorka,1  viewing  it  originally  as  a  form  of 
leprosy,  subsequently  (Hovorka  and  Ehlers)2  retracted  this  opinion. 
Professor  Neumann,  who  visited  the  island  and  examined  several  cases 
(loc.  cit.),  also  dissented  from  this  view.  He  found  that  it  was  not 
leprosy,  but  a  disease  similarly  or  closely  allied  to  symmetric  keratoder- 
mia. In  the  cases  there,  however,  the  thickening  was  not  limited  to  the 
hands  and  feet  alone,  but  the  lower  leg  and  lower  forearms  and  the  patellar 
region  also  were  involved.  Neumann  believes  it  belongs  to  the  category 
of  the  hereditary  anomalies  of  the  skin. 

Pathologically,  the  disease  is  closely  related  to  callositas,  and  about 
the  same  histologic  characters  are  disclosed,  the  chief  and  constant 
factor  being  the  thickening  and  hardening  of  the  corneous  layer.  ^ 

Diagnosis.— The  symmetric  character  of  the  disease,  its  usual 
involvement  of  all  extremities,  the  absence  of  inflammatory  symptoms, 
the  frequent  association  of  hyperidrosis  of  the  parts,  and  the  common 
history  of  its  existence  since  birth  and  of  hereditary  tendency  will  gen- 
erally serve  to  prevent  its  confusion  with  thickened  squamous  eczema, 
ordinary  callosities,  and  the  thickening  occasionally  seen  in  connection 
with  other  maladies.  The  possibility  of  a  similar  or  closely  similar 
condition  being  due  to  the  prolonged  ingestion  of  arsenic  is  not  to  be 
overlooked,  nor  that  such  keratosis,  after  once  thoroughly  establ  ed, 

is  sometimes  persistent. 

Prognosis  and  Treatment.— The  condition  is  irremediable  as 
to  permanent  relief,  but  treatment  can  do  much  to  keep  the  malady  in 
abeyance.  But  little,  if  anything,  is  to  be  expected  from  general  treat- 
ment, although  Brocq  advises  large  doses  of  sodium  arsemate;  a 

i  Hovorka,  "Ueber  einen  bisher  unbekannten  endemischen  Lepraherd  in  Dalma- 
tian," Archiv,  1896,  vol.  xxxiv,  p.  51.  ,  , 

»  Hovorka  and  Ehlers,  "Mal  de  Meleda,"  Archil',  1897,  vol.  xl,  p.  251. 


532 


HYPER  TR  OPHIES 


the  symmetric  erythematous  keratodermia  the  same  drug,  together  with 
the  bromids,  and  the  application  of  revulsives  to  the  nape  of  the  neck. 
Brooke  thought  the  internal  administration  of  ichthyol,  3-minim  doses 
(0.2),  in  association  with  local  treatment,  of  curative  value.  Klotz1 
believed  in  one  case  benefit  derived  from  the  internal  use  of  pilocarpin. 
The  important  and  usually  only  treatment  which  has  any  effect  consists 
in  external  applications,  and  the  most  valuable  of  all  are  those  in  which 
salicylic  acid  is  the  active  constituent,  the  treatment  being  the  same, 
in  fact,  as  advised  in  ordinary  callositas  (q.  ».)•  A  strong  salicylic  acid 
plaster  seems,  in  my  experience,  the  best  method  of  its  application — 15 
to  25  per  cent,  strength.  A  10  to  20  per  cent,  salicylated  soap-plaster, 
as  advised  by  Klotz,  is  also  valuable.  Soft-soap  (sapo  viridis)  cataplasms 
and  hot-water  soakings  may  also  be  used  to  soften  and  remove  the 
hardened  accumulation;  or  instead  of  sapo  viridis,  caustic  potash  solu- 
tion, 10  to  30  per  cent,  strength,  can  be  cautiously  employed.  In  a  few 
instances  frequently  repeated  short  exposures  to  the  Rontgen  rays  have 
been  followed  by  a  disappearance  of  the  thickening. 

KERATOSIS  BLENORRHAGICA2 

Synonyms. — Keratosis  blenorrhoica;  Keratodermia  blenorrhagica;  Fr.,  Kerato- 
dermie  blenorrhagique. 

This  rare  condition  associated  with  gonorrheal  arthritis  was  first 
described  (1893)  by  Vidal;  and  later  by  Jeanselme  and  Ghika,  Chauf- 
fard,  Robert,  and  others  in  France,  Buschke,  Stanislawsky,  Baermann, 
Roth,  and  Sabotka  in  Germany  and  Austria,  Sequeira,  Williams,  Graham 
Little  and  Douglas  in  England,  Swift  in  Australia,  and  Simpson  in  our 
own  country.  Several  eruptive  conditions,  such  as  erythema,  urticaria, 
erythema  nodosum,  hemorrhagic  and  bullous  lesions  have  been,  from 
time  to  time,  observed  associated  with  gonorrhea  and  systemic  gonor- 
rheal infection;  these  have  been  variously  attributed  to  coincidence,  to 
the  gonorrheal  poison,  to  the  occasionally  associated  septicemia,  and 
to  the  drugs  used  or  administered.  There  is  nothing  special  or  char- 
acteristic, moreover,  in  these  cases.  The  rare,  more  or  less  symmetric, 

1  Klotz,  Jour.  Culan.  Dis.,  1899,  p.  373  (society  discussion). 

2  Literature:  Vidal  Annales,  1893^.3;  Jeanselme,  ibid,  1895,  p.  525;  Jacquet  and 
Ghika,  Soc.  med.  hop.  de  Paris,  Jan.  22,  1897;  Chauffard,  ibid.,  April  23,  1897;  Robert. 
These  de  Paris,  April  28,  1897;  Lannois,  Soc.  med.  de  hop.  de  Paris,  July  21,  1899; 
Buschke,  Archiv,  1899,  xlviii,  pp.  181  and  385;  Stanislawsky,  Monatsber icht  f.  Urol., 
1000,  v,  p.  643;  Malherbe,  Gaz.  med.  de  Nantes,  1901,  No.  6;  Baermann,  Archiv,  1904, 
Ixix,  p.  363;  Roth,  Munchen.  med.  Wochenschr.,  May  30, 1905,  p.  104;  Chauffard  and 
Froin,  Arch,  de  med.  exper.,  Sept.,  1906,  p.  609;  Chauffard  and  Fiessinger,  Bull,  de  I. 
soc.  Fr.,  de  Derm,  et  Syph.:  May  1909,  p.  162,  also  Ikonographia  Dermatologica,  1910, 
H.  S»  P-  193;  Rivet  and  Bricout,  Bull,  med.,  1909,  p.  851;  Sequeira,  Brit.  Jour.  Derm., 

1910,  p.  139;   Williams,  ibid.,  1910,  pp.  361-369;   Waelsch  (Arthropathia  psoriatia), 
Archiv,  1910,  civ,  pp.  195  and  453;  Graham  Little  and  Douglas,  Brit.  Jour.  Derm., 

1911,  p.  360;  Arning  and  Meyer-Delius,  Archiv,  1911,  cviii,  p.  3;  Rost,  Dermatolog. 
Zeitschr.,  1911,  xviii,  H.  3;  Simpson,  (case  report,  review,  and  bibliography;  apparently 
first  American  case),  Jour.  Amer.  Med.  Assoc.,  Aug.  24, 1912,  p.  607;  Swift,  Australasian 
Med.  Gaz.,  Nov.  30,  1912  (first  case  recorded  in  Australasia);  Arning,  Archiv,  1912, 
cxiii,  p.  50;  Buschke,  ibid.,  1912,  cxiii,  p.  223;  Gennerich,  Munchen.  med.  Wochenschr., 

1912,  p.  811;  Zicler,  Med.  Klinik.  1912,  No.  6;   Sabotka,  Dermatolog.,  Wochenschr., 
Feb.  15. 1913, p.  i8i,andFeb.  22, p.  218  (with  review  and  bibliography).  I  am  especially 
indebted  to  Simpson's  and  Sabotka's»papers. 


KERATOSIS  BLENORRHAGICA  533 

keratodermic  conditions,  however,  to  be  described  are  apparently 
peculiar  and  distinctive.  Two  varieties  are  'usually  observed:  (i)  a 
localized  form  involving  the  hands  and  feet,  more  especially  the  palms 
and  soles;  and  (2)  a  more  or  less  generalized  form,  in  which,  however, 
the  brunt  of  the  malady  is  usually  upon  the  extremities,  with  the  legs 
and  forearms  involved,  frequently  the  thighs  and  arms  also,  and  some- 
times the  trunk— rarely  the  face  and  scalp.  The  former  is  the  common 
one;  and  in  this  there  is  noted  thickening,  often  quite  marked,  of  the 
palmar  and  plantar  epidermis  with  irregular  and  uneven  horny-looking, 
sometimes  waxy  or  translucent-looking,  or  brownish  crusts  or  projec- 
tions giving  the  appearance  of  a  relief  map;  the  eruptive  condition  may 
extend  to  the  dorsum  of  the  hands  and  feet,  with  somewhat  horny  crusts, 
or  scab-like  crusts  resembling  rupial  crusts;  and  there  may  be  here  and 
there  some  pea-  to  larger-sized  waxy  nodules,  and  horny-capped  pustules, 
with  but  relatively  insignificant  inflammatory  base  or  areola.  In  fact, 
the  hyperemic  element  is  generally  insignificant.  When  the  waxy 
nodules  are  scraped  off  or  rubbed  off,  a  rather  succulent-looking 
slightly  reddish  surface  is  disclosed;  the  waxy  formation  is,  as  a  rule, 
soon  reproduced.  The  under  part  of  the  nails  is  usually  packed  with 
horny,  waxy  crust  accumulation,  sometimes  slightly  purulent,  and  fre- 
quently the  nails  are  cast  off.  The  eruption  may  involve  hands  only, 
or  both  hands  and  feet.  The  lesions  when  fully  developed  are  apt  to 
remain  stationary  for  a  long  time.  Recovery  gradually,  after  several 
weeks  or  more,  ensues.  There  are  no  positive  subjective  symptoms, 
beyond  a  feeling  of  stiffness,  moderate  soreness,  and  discomfort. 

In  the  generalized  form  the  hands  are  usually  involved  as  described, 
with  eruptive  elements  on  other  parts  partaking  of  the  nature  of  small  to 
moderate-sized  horny  papulopustules,  and  waxy,  horny,  irregular  crust 
accumulation,  with  usually  a  hyperemic  border.  When  the  crust  falls 
off  a  reddish  or  pigmented  surface  is  left,  which  in  time  disappears. 
Scarring  does  not  seem  to  result.  The  subjective  symptoms  in  the  gen- 
eral cases  are  practically  the  same  as  in  the  local  variety,  with  the  dis- 
comfort naturally  much  greater.  The  associated  systemic  gonorrheal 
infection  and  gonorrheal  arthritis  give  rise  to  the  most  discomfort;  the 
latter  has  been  present  in  all  except  2  cases. 

The  belief  seems  fairly  general  that  the  malady  is  dependent  upon 
the  gonorrheal  systemic  infection  and  that  possibly  the  gonococcus 
invades  the  skin  and  is  directly  responsible  for  the  eruption  of  keratotic 
crusts— but  positive  proof  is  wanting.  The  histologic  conditions  have 
been  studied  by  Chauffard,  Baermann,  Sequeira,  Simpson,  and  others, 
but  have  disclosed  nothing  characteristic;  the  distinguishing  features 
seem  to  be  "deep,  and  epidermic  leukocytic  infiltration,  composed  of 
polynuclear  leukocytes  and  mast  cells,  together  with  parakeratosis. 
Arning  and  Meyer,  Delius  and  Sabotka  concluded  that  the  first  stage 
was  vesicle  formation,  the  hyperkeratotic  condition  being  secondary 
to  this  The  horny  formations  characteristic  of  the  disease  are  ap- 
parently, however,  not  true  keratosis  but  the  result  of  parakeratosis 
The  striking  features,  the  waxy,  horny-looking  nodules  and  crusts,  and 
the  epidermic  thickening  of  the  eruption,  together  with  the  associated 


534 


//  YPER  TR  OPHIES 


general  gonorrheal  infection  doubtless  permit  of  a  diagnosis  without 
much  difficulty.  There  is  slight  suggestiveness  of  the  hard  crustaceous 
syphiloderm,  and  in  the  instances  (in  several  of  the  reported  cases)  in 
which  an  iritis  developed,  such  suspicion  might  be  strengthened,  but 
this  possibility  seems  to  have  been  ruled  out  by  the  observers  of  the  cases 
— all  trained  men.  There  is  also  some  suggestive  resemblance  in  places 
to  dermatitis  seborrhoica,  and  also  to  the  cases  usually  described  as 
"psoriasis  ostreacea,"  which  is  also  usually  associated  with  arthritic 
symptoms. 

Prognosis  and  Treatment. — Spontaneous  involution  of  the 
eruption  takes  place  with  the  subsidence  of  the  arthritic  symptoms. 
Soap  and  hot  water  washings,  and  hot  water  embrocations  are  said  to 
have  a  macerating  effect  upon  the  lesions.  Simpson  found  a  "resorcin 
and  sulphur"  ointment  of  benefit.  Sequeira  used  gonococcal  vaccine 
with  favorable  influence. 

KERATOSIS  SENILIS 

Old  age  of  the  skin,  or  atrophia  senilis  (q.  v.),  is  characterized  by 
various  changes:  sometimes  more  or  less  thinning  of  the  derma,  freckle- 
like  and  larger  pigmentary  spots,  seborrheic  warts  (q.  v.) ,  greasy  crusted 
or  scaly  patches,  usually  pea-  to  bean-sized  or  larger,  and  somewhat 
hard,  generally  small,  thickened  epidermic  patches.  This  last  formation 
is  the  ordinary  type  of  lesion  to  which  the  name  of  keratosis  senilis  is 
commonly  applied,  but  in  reality  it  is  often  applied  to  the  last  two. 
The  greasy  crusted  or  scaly  spots  begin,  as  a  rule,  by  a  slight  pigmenta- 
tion, and  this  may  remain  as  such,  or  after  a  time  it  is  noted  to  be  greasy 
to  the  sight  and  touch.  Later  it  becomes  irregularly  covered  with  a  thin 
scarcely  noticeable,  scaly  coating,  which  can  easily  be  rubbed  off.  Grad- 
ually the  scaliness  increases  in  thickness,  and  sometimes  in  area,  is  dirty 
gray  or  brownish  gray  in  color,  and  often  quite  adherent;  and  when 
removed,  the  surface  is  moist  or  oily,  and  after  a  time  an  atrophic  thin- 
ning is  observed.  It  may  remain  almost  indefinitely  as  such,  the  scaly 
crust  being  rubbed,  washed,  or  cast  off  from  time  to  time,  and  gradually 
renewed.  In  many  instances,  however,  the  process  advances,  and  the 
degenerative  thinning  is  followed  by  superficial  abrasion,  and  sometimes 
with  scarcely  noticeable  papillary  prominences,  and  now,  when  the  crust 
is  at  all  forcibly  or  harshly  removed,  slight  bleeding — one  or  two  droplets 
— may  occasionally  be  observed.  The  discharge  from  the  abrasion,  or 
perhaps  now  superficial  ulceration,  together  with  the  oiliness  of  the  im- 
mediately surrounding  border,  gives  rise  to  a  slightly  thicker  crust. 
From  such  a  degenerative  seborrheic  patch  often  results  a  beginning 
superficial  epithelioma  or  rodent  ulcer.  In  other  instances  the  sebaceous 
scaliness  may  be  more  of  the  nature  of  a  somewhat  horny  concretion, 
and  limited  to  one  or  several  contiguous  gland-ducts,  finally  presenting 
sometimes  an  ill-defined,  warty-looking  aspect.  This  coating  or  forma- 
tion is  apt  to  be  more  adherent,  and  not  so  readily  dislodged,  partaking 
of  the  nature  of  both  a  keratosis  and  a  degenerative  seborrhea.  After 
a  time  atrophy  may  take  place,  or  the  base,  especially  the  peripheral 


KERATOSIS  SENILIS 


535 


portion,  shows  slight  abrasion  or  ulceration,  and  practically  the  same 
stage  is  reached  as  above  indicated. 

In  the  true  keratosis  senilis  the  earliest  manifestation  is  frequently 
a  slight  discoloration,  and  over  which,  after  a  while,  .the  horny  layer 
of  the  epidermis  becomes  harder,  and  thickens  somewhat,  forming  a 
roughness  or  scaliness.  To  the  finger  it  now  feels  rough,  harsh,  and 
hard  or  quite  horny,  not  greasy,  as  a  rule,  as  in  the  degenerative  sebor- 
rheic  patch.  The  spot  becomes  slightly  or  moderately  elevated,  grading 
off  into  the  surrounding  integument,  or  being  somewhat  sharply  defined. 
It  now  consists  of  a  hardened  or  horny  elevated  spot,  with  trifling  dry 
harsh  adherent  scaliness,  and  appearing  as  if  the  tissue  thickening  involve 
both  the  upper  corium  and  epidermis.  The  surface  in  some  instances 


3s 

;T-   ^ 


Fig.  126. — Keratosis  senilis,  scurfy  and  scaly  spots  and  patches,  with  degenerative 
changes,  on  the  cheek,  tending  to  become  epitheliomatous;  small  epithelioma  on  neck, 
developed  from  a  similar  spot. 

is  uneven  and  wart-like,  and  the  color  is  usually  dirty  or  yellowish  gray 
or  blackish  gray,  and  occasionally  quite  dark.  In  area  it  varies  from 
that  of  a  pea  to  a  half-inch  or  so  in  diameter.  It  may  remain  more  or 
less  indefinitely  as  such,  or  atrophic  changes  begin  to  present,  which 
gradually  lead  to  epithelial  degeneration,  abrasion,  ulceration— in  short, 
to  the  development  of  an  epitheliomatous  lesion.  As  with  the  degenera- 
tive seborrheic  patch,  one,  several,  or  many  may  be  present. 

The  usual  site  of  these  formations  is  the  face,  but  the  back  of  the  hand 
is  also  a  quite  frequent  situation.  As  a  rule  they  are  observed  in  those 
past  the  age  of  sixty,  but  to  this  there  are  many  exceptions,  old  age 
changes  in  the  skin  often  presenting  as  early  as  the  age  of  forty  and  some- 
times earlier,  even  though  the  patient  be  yet  in  other  respects  possessed 


5  36  H  YPER  TK  OPHIES 

of  the  attributes  of  vigor  and  active  adult  life.  They  are,  as  White1 
points  out,  much  less  likely  to  develop  upon  persons  who  have  kept 
their  cuticle  and  sebaceous  glands  in  proper  order  through  life  by  suffi- 
cient use  of  soap  than  in  those  who  have  been  more  or  less  negligent  in 
this  respect.  Habitual  exposure  to  sun  and  to  wind,  has  also  a  favoring 
influence,2  especially  to  actinic  rays  of  light.  There  is,  however,  in 
some  individuals  a  peculiar  proneness  to  these  degenerative  formations. 

Prognosis. — Ordinarily  in  their  earlier  development,  both  as  to 
the  degenerative  seborrheic  spots  and  the  keratoses,  if  properly  looked 
after,  their  further  formation  or  progress  can  be  prevented  by  proper 
measures.  Their  chief  significance  is  the  possibility  or  probability  of 
undergoing  epithelial  degeneration  and  development  into  epithelioma— 
not  at  all  an  uncommon  result  when  neglected,  although,  for  the  most 
part,  usually  into  but  slowly  progressing  and  comparatively  benign 
lesions,  which,  however,  sometimes  become  transformed  into  an  epi- 
theUoma  of  more  malignant  character. 

Treatment.  —In  their  earliest  appearance  the  use  of  a  simple 
mild  ointment,  such  as  cold  cream  or  vaselin,  rubbed  in  gently  at  night 
and  washed  off  with  soap  and  water  in  the  morning,  will  often  suffice 
to  remove  the  blemish,  or,  at  all  events,  stay  its  progress.  If  of  more 
positive  character,  the  ointment  can  be  rubbed  in  after  the  morning 
washing  as  well.  When  there  is  considerable  hardness,  the  continuous 
application  of  the  ointment  over  night  as  a  spread  plaster  is  more  efficient. 
The  addition  of  salicylic  acid,  in  the  proportion  of  i  to  4  or  5  per  cent., 
is  to  be  made  when  the  condition  is  obstinate  or  more  advanced.  In 
the  latter  event  an  ointment  composed  of  5  to  20  grains  (0.33-1.33) 
each  of  salicylic  acid  and  sulphur  to  the  half-ounce  (16.)  of  ointment 
base, — vaselin  or  equal  parts  of  vaselin  and  lard  or  cold  cream, — and 
gently  rubbed  in  at  night  after  a  preliminary  soap-and-water  washing, 
will  be  found  of  greater  value,  and  often  curative.  I  have  found  these 
two  drugs  especially  valuable  in  these  conditions;  D.  W.  Montgomery3 
and  likewise  others  have  had  similar  experience.  In  the  treatment  of 
the  degenerative  seborrheic  spots  it  is  not  necessary  to  go  beyond  the 
treatment  indicated,  unless  epithelial  changes  with  ulceration  have  already 
set  in,  in  which  case  the  management  becomes  that  of  superficial  epithe- 
lioma (q.  v.). 

The  advanced,  and  sometimes  the  slight,  true  keratosis  senilis,  in 
which  there  is  a  good  deal  of  horny  hardness  or  wart-like  development, 
will  usually  require  more  energetic  measures.  If  rebellious  to  the  means 

J  J.  C.  White,  "The  Old  Age  of  the  Skin,"  Boston  Med.  and  Surg.  Jour.,  1882,  vol. 
cvii,  p.  484.  This  and  other  forms  of  keratosis  will  also  be  found  more  or  less  exhaust- 
ively dealt  with  in  the  paper  by  Dubreuilh,  "Des  Hyperkeratoses  circonscrites." 
AnnaJes,  1896,  p.  1158  (with  review  of  the  subject  and  references);  and  especially  as 
regards  their  significance  as  precanervous  affections,  by  Hartzell,  Jour.  Culan.  Dis., 
1003-  P-  393  (with  3  histologic  cuts  and  bibliography). 

•   ,,2  D' W'  Montg°mery.  "Unusual  Exposure  to  Light  Followed  by  Seborrhceic  Kerato- 
sis,   Jour.  Amer.  Med.  Assoc.,  Jan.  4,  1913,  p.  7>  briefly  reviews  this  question;  Hyde, 
mer.  Jour.  Med.  Sci.,  Jan.  1906,  and  Dubreuilh,  Annales,  1907,  p.  387,  were  of  the 
opinion  that  such  exposures  favor  the  production  of  epithelioma,  doubtless  in  conse- 
quence of  later  changes  and  irritation  of  such  keratoses. 

3  D.  W.  Montgomery,  "A  Contribution  to  the  Treatment  of  Senile  Patches,"  Phila. 
Med.  Jour.,  1898,  vol.  i,  p.  211. 


KERATOSIS  PILARIS  537 

already  suggested,  trichloracetic  acid1  may  be  carefully  applied,  washing 
it  off  as  soon  as  the  patch  gets  white;  or  a  strong  salicylic  acid  ointment, 
5  to  15  per  cent,  strength,  can  be  applied  as  a  plaster  over  night  for  one 
to  several  nights,  a  mild  salve  application  being  made  in  the  daytime. 
This  latter  remedy  may  also  be  applied  in  the  form  of  a  10  to  25  per  cent, 
plaster-mull,  or  in  collodion,  in  5  to  15  per  cent,  proportion.  Two  or 
three  such  applications  will  often  suffice  to  remove  the  thickening,  and 
subsequently  the  mild  salicylic  acid  salve,  with  or  without  the  addition 
of  sulphur,  can  be  used.  Sometimes,  however,  their  complete  removal, 
without  cauterizing  or  operative  methods  is  not  possible,  but,  as  a  rule, 
their  further  progress  can  usually  be  stayed.  If  obstinate,  the  strong 
salicylic  acid  plaster  or  collodion  applications  should  not  be  continued 
indefinitely,  as  possible  irritation  and  degenerative  changes  might  be 
promoted.  The  careful  application  of  carbon-dioxid  snow  (q.  r.)  often 
acts  surprisingly  well  in  these  keratoses.  If  unyielding  as  to  complete 
obliteration,  if  stationary,  nothing  further  need  be  done;  but  should 
the  patient  desire  removal  or  should  epitheliomatous  changes  have 
presented,  then  one  of  the  various  plans  for  superficial  epitheliomata 
can  be  resorted  to,  or  Rb'ntgen  ray  exposures  can  be  tentatively  tried. 
For  the  treatment  of  seborrheic  warts  and  other  senile  cutaneous  changes, 
the  same  plans  are  practised;  the  treatment  of  the  former  is  also  con- 
sidered under  warts. 

KERATOSIS  PILARIS 

Synonyms. — Pityriasis  pilaris;  Lichen  pilaris;  Fr.,  Keratose  pilaire;  X£rodermie 
pilaire  (Besnier). 

Definition. — Keratosis  pilaris  is  a  hypertrophic  affection  char- 
acterized by  the  formation  of  pin-head-sized  or  slightly  larger  conic 
epidermic  elevations  seated  about  the  apertures  of  the  hair-follicles, 
and  most  commonly  presenting  on  the  outer  anterolateral  and  pos- 
terolateral  aspects  of  the  thighs  and  arms. 

Symptoms.— In  this  disease  conic,  sometimes  slightly  acuminate 
or  flattened,  papules,  the  size  of  a  pin-head,  and  of  a  whitish,  grayish, 
or  dark-gray  color,  and  consisting  of  epithelial  cells  and  sebaceous  mat- 
ter, are  situated  at  the  outlets  of  the  hair-follicles,  from  which  they  pro- 
ject.    Not  infrequently   the  lesions  are  somewhat   larger,   and  quite 
elevated;  exceptionally  the  color  is  blackish.      They  are  discrete,  nu- 
merous, do  not  form  patches  or  distinct  aggregations,  but,  although  closely 
set,  are  more  or  less  evenly  distributed  over  the  affected  regions, 
are  usually  located  on  the  extensor  and  outer  surfaces  of  the  thighs  anc 
arms,  and'sometimes  also  on  the  trunk,  and  in  rare  instances  show  a  mort 
or  less  general  distribution.     On  close  inspection  the  papules  are  seen 
be  pierced  by  a  hair,  which  is  either  lanugo-like  in  character  o 
off  at  the  apex  of  the  papule,  when  it  is  seen  as  a  dark  point  in  tl 
of  the  lesion,  or  is  coiled  within  the  papule.     They  are  somewhat  1 
harsh,  and  dry,  and  the  apex  slightly  scaly,  and  to  the  hand  passed  over 
the  part  feel  like  the  surface  of  a  nutmeg-grater.     If  the  accumulate 
falls  out  or  is  rubbed  or  picked  out,  a  small  depression  marks 

i  See  prelimininary  chapter  on  Treatment  for  references  to  trichloracel 


53  g  a  yPER  TR  OPHIES 

temporarily,  occupying  the  opening  of  the  hair-follicle.  Sometimes 
the  enveloping  basal  follicular  outlet  is  somewhat  reddened  and  elevated, 
and  the  papule  then  noted  to  be  of  a  slightly  inflammatory  character. 

The  intervening  skin  between  the  papules  is  generally  dry  and 
harsh  to  the  touch,  sometimes  with  a  trifling  furfuraceous  scaliness. 
On  the  neighboring  regions  it  may,  and  usually  does,  present  a  per- 
fectly healthy  appearance,  although  not  infrequently  the  skin  over  most 
of  the  surface  is  also  found  harsh  and  dry,  and  suggestive  of  a  mild 
ichthyosis,  which  malady,  in  fact,  occasionally  may  be  associated.  In 
rare  instances  in  a  few  of  the  lesions  there  may  be  an  accidental  pus- 
tular capping.  There  are,  indeed,  considerable  variations  in  extent 
and  development.  In  its  milder  forms  it  is  not  uncommon,  and  often 
it  is  so  slight  as  almost  to  escape  notice.  In  the  latter  instances  it  bears 
rough  resemblance  to  goose-flesh.  Quite  often  it  is  limited  to  the  thighs 
alone.  In  other  cases  the  lesions  are  very  pronounced  and  may  be 
distributed  over  a  considerable  part  of  the  surface.  It  is  rare,  however, 
to  find  the  eruption  on  the  flexor  aspects.  Its  development  is  insidious 
and  slow,  and  occurs  during  the  cool  or  cold  season;  warm  weather  gives 
rise  to  free  action  of  the  sweat-  and  sebaceous  glands,  the  skin  is  kept 
soft,  supple,  and  moist,  and  the  dryness  and  epidermic  papules  cannot 
readily  be  produced.  Subjective  symptoms  are  usually  absent,  although 
occasionally  moderate  or  even  considerable  itching  is  complained  of. 

"Etiology  and  Pathology. — The  affection  is  more  common 
during  early  adult  life,  although  it  may  be  met  with  at  any  age,  except- 
ing possibly  earliest  infancy.  It  is  most  frequently  observed,  moreover, 
during  the  winter  months,  and  usually  in  those  who  have  naturally 
rather  dry  skin  and  who  are  unaccustomed  to  frequent  bathing.  In 
some  individuals,  however,  there  is  a  greater  tendency  to  development 
exhibited,  and  sometimes  in  spite  of  moderately  frequent  washing,  so 
that  there  is  probably  another  etiologic  element — doubtless  a  hereditary 
predisposition  to  a  dry  skin.  It  has  been  considered  by  some  observers 
to  occur  much  more  frequently  in  those  of  a  cachectic  or  scrofulous 
tendency,  but  apparently  it  is  just  as  common  in  those  of  vigorous  and 
robust  nature.  Those  who  naturally  have  somewhat  active  perspira- 
tory secretion  are  rarely  affected.  Its  greatest  development  is  observed 
in  ichthyosis,  of  which  disease  it  is  a  pathologic  part. 

Anatomically  the  malady  essentially  consists  of  a  hyperkeratinization 
of  the  upper  part  of  the  pilosebaceous  follicular  outlet,  and  the  papular 
elevation  results  from  the  formation  of  this  superabundant  or  accumu- 
lated epidermic  horny  mass,  which  projects  beyond  the  orifice.  To 
this,  in  some  instances,  slight  basal  congestion  is  added  secondarily,  and 
probably  purely  as  the  result  of  the  irritation  produced  by  this  collection 
or  possibly  for  some  unknown  pathologic  reason;  and  in  occasional  cases, 
instead  of  such  trifling  basal  congestion,  there  is  distinct,  though  usually 
extremely  slight,  inflammatory  infiltration.  In  extreme  instances  of 
these  latter  types  there  is  some  suggestion  of  the  same  pathologic  process 
as  in  pityriasis  rubra  pilaris,  and  it  is  not  impossible  that  some  of  the 
cases  of  keratosis  pilaris  occasionally  referred  to  as  of  peculiar  distribu- 
tion and  of  excessive  horny  development,  and  otherwise  anomalous, 


KERATOSIS  PILARIS  539 

are  on  the  border-line  between  these  two  maladies.  It  is  probably  in 
such  instances  only  that  the  superficial  perifollicular  cell-infiltration  is 
found  (Crocker,  Unna,  GioVannini,  and  others).  The  congestive  and 
inflammatory  elements,  when  present,  give  the  lesions  a  somewhat 
different  aspect,  and  doubtless,  chiefly  based  upon  these  factors,  Brocq1 
divides  the  cases  into  several  forms— keratosis  pilaris  alba,  keratosis 
pilaris  rubra,  and  two  intermediate  divisions.  In  the  extreme  cases 
of  the  latter — the  inflammatory  type — slight  atrophy  or  scarring  may 
exceptionally  result.  Mibelli,  Unna,  and  a  few  others  do  not  consider 
the  lesion  of  this  malady  and  the  apparently  similar  one  of  ichthyosis  as 
pathologically  identical.  According  to  Giovannini,2  Mibelli,3  and 
Lemoine,4  there  are  also,  at  least  in  some  cases,  atrophic  changes  in  the 
sebaceous  glands,  which  may,  in  fact,  entirely  disappear;  the  first  named, 
moreover,  found  atrophy  of  the  hair-papilla. 

Diagnosis. — The  character  of  the  eruption,  its  persistently  dis- 
crete lesions,  with  no  attempt  at  grouping  or  to  the  formation  of  coal- 
escent  solid  patches,  and  its  common  localization  will  serve  to  prevent 
error.  It  is  to  be  distinguished  chiefly  from  goose-flesh  (cuds  anserina), 
the  miliary-papular  syphiloderm,  and  lichen  scrofulosus.  In  goose-flesh 
the  elevations,  due  to  sudden  chilling  or  excitement,  are  evanescent, 
not  rough,  harsh,  and  scaly,  and  subside  rapidly  as  suddenly  as  they  came 
upon  the  surface  being  warmed,  being  rarely  present  more  than  a  few 
minutes.  The  dull  ham,  brownish-red  colored  papules  in  the  miliary- 
papular  syphilid  have  a  more  general  distribution,  are  distinctly  in- 
filtrated, and  therefore  firmer  to  the  touch,  and  tend  to  aggregation  and 
groups;  the  slight  scaliness  is  a  late  phase.  There  will  be  found  also 
other  symptoms  of  syphilis.  In  lichen  scrofulosus — a  rare  disease — 
the  eruption  is  usually  limited,  and  occurs  in  distinct,  more  or  less  rounded 
groups  or  patches,  and  most  commonly  upon  the  trunk,  especially  the 
abdomen,  the  extensor  aspects  of  the  extremities  rarely  being  involved; 
the  lesions  are  firmer  and  less  scaly.  In  pityriasis  rubra  pilaris  the  scaly 
condition  of  the  scalp  and  the  horny  thickening  of  the  palms,  as  well  as 
the  plaque  and  confluent  tendency  and  distribution,  are  totally  different 
from  the  eruption  of  keratosis  pilaris.  It  can  scarcely  be  confused  with 
eczema  or  lichen  planus,  both  itchy  inflammatory  diseases  of  different 
character,  behavior,  and  distribution. 

Treatment. — The  common  clinical  type  yields  readily,  the  con- 
dition often  being  removed  in  the  course  of  a  few  weeks,  and  wholly 
as  the  result  of  external  treatment.  In  some  rare  instances,  more  espe- 
cially, however,  the  inflammatory  type,  the  end  is  not  so  soon  reached. 
In  such  cases,  particularly  in  ill-nourished  individuals,  cod-liver  oil, 
arsenic,  and  iron  are  sometimes  to  be  advised.  Rarely,  however,  are 
more  than  external  measures  required,  and  these  consist  ordinarily  of 

1  Brocq,  "Notes  pour  servir  a  1'histoire  de  la  kdratose  pilaire,"  Annalex,  1890,  pp. 
25,  97,  and  222  (a  complete  exposition  and  review  of  the  subject  with  many  references}. 

2  Giovannini,  "Contributione  allo  studio  istologico  della  cheratosi  pilare,    Lo  Sper, 
mentale,  18915,  p.  661— abstract  in  Brit.  Jour.  Derm.,  1896,  p.  151. 

3  Mibelli,  "Zur  Aetologie  und  die  Varietataten  der  Keratosen,    Monalshefte,  1897, 
vol.  xxiv,  pp.' 345  and  415  (with  numerous  references). 

4  Lemoine,  "De  1'ichthyose  anserine  des  scrofuleux,"  Annales,  1882,  p.  275. 


540 


H  YPER  TR  OPHIES 


frequent  local  or  general  baths,  plain  warm  baths,  with  the  use  of  an 
ordinary  toilet  soap  or  sapo  viridis.  In  other  cases  the  baths  should 
be  alkaline,  using  for  this  purpose  from  i  to  6  ounces  (32.-IQ2.)  of  sodium 
carbonate,  sodium  borate,  or  sodium  bicarbonate  to  about  30  gallons 
(120.  1.)  of  water;  in  others,  in  addition  to  the  baths,  supplementary 
applications  of  a  mild  salicylated  ointment,  from  10  to  30  grains  (0.65-2.) 
to  the  ounce  (32.)  of  petrolatum  or  lard  and  lanolin,  will  be  found  nec- 
essary. In  fact,  the  management  is  practically  the  same  as  employed 
in  the  milder  cases  of  ichthyosis.  In  some  individuals,  however,  fre- 
quent bathing  must  be  subsequently  followed  to  prevent  its  recurrence. 

I/ichen  Spinulosus. — Crocker  describes1  (under  the  name 
lichen  pilaris  seu  spinulosus)  another  somewhat  similar  malady  in  some 
of  its  aspects,  but  which  is  slightly  inflammatory,  often  patchy,  and 
occurs  on  almost  any  region.  I  draw  largely  from  his  description. 
It  may  develop  acutely  or  subacutely  in  crops,  and  consists  of  papules 
about  the  size  of  a  pin-head,  red,  conic,  and  containing  in  its  center  a 
horny  spine  projecting  about  TV  of  an  inch;  this  epidermic  plug  can  be 
picked  out,  leaving  a  depression  in  the  papule.  After  some  duration 
the  papule  loses  its  redness  and  becomes  the  color  of  the  normal  skin. 
The  papules  are  densely  crowded  into  patches,  often  large  and  irregular 
in  outline,  symmetrically  distributed,  sometimes  in  a  few,  sometimes 
in  many,  regions.  The  favorite  sites  are  the  back  of  the  neck,  the  but- 
tocks, over  the  trochanters,  the  abdomen,  the  back  of  the  thighs,  the 
popliteal  spaces,  and  the  extensor  surfaces  of  the  arms.  The  hands,  feet, 
face,  and  upper  part  of  the  chest  are,  according  to  Crocker's  observations, 
not  attacked.  There  is  a  tendency,  in  cases  in  which  the  eruption  is 
not  dense,  to  form  roundish  groups,  with  some  scattered  papules  between. 
The  eruption  comes  out  in  crops,  sometimes  a  patch  appearing  over  night, 
gradually  increasing  in  extent  for  a  week;  after  this  the  lesions  grow 
paler,  but  beyond  this  the  eruption  usually  persists  without  change 
more  or  less  indefinitely.  The  cause  is  unknown.  It  occurs  chiefly 
in  children,  and  in  Crocker's  experience  more  frequently  in  boys.  In  a 
few  instances  it  was  associated  with  lichen  planus  and  with  lichen  scrofu- 
losus.  It  bears  resemblance  to  keratosis  pilaris  and  to  pityriasis  rubra 
pilaris.  Alkaline  baths  with  friction,  and  in  the  inflammatory  stage 

1  Crocker,  Diseases  of  the  Skin,  third  edit.,  p.  452;  Adamson,  "Lichen  Pilaris,  seu 
Spinulosus,"  Brit.  Jour.  Derm.,  Feb.  and  March,  1905  (with  case  illustration  and  histo- 
logic  cuts),  has  recently  given  a  full  account  and  review  of  the  disease  and  the  literature. 
As  examples  of  lichen  spinulosus  to  be  found  in  French  literature,  he  quotes  the  follow- 
ing: (i)  possibly  the  acne  cornee  of  Hardy;  (2)  certainly  the  acne  cornee  of  Guibout 
and  of  Leloir  and  Vidal;  (3)  the  case  of  acne  cornee  en  aires  of  Hallopeau,  possibly 
his  3  cases  of  acne  cornee  in  adults;  (4)  Barbe's  cases  of  keratose  folliculaire  (type  de 
Brooke);  (5)  Audry's  cases  of  keratose  pilaire  engainante:  and  in  Italy  (6)  Giovannini's 
case  of  acne  cornea.  Histologically  the  lesions  show  that  the  pathologic  process  is  essen- 
tially a  hyperkeratosis  of  the  follicle;  perifollicular  inflammation  is  absent  or,  at  any  rate, 
very  little  marked.  Lewandowsky,  Archiv,  1905,  vol.  Ixxiii,  p.  343  (with  histologic 
cuts),  who  describes  a  German  case,  believes  it  an  inflammation  of  the  follicle  with  a 
secondary  parakeratosis;  Bowen,  Jour.  Cutan.  Dis.,  1906,  p.  416  (report  of  a  case; 
youth  aged  nineteen).  I  have  seen  2  cases  in  the  past  two  years;  before  that  date  the 
condition  had  never  been  under  my  observation;  Beck,  "Ueber  keratosis  spinulosa" 
(Lichen  spinulosus,  Crocker),  Dcrmatolog.  Wochenschr.,  Nov.  30,  1912,  Iv,  p.  1459, 
clinical  and  histolog.,  with  review  and  bibliography. 


KERATOSIS  FOLL1CULARIS  54! 

supplemented  by  a  mild  grease  or  oil;  or,  if  sluggish,  with  weak  tincture 
of  green  soap,  containing  a  dram  (4.)  of  oil  of  cade  to  the  ounce  (32.), 
prove  successful.  The  constitutional  treatment  is  according  to  indica- 
tions: cod-liver  oil,  iron,  and  other  tonic  measures  are  most  frequently 
called  for. 

KERATOSIS  FOLLICULARIS 

Synonyms.— Ichthyosis  follicularis;  Darier's  disease;  Psorospermosis;  Psorosper- 
mose  folliculaire  vegetante;  Acne  sebacee  cornee;  Ichthyosis  sebacea  cornea  (E.  Wilson). 

This  rare  disease  was  first  reported  by  Morrow1  in  1886,  and  a  few 
years  later  (1889)  was  described  and  thoroughly  investigated  almost  sim- 
ultaneously by  Darier2  and  Thibault  in  France,  and  by  J.  C.  White3  in 
our  own  country.  Since  then  Boeck,  Lustgarten,  De  Amicis,  Bowen,4 
Lieberthal,  Mook,  Trimble,  Omerod  and  Macleod,  and  others  have 
reported  cases. 

The  disease  has  been  frequently  noted  to  appear  first  upon  the  head 
and  face.  In  the  beginning  the  lesions  do  not  vary  much  in  color  from 

1  Morrow,  Jour.  Cutan.  Dis.,  1886,  p.  257. 

2  Darier  and  Thibault  (2  cases),  These  de  Paris,  1889;  Annales,  July,  1889. 

3  J.  C.  White,  Jour.  Cutan.  Dis.,  1889,  p.  201  (i  case),  and  1890,  p.  13  (i  case),  with, 
in  each  case,  a  histologic  examination  by  Bowen.     Morrow's  case,  published  under  this 
name  (Jour.  Cutan.  Dis.,  1886,  p.  257),  seems  histologically  different  from  those  now 
accepted  as  representing  this  malady,  and  more  accords  with  the  conditions  found  in 
keratosis  follicularis  contagiosa  (Brooke). 

4  Bowen,  Jour.  Cutan.  Dis.,  1896,  p.  209,  reports  a  case  and  gives  a  review  of  the 
subject;  literature  references  are  made  to  the  other  published  cases  by  Boeck  (5),  Buzzi 
and  Miethke,  Bulkley  and  Lustgarten,  Schwimmer,  De  Amicis,  Schweninger  and  Buzzi, 
Pawloff  (2),  Fabry,  Mourek,  and  Jarisch.     It  is  upon  this  paper  and  that  by  White 
that  the  account  of  the  disease  here  given  is  largely  based. 

Since  this  date  additional  cases  have  been  recorded  by  Hallopeau,  Annales,  1896,  p. 
737,  and  pathologic  anatomy  of  the  same  by  Darier,  ibid.,  p.  742;  Savill  (case  demon- 
stration), Brit.  Jour.  Derm.,  1896,  p.  229;  Bowen  (limited  to  head  and  hands),  Annales, 
1898,  p.  6;  Graham  Little  (case  demonstration),  Brit.  Jour.  Derm.,  1901,  p.  51  and 
(histologic  report)  p.  98;  Ehrmann,  abstract  in  Brit.  Jour.  Derm.,  1902,  p.  41;  Ormerod 
and  Macleod,  ibid.,  1904,  p.  32  (with  histologic  cuts,  review,  and  complete  bibliography) ; 
Lieberthal,  Jour.  Amer.  Med.  Assoc.,  July  22, 1904  (good  effects  from  *-ray  treatment) ; 
Audrey  and  Dalous,  Jour.  Mai.  Cutan.,  1904,  vol.  xvi,  p.  8oi_(a  woman  aged  forty-four, 
and  of  twelve  years'  duration;  urine  examination  showed  a  diminution  of  sulphur) ;  Se- 
queira,  Brit.  Jour.  Derm.,  1905,  p.  266  (case  demonstration — woman  aged  forty-six,  of 
eight  years'  duration);  Malinowski,  Monatshefle,  1906,  vol.  xliii,  p.  209  (girl  aged  seven- 
teen, began  in  first  year;  review  with  bibliography,  and  4  histologic  illustrations); 
Mook,  St.  Louis  Courier  of  Med.,  March,  1906  (good  effects  from  *-ray  treatment); 
Jamieson,  Edinburgh  Med.'  Jour.,  Jan.  1907,  p.  32  (woman  aged  thirty-two,  three  and 
one-half  years'  duration,  beginning  simultaneously  in  the  left  leg  and  in  the  sulcus 
behind  ears;  case  and  histologic  illustrations);  Constantin  and  Levrat,  Annales,  1907, 
P-  337  (case,  male,  aged  twenty-four,  existed  since  early  childhood;  mother  (Audry 
and  Dalous  case)  had  same  disease);  Herxheimer,  Dermatolog.  Zeitschr.,  1908,  vol.  xv, 
p.  45  (3  cases;  curative  effects  of  thermocauterization) ;  Grover  W.  Wende,  Jour.  Cutan. 
Dis.,  1908,  p.  512  (case,  male,  aged  thirty-seven,  beginning  twenty  years  previously, 
and  resulting  in  multiple  epithelioma;  with  case  and  histologic  illustrations,  review, 
and  references);  Pohlmann,  Archiv.  Ed.,  1909,  xcvii,  i,  2, and  3  (5  cases  in  3  genera- 
tions—father, 3  children  and  grandchild);  Daisy  Orleman  Robinson,  Jour.  Cutan. 
Dis.,  1911,  p.  349  (case  demonstration),  records  a  case  which  presented  the  combined 
features  of  a  seborrheal  eczema  and  lesions  resembling  those  of  verruca  vulgans; 
Trimble,  "Observations  on  Keratosis  Follicularis,"  Jour.  Amer.  Med.  Assoc.,  Aug. 
24,  1912,  p.  604  (with  case  and  histologic  illustrations);  5  cases  in  one  family,  3  gener- 
ations—mother, three  children,  and  a  grandchild;  Ritter,  Dermatolog.  Wochenschr., 
Feb.  10,  1912,  liv,  p.  165,  case  cured  by  ac-ray  treatment;  Mook,  Jour.  Cutan.  Vis., 
1912,  p.  723,  4  cases,  all  males,  aged  18,  21,  24,  and  45;  one  patient  stated  his  brot 
had  same  disease,  another  that  his  sister  had  it;  all  improved  under  *-ray  treatment. 


542  HYPER  TR  OP  HIES 

that  of  the  normal  skin;  they  look  not  unlike  those  of  keratosis  pilaris, 
and  may  have,  especially  later,  when  more  pronounced  and  increased 
in  size,  the  appearance  of  greasy-looking  papules,  or  dry,  firm,  brownish 
papular  elevations,  semiglobular  in  shape,  and  varying  in  size  from  a 
small  to  a  large  pin-head.  They  are  at  first  discrete,  and  sparsely  or 
thickly  set.  When  closely  examined,  most  of  the  lesions — those  of  any 
size — are  observed  to  contain  in  the  center  a  hardened  or  fatty-looking 
mass  or  plug.  The  disease  extends  slowly,  and  gradually  invades  other 
parts;  finally,  usually  after  several  years  or  longer,  it  becomes  more  or 
less  generalized,  being,  as  a  rule,  most  abundant  and  showing  greatest 
development  about  the  face,  scalp,  the  chest  anteriorly,  the  loins,  geni- 
tocrural  regions,  and  the  extremities;  with  frequently  keratosis  of  the 
soles,  and  less  frequently  the  palms  also.  Bowen  has  recently  reported 
a  case,  however,  in  which  it  was  limited  to  the  head  and  hands.  On  the 
scalp  there  is  usually  a  thick,  seborrheic-looking  coating,  but  no  special 
hair  loss.  When  at  all  developed  or  advanced,  the  lesions  are  noted  to 
have  grown  larger,  and  in  some  places  may  become  confluent,  and  present 
an  irregular,  papillomatous,  or  nutmeg -grater-like  surface,  with  sometimes 
a  fissured  appearance  or  even  distinct  fissuring.  They  are  noted  to  be 
of  various  sizes,  some  of  them  bearing  resemblance  to  keratosis  pilaris, 
some  larger  and  containing  the  firm  or  fatty  central  concretion,  and  others 
— a  smaller  number — rounded  or  flattened,  dull  red  to  dark  brown  in 
color,  and  exhibiting  no  central  opening,  bearing  a  slight  resemblance 
to  lichen  planus  papules.  Others,  again,  especially  in  the  advanced 
stage,  are  quite  hard  and  horn-like,  of  dark-gray  or  dark-brown  color, 
hemispheric  or  conic,  and  projecting  well  above  the  surface.  In  places 
if  the  disease  is  at  all  extensive,  elevated  areas  are  formed  by  confluence 
of  the  lesions,  presenting  uneven  surfaces,  covered  by  thick,  yellowish 
or  brownish,  flattened,  horny  concretions.  Less  frequently  are  noted 
elongated  horny  masses,  from  \  to  \  of  an  inch  in  diameter,  and  from  \  to 
\  of  an  inch  in  height,  of  irregular  outline,  with  blunt,  truncated  apices, 
yellowish  in  color,  of  dense  consistence,  and  compactly  crowded.  They 
can  be  removed  with  difficulty,  and  then  show  bases  of  corresponding 
area,  considerably  elevated  above  the  general  surface,  and  hyperemic 
and  moist.  On  some  of  these  areas  are  found  scattered  smaller  or  larger 
crateriform  openings,  distended  follicular  openings,  filled  with  firm  con- 
cretions; occasionally  some  of  these  underlying  openings  show  ulceration, 
and  the  whole  area  is  the  seat  of  a  mucopurulent  discharge.  In  one  case 
reported  (G.  W.  Wende)  the  larger  lesions  developed  into  epithelioma. 
Close  inspection  shows  that  the  greater  part  of  the  lesions  are  grouped 
about  the  follicular  orifices — in  other  words,  that  the  disease  is  essen- 
tially a  follicular  one,  at  least  in  its  beginning;  in  some  places,  however, 
where  the  lesions  are  confluent  and  form  the  papillomatous,  irregular, 
elevated  areas,  it  can  be  seen  that  the  process  has  invaded  the  inter- 
follicular  structures  also.  The  subjective  symptoms  are  variable — 
sometimes  intense  itching;  in  other  cases,  no  troublesome  features. 
The  general  health  remains  comparatively  undisturbed.  A  rather  weak 
mental  condition  has  been  noted  in  some  cases.  The  skin  is  usually 
noted  to  be  of  an  offensive  odor — more  particularly  in  extensive  cases, 


KERATOSIS  FOLLICULARIS 


543 


and  in  those  in  which  excoriations  have  been  produced  by  scratching; 
the  odor  is  more  or  less  characteristic  of  decomposing  epithelium  (White) 
or  sebaceous  matter. 

Etiology.— The  age  at  which  the  affection  begins  seems  to  vary 
somewhat;  in  the  larger  number  of  cases,  however,  it  occurred  before 
the  sixteenth  year,  and  in  several  instances  in  infancy.  Of  24  patients, 
15  were  males  and  9  females.  The  question  of  heredity  and  contagious- 
ness has  been  considered;  Boeck  had  3  cases  in  one  family,  White's 
patients  were  father  and  daughter,  Ehrmann  had  a  patient  whose  father 
had  the  same  malady;  Trimble  had  5  cases  in  a  family  in  three  genera- 
tions (mother,  3  children  and  i  grandchild),  and  Pohlmann  had  also  5 


Fig.  127. — Keratosis  follicularis.     (The  three  cuts  of  this  disease  are  of  the  same  case). 

cases  in  a  family,  three  generations  (father,  i  son,  2  daughters,  and  i 
grandson) ;  with  these  exceptions,  however,  no  other  support  for  either 
of  these  possibilities  is  available.  Darier  believed  he  had  discovered 
the  cause  in  peculiar,  coccidia-like  bodies  in  the  lesions,  and  hence  sug- 
gested the  name  psorospermosis.  This  view  obtained  some  credence 
and  was  seemingly  supported  by  Wickham's  investigations.  Both 
observers  thought  them  of  etiologic  significance  not  only  in  this  disease, 
but  also  in  molluscum  contagiosum,  Paget's  disease,  etc.  In  later 
studies,  however,  by  Bowen,  Buzzi,  Miethke,  Piffard,  Boeck,  and  Darier 
himself  these  bodies  were  demonstrated  to  be  due  to  cell  transformation, 
and  not  psorosperms,  as  originally  believed. 


544 


H  YPER  TR  OPHIES 


Pathology.— Darier's  psorosperm  theory  of  the  origin  of  the 
disease  having  been  abandoned,  the  view  adyanced  by  White  and  Bowen, 
and  corroborated  since  by  others,  that  the  affection  is  evidently  in  all 
its  phases  a  keratosis  or  modified  cornification  of  the  epithelial  layers 
having  its  seat  in  the  mouths  of  the  pilosebaceous  ducts,  has  been  gen- 
erally accepted.  Bowen,  who  has  had  the  opportunity  of  studying  both 
of  White's  cases,  2  of  his  own,  and  also  sections  from  Lustgarten's  case, 
confirms  Darier's  conclusion  as  to  the  follicular  character  of  the  malady, 
although  admitting  that  the  process  is  not  confined  wholly  to  them, 
but  is  found  also  in  their  neighborhood.  Boeck,  on  the  contrary,  can- 
not agree,  from  his  investigations,  that  the  lesions  are  in  great  part 
confined  to  the  follicles.  Ormerod  and  Macleod,  from  a  study  of  their 
case  and  a  review  of  the  subject,  conclude,  that  "it  is  a  type  of  dyskera- 
tosis  associated  with  a  peculiar  cellular  degeneration,  which  may  affect 


Fig.  128. — Keratosis  follicularis. 

any  portion  of  the  epidermis,  and  is  frequently  located  at  the  upper  third 
of  the  pilosebaceous  follicle  or  the  opening  of  the  sweat  ducts."  The 
very  smallest  lesions  are  histologically  scarcely  distinguishable  from  the 
papules  of  keratosis  pilaris,  although  there  are  even  then  traces  of  the 
perverted  process  of  cornification  which  characterizes  the  disease.  The 
"corps  ronds"  and  the  "grains"  described  by  Darier  are  interesting  fea- 
tures. The  former,  which  were  thought  to  be  psorosperms,  as  already 
remarked  under  etiology,  are  now  known  to  be  transformed  cells;  they  are 
found  especially  in  the  deeper  and  middle  rete  layers,  and  at  the  base 
of  the  horny  or  greasy  mass,  and  probably  are,  as  Bowen  states,  epidermal 
cells  that  are  enlarged  and  swollen,  and  made  up  of  a  nucleus,  with 
usually  a  clear  or  hyaline  protoplasm  around  it.  The  "grains"  are 
probably  cells  from  the  bottom  of  the  dilated,  funnel-shaped  openings 
below  the  follicle  plugs,  which  have  become  cornified  without  passing 
through  the  keratohyalin  stage.  They  are  rounded,  and  somewhat 


PLATE  XIX. 


Keratosis  follicularis  in  a  male  adult  aged  forty  ;  of  many  years'  duration.     Some 
improvement  under  jr-ray  treatment. 


KERATOSIS  FOLLICULARIS  545 

polygonal,  shrunken  bodies,  homogeneous,  and  with  feebly  differentiated 
nucleus. 

As  to  be  inferred,  the  anatomic  changes  in  the  disease  are  essentially 
epidermic— a  parakeratosis  as  well  as  a  hyperkeratosis.  In  addition 
to  the  evidences  of  keratosis  there  is  at  the  periphery  of  the  lesions  a 
marked  increase  in  the  pigment  in  the  normal  rete  cells.  The  corium 
presents  but  few  changes  of  any  significance — some  enlargement  of  the 
papillae  at  the  sides  of  the  lesions,  and  a  moderate  round-celled  infiltration 
about  the  vessels. 

Diagnosis. — In  advanced  stages  the  disease  can  scarcely  be  con- 
founded with  other  dermatoses.  In  the  earliest  beginning  the  malady 
bears  resemblance  to  keratosis  pilaris,  but  its  presence  on  unusual 
locations  for  this  latter  affection  is  a  point  of  difference.  Some  of  the 
lesions,  especially  those  on  the  trunk,  may  also,  early  in  the  disease, 
suggest  lichen  planus,  but  an  inspection  of  the  eruption,  as  a  whole, 
would  prevent  error.  At  certain  stages  or  in  certain  lesions  the  soft 
central  plug  will  call  to  mind  molluscum  contagiosum;  but  this  latter 
never  has  so  wide  a  distribution,  and  its  pearly-looking  characters  and 
the  contained  mass  with  the  so-called  "molluscum  bodies"  are  points 
of  difference.  Moreover,  the  opening  of  molluscum  contagiosum 
lesions  is  small,  that  of  keratosis  follicularis  is,  when  emptied,  crateri- 
form.  It  can  scarcely  be  mistaken  for  pityriasis  rubra  pilaris  or  for 
ordinary  cases  of  ichthyosis. 

Prognosis  and  Treatment — The  disease  is  persistent,  and 
usually  slowly  progressive,  with  periods  of  greater  or  less  activity. 
The  general  health  does  not  seem  to  be  compromised,  although  toward 
advanced  life  one  would  expect  to  find  beginning  degenerative  epithelial 
changes;  in  G.  W.  Wende's  exceptional  case  epitheliomatous  develop- 
ment seemed  to  be  a  consecutive  part  of  the  disease  process.  No  cure 
has  been  reported,  but  much  can  be  done  by  treatment  to  render  the 
disease  less  disgusting  and  disfiguring,  and  possibly  to  somewhat  restrain 
its  course.  Frequent  alkaline  baths,  as  given  in  psoriasis,  and  the  em- 
ployment of  stimulating  and  keratolytic  applications,  such  as  salicylic 
acid,  resorcin,  and  sulphur  ointments,  are  of  decided  benefit.  Pyrogallol 
can  also  be  used  in  ointment  form,  but  only  to  limited  areas  at  a  time. 
Lieberthal's,  Mook's,  and  G.  W.  Wende's  cases  showed  improvement 
from  #-ray  treatment,  and  in  a  case  now  under  my  own  care  there  has 
been  also  considerable  change  for  the  better;  Ritter  claims  to  have 
cured  one  case.  Herxheimer  has  had  marked  success  with  thermo- 
cauterization;  he  has  employed  both  the  Paquelin  cautery  and  the 
galvanocautery. 

Keratosis  Follicularis  Contagiosa.— Under  this  name  Brooke1  de- 
scribed a  rare  affection,  apparently  of  contagious  nature,  occurring  in 
children,  and  sporadically  in  adults,  and  characterized  by  an  abnormal 
cornification.  The  first  change  in  the  affected  parts  consists  of  a  slight, 
but  visible,  thickening  of  the  horny  layer,  with  an  accentuation  of  the 
cutaneous  furrows,  and  a  yellowish  to  yellowish-black  discoloration. 
Upon  these  areas  are  gradually  noted  several  or  more  black  points,  later 

1  Brooke,  International  Atlas,  1892,  part  vii,  plate  xxii. 
35 


546  HYPERTROPHIES 

resembling  comedo  plugs,  seated  at  the  follicular  outlets,  and  of  which 
one  or  more  develop  into  papular  elevations  from  which  project  horny, 
straight  or  bent,  spike-like  formations  of  variable  length.  The  regions 
usually  invaded  are  the  neck,  trunk,  extensor  aspects  of  the  extremities, 
and,  less  commonly,  the  face  and  flexor  surfaces.  The  hyperkeratosis, 
according  to  Brooke  and  Unna,  is  not  limited  to  the  follicles  alone,  but 
extends  superficially  in  their  neighborhood  and  also  slightly  into  the 
sweat-pores.  Unna  states  that  two  main  groups  of  changes  are  to  be 
noted:  (i)  simple  appearances  of  retention  and  (2)  formation  of  horny 
plugs  at  the  seat  of  the  follicles.  It  is  a  dry,  non-fatty  affection.  The 
process  consists  essentially  of  a  hyperplasia  of  the  epithelial  cells.  It  is 
not  improbable,  as  Unna  suggests,  that  the  more  localized  forms  of  so- 
called  acne  sebacee  cornee  of  the  French  also  represent  this  malady. 
This  writer  would  include  Morrow's  case  of  keratosis  follicularis  in  the 
same  category,  the  histologic  examination  (Robinson)  giving  support 
to  this  opinion.  The  malady  responds  readily  to  simple  softening  and 
alkaline  applications. 

VERRUCA 

Synonyms. — Wart;  Fr.,  Verrue;  Ger.,  Warze. 

Definition. — Verruca,  or  wart,  is  a  small,  but  somewhat  vari- 
ously sized,  circumscribed  epidermal  and  papillary  growth,  which  may 
be  soft  or  hard,  and  rounded,  flat,  acuminated,  or  filiform. 

According  to  the  shape  and  predominance  of  one  of  the  several  char- 
acters it  is  convenient  to  divide  these  formations  into  several  clinical 
varieties:  verruca  vulgaris,  verruca  digitata,  verruca  plana,  verruca 
filiformis,  and  verruca  acuminata. 

Verruca  Vulgaris. — This  is  the  common  wart  so  frequently  seen, 
and  occurring  mostly  upon  the  hands.  It  is  somewhat  variable  as  to 
size,  averaging  that  of  a  pea,  and  having  a  broad  base.  It  is  generally 
hard  or  horny,  somewhat  rounded  or  slightly  flattened,  elevated,  and 
circumscribed.  It  is,  as  a  rule,  of  slow  and  gradual  growth,  and  at  first 
is  smooth  and  covered  with  slightly  thickened  epidermis,  but  later  the 
smoothness  usually  disappears  to  a  variable  extent,  and  the  surface 
becomes,  partly  in  consequence  of  the  hypertrophy  of  the  papillae,  but 
chiefly  of  the  rete  proliferation,  rough  and  irregular,  with  minute  ele- 
vations. Sometimes  the  projections  are  sufficiently  pronounced  as  to 
give  it  a  slightly  papillomatous  appearance,  and  to  give  some  cause 
for  the  name  "papilloma,"  which  has  occasionally  been  used.1  In  its 

'The  term  "papilloma"  was  formerly  used  with  a  somewhat  indefinite  meaning 
and  indiscriminate  application,  not  only  to  warts,  but  to  all  growths  with  projecting 
excrescences  or  vegetations,  which  were  then  erroneously  thought  to  be  exclusively  due 
to  papillary  hypertrophy,  and  hence  the  name.  Observation  has  shown  that  this  fea- 
ture is  only  an  accidental  or  occasional  development,  and,  moreover,  observed  in  various 
and  often  totally  diverse  diseases,  and  is,  therefore,  not  descriptive  of  any  special 
disease  entity.  For  these  reasons  it  is  no  longer  to  be  considered  a  scientific  term, 
and  has  been  practically  dropped,  and  given  place  to  the  employment  of  the  proper 
disease  title  in  each  instance,  with,  to  designate  this  particular  clinical  feature,  the 
addition  of  the  descriptive  adjective  papillomatous,  or  its  equivalent,  papillary,  vege- 
tating, verrucous,  etc. — as,  for  example,  the  papillomatous  or  vegetating  syphiloderm 
(syphiloderma  papillomatosa  seu  vegetans),  papillary  or  papillomatous  epithelioma, 
lupus  verrucosus,  etc. 


VERRUCA  547 

earliest  formation  the  color  may  be  that  of  the  normal  skin,  but  later 
it  is  grayish,  with  a  slight  or  decided  yellowish  or  brownish  tinge;  ex- 
ceptionally it  is  almost  black.  On  the  average  there  are  several  present, 
but  there  may  be  but  one,  or  they  may  be  present  in  numbers.  Not 
uncommonly  one  lesion  appears — the  co-called  "mother  wart"  (the 
verrue  mere  of  Vidal),1 — attains  full  growth,  and  several  others  or  more 
gradually  present,  and  usually  close  to  the  first  or  not  far  distant.  Some- 
times several  are  in  such  proximity  that  coalescence  ensues,  and  a  wart 
of  relatively  considerable  size  results.  There  are  no  subjective  symptoms 
— no  itching,2  but,  as  with  any  other  growths  if  irritated,  they  may  be- 
come slightly  painful  when  knocked. 

While  the  fingers  and  hands  are  the  usual  sites  of  these  lesions, 
they  are  also  occasionally  found  upon  other  parts,  and  Dubreuilh3  and 
other  writers4  have  called  attention  to  the  fact  that  they  are  sometimes 
observed  on  the  feet,  especially  the  soles  (verruca  plantaris,  papilloma 


Fig.  129— Plantar  wart  covered  by  cal-  Fig.  130— Plantar  wart  (same  case) 
lous.  in  a  very  frequent  location  (cour-  after  removal  of  the  callous  (courtesy 
tesy  of  Dr.  Richard  L.  Sutton).  of  Dr.  Richard  L.  Sutton). 

of  the  sole),  where  at  times,  from  friction  and  pressure,  the  covering  and 
surrounding  horny  layer  are  much  thickened,  smooth,  and  hard,  forming 
a  "wart-containing  callosity,"  so  that  they  are  usually  mistaken  for 
corns;  upon  shaving  off  the  surface  the  wart-like  character  is  disclosed, 

1  Vidal  "Verrue  m6re— verrues  filles,"  cited  by  Gimy,  Annales,  1889,  p.  94. 

*  Corlett,  Jour.  Cutan.  Dis.,  1896,  p.  301  (with  illustration) ,  reports  a  case  of  some 
what  doubtful  nature  in  which  numerous  lesions  of  a  warty  character  were ;on ^the  egs 
and  in  which  there  was  a  good  deal  of  itching;  probably  a  case  of  prungo  noc 

(9'  3  Dubreuilh,  «De  la  verrue  plantaire,"  Annales,  1895,  p.  44U  also  review  of  this 
paper  by  Bowen,  Boston  Med.  and  Surg.  Jour  1896  vol.  cxxxv,  p.  262 

4Fddowes    "Warts  on  the  Feet,"  Brit.  Jour.  Derm.,  1896,  p.  195,  also          ns, 
True  SSSSS***.  ^d.  Jour'.,  Dec.  «,  ,895;  D.  W.  **£ 
Med  Assoc    Tulv  11    iQor,  Berry,  Jour.  Cutan.  Dts.,  1904,  P-  22 
JM  £K#fc£  W  vol,  cfcii,  p.  781  (24  cases;  f^ 
p.  937;  Sutton,  Jour.  Cutan.  Dis.,  1909,  P-  iSS!  and   Amer.  Jour. 
1912,  p.  71  (with  case  illustrations). 


548  HYPERTROPHIES 

and  in  such  operation  bleeding  is  very  readily  produced.  This  plantar 
wart  is  not  an  infrequent  one  in  my  experience,  and  is  usually  painful 
and  troublesome.1  The  scalp  may  also  be  the  seat  of  the  common  wart, 
although  in  this  region  the  digitate  variety  is  the  usual  one.  Excep- 
tionally the  growths  are  found  on  the  vermilion  of  the  lips — on  both  lips 
in  a  case  observed  by  Elliot.2  In  Gemy's3  case  not  only  were  the  lesions 
present  in  great  numbers,  but  the  legs  were  the  principal  seat. 

Verruca  plana,  or  the  flat  wart,  is  a  name  more  especially  used  for 
those  pea-  to  finger-nail-sized  growths,  usually  but  slightly  or  moder- 
ately elevated,  and  observed  most  commonly  on  the  back  and  face  of 
middle-aged  and  elderly  people,  although  they  may  also  occasionally 
be  seen  in  this  form  in  younger  individuals.  In  older  people,  however, 
they  are  usually  of  a  darker  color,  and  not  infrequently  after  a  time  be- 


Fig.i3i. — Verruca  of  the  juvenile  flat  variety  in  a  young  adult;  was  also  on  face  and 
forehead.  There  were  some  lesions,  however,  showing  a  tendency  to  develop  into  the 
verruca  vulgaris  type. 

come  slightly  papillomatous  and  covered  with  a  rough,  dark,  often  black- 
ish, somewhat  greasy  scale,  constituting  the  formations  also  variously 
known  as  keratosis  pigmentosa,  verruca  senilis,  seborrheic  wart  (verruca 
seborrhceica) ,  quite  frequently  seen  associated  with  other  degenerative 
changes  in  the  skin  (see  old  age  of  the  skin).  There  is  sometimes  slight 
or  moderate  itching.  They  possess  a  close  analogy  at  times  to  dark, 
slightly  elevated  moles,  and  could  be  often  clinically  well  described  by 
the  term  "warty  mole."  There  may  be  one,  several,  or  more  present, 
and  usually  scattered.  In  some  instances,  sooner  or  later,  there  is  a 
tendency  to  development  into  epithelioma. 

1  Hardaway  and  Allison,  Jour.  Culan.  Dis.,  1906,  p.  127,  express  the  opinion  that 
these  growths,  as  well  as  callosities,  and  hyperidrosis  of  this  part  are  more  common  in 
those  having  malpositions  of  the  feet,  especially  flat-foot  and  Morton's  foot. 

-  Elliot,  Jour.  Ctitan.  Dis.,  1889,  p.  306  (case  demonstration). 

3  Gemy,  "Verrues  confluentes  des  deux  jambes,"  Annales,  1889,  p.  94. 


VERRUCA 

Under  verruca  plana  can  also  be  most  conveniently  considered  a 
totally  different  variety  of  warts,  both  as  to  the  age  of  those  affected 
and  their  clinical  characters,  known  as  verruca  plana  juvenilis,  and 
which  has  attracted  notice  in  more  recent  years  through  the  contribu- 
tions of  Thin,1  Darier,2  Besnier,3  Herxheimer  and  Marx,4  and  others. 
Their  sole  feature  possessed  in  common  with  the  ordinary  verruca  plana 
just  described  is  the  flat  character,  in  other  respects  being  wholly  dis- 
similar. They  are  somewhat  peculiar,  lichen-planus-looking  warts, 
with  roundish,  squarish,  or  polygonal  base,  with  a  flat  and  smooth  surface' 
rarely  larger  than  a  small  French  pea,  and  usually  much  smaller,  and 
generally  seated  upon  the  face,  where  they  may  exist  in  moderate  or 
great  number.  Occasionally  in  some  lesions  a  scarcely  perceptible 
central  depression  can  be  detected.  They  are  normal  skin  color  or  gray- 
ish or  brownish;  are  discrete  or  aggregated,  and  when  several  or  more  are 
close  together,  coalescence  sometimes  takes  place,  resulting  in  a  small, 
irregular  shaped,  occasionally  somewhat  linear,  patch.  Their  elevation 
is  usually  slight,  with  some  lesions  scarcely  appreciable.  While  all  are 
almost  always  perfectly  flat,  occasionally  a  few  will  show,  especially  in 
their  earliest  existence,  a  slightly  rounded  top.  The  chin,  lower  part  of 
the  cheeks,  and  the  forehead,  more  particularly,  as  a  rule,  toward  the 
temporal  region  and  the  hair  border,  are  the  favorite  situations.  They 
are  seen  in  children,  frequently  in  those  quite  young,  but  are  also  ob- 
served in  youth  and  early  adult  age.  They  are  generally  slow  and  in- 
sidious in  their  coming,  and  are  persistent,  lasting  often  for  months  and 
years,  but  unattended  by  subjective  symptoms. 

Verruca  Digitata. — This  is  a  variety  of  wart  more  commonly  ob- 
served upon  the  scalp,  and  which  is  characterized  by  clefts  or  digitations 
extending  sometimes  nearly  or  quite  down  to  the  base.  This  feature 
may  involve  the  whole  body  of  the  growth,  but  it  is  always  most  marked 
at  the  peripheral  portion.  The  wart  may  arise  as  such,  being  practically 
of  this  nature  almost  from  the  start,  or  it  may  appear  at  first  as  an 
ordinary  wart,  but  as  it  grows,  the  epidermic  covering  seems  to  extend 
down  between  the  projecting  and  enlarging  papillae,  while  the  latter 
grow  upward,  and  clefting  results.  When  the  digitations  do  not  ex- 
tend completely  to  the  base,  the  lower  part,  or  neck,  is  sometimes 
relatively  much  smaller  or  apparently  constricted,  and  the  growth  has 
then  a  pedunculated  appearance,  the  upper  cleft  part  tending  to  spread 
out  some.  The  surface  is  hard  and  horny,  the  lower  portion  somewhat 
soft.  If  at  all  forcibly  disturbed,  they  are  apt  to  bleed — much  more 
readily  than  common  warts.  In  size  they  vary  from  that  of  a  small 
pea  to  a  dime,  and  are  elevated  from  one  to  several  lines.  Their  color 
is  usually  that  of  other  warts.  But  one  or  several  may  be  present; 

1  Thin,  "An  Unusual  Case  of  Warty  Growths  on  the  Face,"  London  Med.-Chir., 
Soc'y  Trans.,  1881,  vol.  Ixiv,  p.  283  (with  case  illustration  (colored  plate)  and  two 
histologic  cuts). 

2  Darier,  "Verrues  planes  juveniles  de  la  face,"  Annales,  1889,  p.  617. 

3  Besnier-Doyon,  French  translation  of  Kaposi's  work;  also  Annales,  1889,  pp.  2: 
and  200  (in  discussion). 

4  Herxheimer  and  Marx,  "Zur  Kenntniss  der  Verrucae  planae  juveniles,    Miinchcner 
med.  Wochenschr.,  1894,  p.  591  (a  report  of  29  cases,  with  review  of  subject  and  refer- 
ences). 


550 


H  YPER  TR  OPHIES 


quite  frequently  somewhat  aggregated,  sometimes  sufficiently  so  to  form 
a  coalescent  group. 

Verruca  Filiformis.— This  is  a  thread-like  growth,  most  commonly 
seated  about  the  neck,  face,  and  eyelids.  It  is  of  varying  length,  from 
that  of  a  line  to  \  of  an  inch  or  longer,  and  from  scarcely  more  than  a 
thick  thread  to  a  line  in  diameter,  apparently  depending  upon  whether 
one  or  several  papillae  are  hypertrophied.  It  is,  as  a  rule,  soft  to  the  touch 
and  quite  flexible,  with  a  narrowed  conic  or  pointed  end.  It  occurs  more 
frequently  as  a  single  formation,  although  occasionally  several  are  to  be 
seen  scattered  or  more  or  less  closely  grouped. 

Verucca  Acuminata  (Synonyms:  Condyloma  acuminata;  Venereal 
wart;  Moist  wart;  Pointed  wart;  Pointed  condyloma ;  Condyloma  acumi- 
natum;  Fig- wart;  Cauliflower  excrescence;  Fr.,  Vegetation  dermique; 
Ger.,  Spitzencondylom;  Spitzenwarze ;  Venerische  Papillome;  Venerische 
Warze;  Feigwarze). — This  variety  usually  occurs  on  the  mucous  and 
mucocutaneous  surfaces  of  the  genital  and  anal  regions,  although  also 
sometimes  on  the  adjoining  integument  and  in  the  flexures  and  on  other 
parts.1  As  they  usually  result  from  irritating  discharges,  they  are  most 
common  on  the  genitalia  and  genitocrural  regions,  and  in  association  with 
venereal  diseases.  The  formations  are  either  single  or  multiple,  scanty 
or  abundant,  pointed,  tufted,  club-shaped,  and  sessile  or  pedunculated. 
They  have  a  bright  pinkish  or  reddish  color,  sometimes  with  a  purplish 
tone.  In  some  cases  they  have  the  general  features  and  color  of  a  cock's- 
comb.  In  other  instances  instead  of  projecting  vegetations  they  have 
more  the  appearance  of  thick  hypertrophic  and  superabundant  granula- 
tion tissue.  In  the  mildest  examples  they  consist  of  one  or  more  groups 
or  bunches  of  acuminated,  pinkish  or  reddish,  raspberry-like  elevations. 
In  extreme  cases  the  warts  make  up  irregular,  cauliflower-like  masses 
which  cover  the  entire  region  and  project  to  considerable  elevation. 
According  to  the  region,  they  may  be  somewrhat  dry  or  moist;  and  if 
the  latter,  the  secretion,  which  results  from  maceration  due  to  the 
natural  heat  and  friction  of  the  parts,  is  usually  abundant,  of  a  yellowish 
color  and  puriform,  and  develops,  from  rapid  decomposition,  an  offensive 
and  penetrating  odor.  As  the  excrescences  bleed  easily,  the  secretion 
is  sometimes  tinged  with  blood.  In  -some  cases  the  discharge  dries  and 
forms  thickish,  reddish-yellow  or  brownish  crusts,  sometimes  tough  and 
almost  horny,  beneath  which  the  partly  pent-up  secretion  undergoes 
rapid  decomposition. 

Their  most  common  starting-points  in  the  male  are  on  the  glans 
and  in  the  sulcus  and  from  the  inner  side  of  the  prepuce;  and  in  the 
female  in  about  the  clitoris,  inner  side  of  the  labia,  and  from  the  vagina. 
The  anus  may  also  be  the  site,  and  the  condition  may  remain  so  limited, 
but  more  commonly  it  appears  here  secondarily  to  the  eruption  on  the 
genitalia,  especially  in  women.  It  may  exceptionally  also  present  upon 
other  regions,  as  about  the  axillae,  umbilicus,  mouth,  and  between  the 

1  Heidingsfeld  (Condyloma  Acuminata  Linguae),  Jour.  Cutan.  Dis.,  1901,  p.  226 
(with  histologic  cuts),  reports  an  instance  in  which,  in  addition  to  lesions  on  the  labia 
majora,  there  were  some  similar  warts  on  the  tongue;  and  also  reviews  the  subject  of 
extragenital  verruca  acuminata  (with  references). 


VERRUCA 


551 


toes.  On  integumentary  sites  where  there  is  not  much  or  no  friction  or 
excessive  natural  sweat  secretion  they  are  much  drier,  occasionally  free 
from  discharge,  and  their  color,  at  first  at  least,  is  not  materially  different 
from  the  normal  skin,  but  later  becomes  purplish  and  reddish.  Their 
development  is  commonly  quite  rapid,  although  sometimes,  after  attain- 
ing variable  dimensions,  they  may  remain  more  or  less  stationary. 
In  many  cases,  however,  there  is  a  disposition  to  increase  and  extend, 
as  the  secretion  is  auto-inoculable.  The  malady  is,  in  fact,  contagious. 
If  undisturbed,  there  is  usually  no  tendency  to  spontaneous  disappearance. 

Ktiology. — Warts  are  more  common  in  childhood,  in  adoles- 
cents, and  in  early  adult  life.  There  is  a  more  or  less  general  tacit 
acceptance  of  mild  contagiousness,  and  of  the  correctness  of  which  I  feel 
pretty  well  convinced.  Observations  in  many  instances  of  suggestive 
cases  of  auto-inoculation  support  such  a  view.  The  quite  frequent 
development  of  others  from  a  primary  or  mother  wart,  to  which  Vidal 
directed  attention  and  which  many  others  have  noted,  its  spread  by  con- 
tiguity, as,  for  example,  occasionally  around  the  ungual  borders,  ob- 
served by  Morrow,  Allen,  Bronson,1  and  others,  its  spread  from  one 
child  or  member  to  another  of  a  family,  as  not  infrequently  observed,  of 
which  Vives2  recently  reported  an  instance,  are  all  suggestive.  A  short 
time  ago  a  gentleman  was  under  my  care  with  some  warts  on  the  hand, 
who  stated  that  his  fiancee  had  also  subsequently  presented  several 
similar  growths.  Payne3  relates  how  in  a  case  he  thoughtlessly  used 
his  own  thumb-nail  to  scrape  off  a  wart  previously  softened  by  an  applica- 
tion, and  that  some  time  later  a  similar  formation  developed  at  this  site 
(under  the  edge  of  the  nail),  with  subsequently  two  more  on  the  thumb 
higher  up.  These  are  a  few  examples  to  which  many  similar  ones  could 
be  added. 

In  fact,  the  clinical  evidence  is  more  than  suggestive,  and  to  this 
we  can  now  add  the  favorable  inoculation  experiments  by  Jadassohn, 
Variot,  Lanz,  and  one  or  two  others.4  Lanz's  experiment  was  con- 
vincing to  him,  although  unsuccessful  on  the  patient  upon  whom  he 
was  experimenting;  his  patient  had  warts  on  one  hand  and  forearm, 
and  a  small  portion  of  the  growth  was  superficially  implanted  on  the 
arms,  with  negative  result.  He  then  tried  rubbing  across  the  large 
or  mother  wart  on  the  forearm  on  to  the  neighboring  skin  once  or  twice 
daily  for  several  days,  using  his  first  and  second  fingers,  with  no  result 
on  the  patient,  but  some  time  afterward  three  lesions  developed  on  the 
rubbing  surface  of  his  own  fingers.  The  inoculations  by  the  others 

1  Morrow,  Allen,  Bronson,  Jour.  Culan.  Dis.,  1890,  p.  183  (case  demonstration  and 
discussion). 

2  Vives,  "Verrues  de  Famille,"  Jour.  mal.  cutan.,  1899,  p.  463  (3  members,  01 
after  another). 

3  Payne,  "On  the  Contagiousness  of  Common  Warts,'    Bnt.  Jour.  Derm.,  I1IQI, 

Vfadassohn,  "Sind  die  Verrucas  Vulgares  ubertragbar?"  Verhandl.  dcr  V.  Deutschen 
Dermatolog.  Gesdlsch.  (1895),  1896,  p.  497  (with  review  of  the  subject  with  references; 
of  74  inoculations,  made  at  different  times,  on  6  different  persons,  31  were  success!  ul); 
Variot,   "Un  cas  1'inoculation  experimental  des  verrues  de  1  enfant  a  1  hon 
Jour,  de  Clinique  et  de  therap.  infant,  1894,  No.  34,  P-  5  29;  Lanz,     Em  B 
Frage  der  Uebertragbarkeit  von  Warzen,"  Correspondent,  f.  Sshweizer  Aet 
p.  264. 


552  H  YPER  TR  OPHIES 

named  were  on  an  extensive  scale  and  seemingly  conclusive.  The  incu- 
bation period  is  of  long  duration — from  over  one  month  up  to  seven  or 
eight,  although  probably,  in  favoring  locations,  as  in  Payne's  case,  a 
much  shorter  period  suffices.  Jadassohn's  experiments  furthermore 
apparently  indicate,  although  not  sufficiently  positively,  that  the  juvenile 
flat  wart  produces  its  like,  as  does  likewise  an  ordinary  wart,  and  therefore 
of  different  etiology.  There  is  still  wanting  confirmatory  proof  of  micro- 
organisms, Kuhnemann,1 1  believe,  being  the  only  one  who  has  discovered 
a  microbe  (a  bacillus)  of  seeming  pathogenic  importance,  and  with  which 
he  succeeded  in  producing  suggestive  lesions  experimentally  on  rabbits. 
The  influence  of  slight  traumatism,  excoriations,  pressure,  and  the  like, 
which  were  formerly  considered  as  active  causative  factors,  is  now  recog- 
nized as  contributory  toward  furnishing  favorable  opportunities  for  suc- 
cessful inoculation.  Schaal2  and  others,  however,  are  firm  in  the  opinion 
that  local  irritation — implantation  of  some  minute  foreign  body,  accord- 
ing to  Schall — gives  rise  to  hypertrophy  of  the  connective  tissue  and  pa- 
pillae, and  thus  produces  the  wart.  Both  Fox  and  Allen,3  and  also  myself, 
have  noted  cases  in  which  both  molluscum  contagiosum  and  warts  were 
present,  and  Fox  is  inclined  to  believe  that  there  may  be  a  common 
cause  or  close  connection.  Such  conclusion,  it  seems  to  me,  is  scarcely 
warrantable  when  one  considers  the  frequency  of  warts  among  the 
poorer  children,  and  with  which  cutaneous  diseases  other  than  molluscum 
contagiosum  could  be  found  just  as  or  more  frequently  associated,  and 
yet  no  question  of  relationship  arise. 

As  to  verruca  acuminata,  it  is  more  than  probable  that  this  is  an 
entirely  distinct  affection  etiologically  from  the  other  forms.  With 
these,  irritating  secretions  are  unquestionably  of  etiologic  importance. 
These  warts  and  their  secretions  are  doubtless  contagious  and  auto- 
inoculable.  Ducrey  and  Oro4  found  in  the  secretion,  in  the  growth 
and  tissues,  in  addition  to  the  staphylococcus  pyogenes  aureus  and  bacil- 
lus subtilis,  two  colonies  of  unknown  micro-organisms,  but  experiments 
with  these  latter  on  animals  and  man  failed  to  produce  any  result. 

Pathology. — From  what  has  already  been  stated  in  discussing 
etiology,  it  would  seem  highly  probable  that  the  initial  factor  in  the 
formation  of  a  wart  is  a  local  irritation,  and  it  is  not  unlikely  that,  in 
most  instances  at  least,  this  irritant  is  a  microbic  one.  The  organism 
doubtless  gains  entrance,  as  Kuhnemann  suggests,  through  some  small 
break  or  fissure  in  the  epidermis. 

While  anatomically  (Barensprung,  Virchow,  Auspitz,  Unna,  Kuhne- 
mann, and  others)5  there  are  some  slight  differences  in  the  several  varie- 

1  Kuhnemann,  "Zur  Bacteriologie  der  Verruca  Vulgaris,"  Monatshefte,  1889,  vol. 
'*•  P-  *7J  Schweninger  stated  (ibid.,  p.  380)  that  the  culture-inoculations  made  by 
Kuhnemann  had  been  apparently  successful  in  rabbits. 

2  Schaal,  "Zur  Aetiologie  der  Hautwarzen,"  Archiv,  1896,  vol.  xxxv,  p.  207  (the 
accidental  implantation  of  minute  specks  of  glass  gave  rise  to  warts  on  his  own  hand). 

Fox,  Trans.  Amer.  Derm.  Assoc.for  1888,  p.  50  (discussion);  Allen,  "Molluscum 
Contagiosum— an  Analysis  of  50  Cases,"  Jour.  Cutan.  Dis.,  1886,  p.  238. 

4  Ducrey  and  Oro  (The  Pathology  of  Condyloma  Acuminatum),  Naples,  1893— 
abstract  in  Brit.  Jour.  Derm.,  1894,  p.  158. 

'  Kuhnemann,  "Beitrage  zur  Anatomic  und  Histologie  der  Verruca  vulgaris," 
Monatshffle,  1889,  vol.  viii,  p.  341  (with  two  histologic  plates,  review  of  the  subject, 
and  bibliography) ;  Unna,  Hlstopathology,  p.  786. 


VERRUCA 


553 


ties,  there  is  primarily  a  connective-tissue  growth  or  central  prolongation 
common  to  all,  and  the  interior  of  which  contains  one  or  more  vascular 
loops;  and  to  this  are  added  varying  degrees  of  epidermic  and  papillary 
hypertrophy.  In  many  the  hypertrophy  of  the  papillae  is  more  apparent 
than  real,  due  to  their  elongation  and  thinning  by  the  epithelial  growth; 
in  others  there  are  fewer  than  normal,  some  being  flattened  down  by  the 
proliferating  rete.  Both  Auspitz  and  Unna,  as  well  also  as  Kuhnemann, 
state  the  process  starts  in  the  rete  and  that  the  enlargement  of  the  papillae 
is  due,  in  fact,  to  the  proliferation  and  downgrowth  of  the  former,  and 
that  the  vascular  and  other  changes  in  the  corium  are  purely  secondary. 
The  proliferation  of  the  rete,  which,  as  Kuhnemann  especially  contends, 
extends  upward  as  well  as  downward,  brings  about  some  changes  in  the 
upper  epidermal  layers,  the  horny  layer  in  the  ordinary  wart  being 
usually  markedly  hypertrophied.  Owing,  however,  to  defective  or 
modified  action  in  the  process  of  keratinization,  the  thickened  horny 
layer  is  scarcely  so  dense  or  closely  packed  as  normally,  the  nuclei, 
according  to  Kuhnemann,  still  being  susceptible  of  staining.  The  his- 
tology of  the  peculiar  small  flat  warts  of  children  and  young  adults 
(verruca  plana  juvenilis),  according  to  the  studies  of  Thin,  Kuhnemann, 
Herxheimer,  Jadassohn,  Dubreuilh,  and  Darier,  is,  with  the  exception 
of  some  minor  differences,  essentially  that  of  the  beginning  verruca 
vulgaris,  although  both  Darier  and  Dubreuilh  noted  a  slight  preceding 
exfoliation  due  to  breakage  and  separation  of  the  horny  layers  not  ob- 
served in  other  warts. 

The  plantar  wart  has  been  studied  historically  by  Dubreuilh  and 
Bowen,  with  accord  on  the  essential  points.  Bowen  found  no  particular 
deviation  in  the  corium.  The  epidermis  at  the  periphery  showed  pro- 
nounced acanthosis,  papillary  enlargement,  down  growth  of  the  rete 
plugs,  and  marked  hyperkeratosis,  together  with  great  hyperplasia  of 
the  granular  cells;  as  the  center  is  approached  the  middle  rete  cells 
become  vacuolated,  appearing  larger  and  rounder  than  their  neighbors; 
in  many  of  the  warts  were  seen  peculiar  protozoa-like  bodies  in  many  of 
the  nuclei  of  the  rete  cells,  probably  some  form  of  nuclear  degeneration. 
The  anatomy  of  the  seborrheic  wart— the.  verruca  plana  of  old  people 
—has  been  studied  by  Neumann,  Balzer,  Handford,  and  Pollitzer,1 
whose  findings  are  somewhat  divergent.  Pollitzer's  investigations  are 
the  most  recent  and  based  upon  material  from  3  cases,  and  led  to  the 
following  conclusion:  "The  seborrheic  wart  is  characterized  historically 
by  a  slightly  thickened  stratum  corneum,  a  considerably  hypertrophied 
rete,  and  in  the  papillary  and  subpapillary  cells,  the  occurrence  of  epi- 
thelioid  cells  arranged  in  groups  and  lines,  separated  by  bundles  of  con- 
nective tissue,  and  teminating  abruptly  below  the  horizontal  subpapillary 
plexus  of  vessels;  together  with  a  peculiar  infiltration  of  fat,  affecting 
the  coil-gland  epithelium,  the  middle  and  papillary  layers  of  the  cutis, 
and  epithelium  of  the  rete;  and  perhaps  an  atrophy  of  the  sebaceous 
glands  and  hair-follicles."  The  crust,  more  commonly  found  in  t. 

i  Pollitzer,  "The  Seborrheic  Wart,"  Brit.  Jour.  Derm.,  1890  p.  'W  (wjth  tw>  his- 
tologic  cuts,  and  abstract  of  opinions  of  Neumann,  Balzer,  and  Handford- 
erences.) 


554 


H  YPER  TR  OPHIES 


who  make  little  use  of  the  bath,  or  more  pronounced  in  such  cases, 
consists  of  fatty  epidermic  scales  and  foreign  matter,  wool-fibers,  par- 
ticles of  carbon,  etc.,  often  firmly  attached  and  dipping  down  into  the 
follicles. 

In  verruca  acuminata,  made  up  largely  of  connective-tissue  ele- 
ments, are  to  be  found  marked  papillary  enlargement,  excessive  devel- 
opment of  the  rete,  and  an  abundant  vascular  supply.  The  process 
differs  from  the  other  warts  in  the  absence  of  any  special  increase  or 
modification  changes  in  keratinization  (Unna,  Kuhnemann) ;  in  fact,  the 
horny  layer  is  often  almost  or  completely  wanting.  The  most  striking 
and  characteristic  feature  is  the  exuberant  proliferation  of  the  rete. 
The  connective- tissue  framework  contains  large  blood-vessels  and  lym- 
phatics. 

Diagnosis. — The  characters  of  ordinary  warts  are  so  well  known 
and  they  are  so  unlike  other  lesions  that  a  mistake  can  scarcely  occur. 
The  somewhat  rounded  warts,  with  but  little  epidermic  thickening, 
might,  in  their  beginning,  be  confused  with  the  starting  lesions  of  mol- 
luscum  contagiosum,  but  the  central  depression  and  aperture  of  the 
latter,  usually  recognizable  by  the  naked  eye,  certainly  by  a  magnifying- 
glass,  would  prevent  mistakes;  moreover,  the  face  is  their  common  site, 
while  verruca  vulgaris  is  usually  seated  upon  the  hands.  The  plantar 
wart  differs  from  a  callosity  by  its  painfulness  on  pressure;  by  cutting 
or  shaving  off  the  overlying  callous  the  wart  is  readily  recognized,  and 
it  can  thus  be  also  distinguished  from  a  corn,  with  which  it  is  often  con- 
founded. The  small  flat  wart  (verruca  plana  juvenilis)  is  suggestive 
of  lichen  planus,  but  the  latter  rarely  occurs  on  the  face,  except  in  very 
generalized  cases,  and  then  to  a  relatively  slight  extent,  whereas  this  is 
the  usual  place  for  the  small  flat  wart;  and  when  the  latter  is  also  upon 
the  back  of  the  hands  and  fingers,  they  are  generally  more  numerous  on 
the  face.  Moreover,  the  lichen  planus  papules  are  usually  larger,  of  a 
darker,  violaceous  color,  are  itchy,  and  tend  to  run  together  and  become 
rough,  scaly,  and  then  show  a  good  deal  of  infiltration,  features  not  ob- 
served in  small  flat  warts.  Care  should  be  taken  not  to  confound  this 
juvenile  flat  wart,  or  the  common  wart,  with  the  rare  affections  angiokera- 
toma  and  xanthoma,  more  especially  xanthoma  multiplex  and  diabeti- 
corum.  The  ordinary  flat  wart,  or  seborrheic  wart,  of  advancing  years 
is  usually  upon  the  back,  sometimes  on  the  neck,  and  is,  as  a  rule,  quite 
greasy  or  crusted,  and  of  yellowish  or  blackish  color,  and  can  scarcely 
be  confounded  with  any  other  lesion.  The  raspberry  or  mushroom-like 
character  of  verruca  acuminata,  and  the  localities  affected,  are  sufficient 
usually  to  prevent  error  with  other  lesions;  they  should  not  be  confounded 
with  the  flat  moist  papules  of  syphilis,  which  also  occur  about  the  same 
parts. 

Prognosis. — Warts,  as  commonly  met  with,  have  no  significance 
beyond  disfigurement,  being  benign  in  character.  The  seborrheci 
wart,  as  already  stated,  occasionally  shows  epitheliomatous  develop- 
ment. This  wart  exhibits  no  tendency  to  disappearance;  all  the  others 
do,  although  they  may  last  sometimes  almost  indefinitely.  Verruca 
acuminata,  however,  is  usually  persistent,  unless  measures  are  taken  for 


555 

its  removal,  although  under  the  institution  of  rigorous  cleanliness  the 
warts  will  frequently  disappear  without  treatment.  All  these  different 
varieties  are  usually  readily  remediable,  occasionally,  especially  the 
plantar  wart,  requiring,  however,  persistent  treatment,  and  sometimes 
operative  measures. 

Treatment.1— The  therapeutic  management  of  verruca  upon 
which  most  reliance  is  to  be  placed  consists  of  external  treatment  of  an 
antiseptic,  caustic,  or  operative  nature.  It  cannot  be  gainsaid,  however, 
that  there  is  substantial  evidence  that  a  variable  influence  can  be  exerted 
by  certain  remedies  administered  internally,  more  especially  to  be 
advised  in  those  instances  in  which  numerous  lesions  are  present.  The 
curative  action  of  arsenic  is  well  attested  by  the  favorable  experience 
of  a  number  of  observers,  among  whom  are  Sympson,2  Pullin,3  Herxheimer 
and  Marx  (loc.  tit.},  Thin  (loc.  tit.},  Hallopeau  and  Leredde,4  and  many 
others.  My  own  experience  is  confirmatory.  It  is  to  be  given  in  mod- 
erate dosage,  j  of  a  minim  (0.016)  or  more  to  children,  and  2  to  5  minims 
(o-JSS-o-SSS)  to  adults,  three  times  daily.  In  recent  years  magnesium 
sulphate  has  been  commended  by  Colrat,5  and  its  good  effects  in  some 
cases  corroborated  by  Crocker,6  Brocq,7  and  Hall,8  although  many,  nota- 
bly among  whom  Besnier  and  Bowen,9  have  failed  to  see  any  influence. 
The  results  were  negative  in  several  cases  under  my  own  care.  It  is 
given  three  times  a  day,  in  dose  of  i  to  20  grains  (0.065-1.35)  or  so,  ac- 
cording to  age.  Crocker  (loc.  tit?)  states  also  that  in  some  instances 
full  doses  of  nitromuriatic  acid  had  seemed  to  be  of  service. 

Whatever  may  be  the  differences  of  opinion  as  to  the  value  of  internal 
medication,  there  is,  of  course,  unanimity  as  to  the  effectiveness  of  local 
treatment;  and  curious  to  say,  that  in  occasional  cases  (among  which  sev- 
eral of  my  own)10  of  more  or  less  numerous  lesions  the  removal  of  several  is 
followed  by  a  spontaneous  disappearance  of  the  others.11  One  of  the  best 
methods  of  treating  warts,  more  especially  when  but  one  or  several  are 

1  Except  when  otherwise  stated,  the  remarks  apply  to  the  several  varieties,  except 
the  seborrheic  wart  and  verruca  acuminata. 

2  Sympson,  "Note  on  the  Treatment  of  Warts  by  the  Internal  Administration  of 
Arsenic,"  Quarterly  Med.  Jour.,  1893-94,  vol.  ii,  p.  57. 

3  Pullin,  "The  Treatment  of  Warts  by  the  Internal  Administration  of  Arsenic," 
Bristol  Med.  Jour.,  1887,  p.  269. 

4  Hallopeau  and  Leredde,  Dermatologie,  1900,  p.  409. 

5  Colrat,  Lyon  Medicale,  1886,  vol.  liii,  p.  45  (soc'y  communication). 

6  Crocker,  Diseases  of  the  Skin,  third  edit.,  p.  580. 

7  Brocq,  Traitement  des  Maladies  de  la  Peau,  second  edit.,  p.  852. 

8  Hall,  Brit.  Jour.  Derm.,  1904,  p.  264.     Both  Watson  (Brit.  Jour.  Derm.,  1903, 
p.  178),  and  Hall  (ibid.,  1906,  p.  106)  are  inclined  to  believe  that  the  purgative  action 
of  this  or  other  drug  is  the  factor  of  importance. 

9  Bowen,  Twentieth  Century  Practice,  vol.  v  (Diseases  of  the  Skin),  p.  637. 

10  One  of  the  most  striking  instances  was  a  case  in  a  male  relative  with  10  to  12 
warts  on  each  hand  and  which  had  been  present  for  a  year  or  more— removal  with  the 
curved  scissors  of  three  of  the  largest  (2  on  one  hand,  i  on  the  other)  was  followed  in 
the  course  of  two  to  three  weeks  by  spontaneous  disappearance  of  all  the  others. 

11  Galewsky  (Ueber   das    spontane  Verschwinden  juveniles  oder    harter  Warzen 
an  die  Behandlung),  Dermatolog.  Wochenschr.,  1912,  liv,  p.  589,  had  also  recently  re- 
ported such  instances,  and  refers  to  similar  experiences  of  other  observers  (Waelsch, 
Barca),  with  references;   Halberstaedter,  Dermatolog.  Wochenschr,  Dec.  14,  1912,  ly, 
p.  1522,  records  on  instances  of  disappearance  (numerous  warts  on  hands)  after  the 
radiation  of  a  small  number  of  them;  Delbanco,  ibid.,  p.  1524,  had  a  similar  experi- 
ence, the  warts  on  both  hands  disappearing  after  radiation  of  one  hand. 


556  H  YPER  TR  OPHIES 

present,  is  by  means  of  electrolysis,  as  originally  suggested  by  Harda- 
way.  The  growth  is  almost  wholly  or  completely  transfixed  with  the 
needle  attached  to  the  negative  cord,  and  the  wet  positive  electrode 
grasped  by  the  hand  or  applied  near  by;  the  current  is  allowed  to  act 
for  thirty  seconds  to  one  or  two  minutes,  according  to  the  size  of  the 
growth  and  the  strength  of  the  current— the  latter  varying  from  i  to  4 
or  5  milliamperes.  If  the  growth  is  hard,  large,  and  old,  the  needle 
should  be  withdrawn  and  reintroduced,  crossing  the  first  insertion.  In 
small  lesions,  and  also  in  large  growths,  one  to  several  introductions 
from  the  top,  instead  of  transfixing,  will  also  usually  be  successful.  The 
wart  either  gradually  shrivels  away,  or  some  irritation  and  crusting  ensue, 
which  finally  drops  off,  leaving  occasionally  a  slight  but  scarcely  per- 
ceptible scar.  The  method  does  not  seem  to  be  so  satisfactory  for  warts 
on  the  anterior  aspect  of  the  finger-bulbs,  where  they  are  usually  sur- 
rounded with  calloused  and  thickened  epidermis,  the  operation  here 
sometimes  producing  considerable  underlying  irritation  and  swelling. 

Various  applications  are  also  used  and  are  often  quickly  effective; 
paring,  scraping,  or  sand-papering  down  of  the  lesion,  except  when  the 
epidermic  thickening  is  insignificant,  is  usually  a  valuable  preliminary. 
I  am  in  the  habit,  when  the  growths  are  at  all  numerous,  of  prescribing 
frequently  a  saturated  alcoholic  solution  of  salicylic  acid,  with  which 
the  warts  are  moistened  once  or  twice  daily,  removing  the  softened  warty 
coating  thus  resulting  from  time  to  time.  The  same  remedy  is  also  often 
used  in  collodion,  10  to  20  per  cent,  strength.  If  the  latter  is  employed, 
two  or  three  coatings  should  be  made  night  and  morning  for  a  few  days, 
and  then,  after  the  film  loosens  or  cracks,  as  it  commonly  does  in  a  day 
or  two,  the  parts  are  soaked  in  hot  water,  and  the  pellicle  and  softened 
horny  layer  are  rubbed  off,  sometimes  using  with  advantage  pumice 
stone  or  scraping  with  a  curet.  The  salicylic  acid  plan,  which  is,  of 
course,  a  mild  one,  is  slow,  and  often  not  completely  successful.  Paring 
or  sand-papering  the  growth,  combined  with  cauterization  with  silver 
nitrate,  and  repeating  every  several  days,  is  another  mild,  and  often 
efficient,  though  somewhat  slow,  method.  Lactic  acid  applied  scantily 
one  to  several  times  daily  also  acts  in  some  cases  efficiently  and  without 
much  irritation,  the  softened  surface  being  rubbed  or  scraped  away  from 
time  to  time.  Other  applications  resorted  to  are  formalin,1  trichloracetic 
acid,  acid  nitrate  of  mercury,  and  nitric  acid;  chromic  acid,  caustic 
potash,  and  chlorid  of  zinc  are  also  valuable,  but  are  strong  and  destruct- 
ive and  must  be  used  with  care.  Carbon-dioxid  snow  (q.  t>.)  has  been 
commended  as  a  safe  caustic.  The  application  of  the  high-frequency 
spark,  by  means  of  the  carbon  or  glass-point  electrode,  has  been  lately 
lauded.2  The  constant  wearing  of  a  rubber  covering — acting  by  its 
macerating  action — has  also  been  commended.3 

For  the  plantar  corn-like  wart  I  have  usually  employed  the  fol- 
lowing plan:  the  calloused  covering  is  first  removed  by  paring  or  by  a 

1  Engman,  "The  Nature  of  Some  Epithelial  Growths  and  Their  Treatment  with 
Formalin,"  Medical  Review,  1900,  vol.  xli,  p.  405. 

2  Bulkley,  Amer.  Medicine,  Nov.  19,  1904,  p.  882. 

3  Purdon,  "Note  on  Verruca  or  Warts,"  Dublin  Jour.  Med.  Sci.,  1899,  vol.  cviii,  p. 
99- 


VERRLCA  557 

few  days'  application  of  salicylic  acid  plaster,  or  a  25  to  30  per  cent, 
ointment  of  salicylic  acid  continuously  applied,  and  then  the  outer  sur- 
face of  the  uncovered  wart  gently  scraped  or  curetted  away,  or  cau- 
tiously "melted  away"  with  a  strong  solution  of  caustic  potash,  and 
the  cavity  filled  with  salicylic  acid  and  over  this  painted  several  coatings 
of  an  8  per  cent,  salicylated  collodion;  this  must  usually  be  repeated 
one  to  three  times  at  intervals  of  several  days  or  a  week.  Bowen  has 
also  had  considerable  success  with  salicylated  collodion  containing  10 
per  cent,  of  chrysarobin.  The  salicylated  collodion  plan  alone  would 
doubtless  cure  most  cases,  if  persisted  in  long  enough,  and  especially 
the  strong  salicylic  ointment,  removing  the  whitened  horny  layers  from 
time  to  time;  this  is  also  Bowen's  belief,  but,  as  he  states,  the  necessary 
patience  is  not  found  in  all  persons.  Sutton  commends  highly  the  use  of 
carbon-dioxid  snow,  in  pencil  shape,  applied  firmly  for  30  to  60  seconds, 
then  allowing  tissues  to  thaw,  and  reapplying,  with  slightly  smaller  pencil, 
for  30  seconds,  using  boric  acid  powder  as  the  after-treatment.  Hard- 
away  and  Allison  believe  the  correction  of  any  existing  foot  malposi- 
tion is  helpful  and  sometimes  curative. 

The  pedunculated  and  filiform  warts  can  be  readily  snipped  off  with 
the  curved  scissors,  and  the  base  touched  with  silver  nitrate.  This 
method  can  also  be  used  with  the  ordinary  warts.  I  have  found  a  good 
plan  in  the  scalp  warts,  usually  the  digitate  variety,  is  gently  to  curet 
and  touch  the  base  with  pure  carbolic  acid  or  silver  nitrate. 

The  small  flat  warts  can  be  treated  with  repeated  applications  of 
carbolic  acid  applied  with  a  pointed  match-stick  or  wooden  toothpick, 
or  the  milder  applications  already  referred  to  can  be  employed.  If 
electrolysis  is  used,  the  needle  is  introduced  superficially  from  the  top, 
and,  as  a  rule,  a  mild  current  employed.  In  these  cases,  in  which  the 
lesions  are  usually  numerous  and  sometimes  close  together,  I  have  seen 
benefit  from  the  use  of  a  5  to  10  per  cent,  sulphur  or  calomel  ointment, 
rubbed  in  in  small  quantity  twice  daily;  also  from  a  saturated  solution 
of  boric  acid  with  2  to  10  or  15  grains  (0.135-1.)  of  resorcin  to  the  ounce 
(32.)  (Davis) ;  and  from  Vleminckx's  solution.  Arsenic  was  at  the  same 
time  given  internally. 

The  seborrheic  wart  is  to  be  treated  by  frequent  soap-and-water 
washing  and  the  rubbing  in  of  a  mild  sulphur-salicylic  acid  ointment, 
composed  of  20  to  100  grains  (1.35-6.65)  of  precipitated  sulphur,  10 
to  60  grains  (0.65-4.)  of  salicylic  acid,  and  i  ounce  (32.)  of  ointment 
base,  consisting  of  petrolatum  or  equal  parts  of  petrolatum  and  lard. 
If  there  is  a  thick  or  hardened  horny  layer  or  crust,  the  salicylic  acid 
collodion,  already  referred  to,  can  be  at  first  employed.  Ordinarily 
treatment  well  followed  out  can  keep  the  growth  down  to  clean  plain 
flat  warts,  and  prevent  the  tendency  to  epitheliomatous  degeneration 
displayed  in  some  lesions.  If  it  is  desired  to  remove  the  growth  com- 
pletely, the  stronger  caustics  named  can  be  used,  first,  however,  trying 
the  salicylic  acid  collodion,  and  a  strong,  20  to  40  per  cent,  salicylic  acid 
plaster-mull  or  ointment.  Trichloracetic  acid  sometimes  acts  satis 
factorily.  The  carbon-dioxid  snow  is  also  valuable  in  these  cases. 

In  the  management  of  verruca  acuminata  the  maintenance  of  cleanh- 


e  [j  8  HYPER  TR  OPHIES 

ness  is  absolutely  essential.  The  parts  should,  therefore,  be  cleansed 
at  least  twice  daily  by  the  ordinary  washing  methods,  or,  if  numerous 
and  crowded,  by  free  irrigation,  and  subsequently  the  bountiful  use  of 
powdered  boric  acid,  to  which,  in  some  instances,  i  to  10  per  cent,  of 
alum  can  be  added  with  advantage.  Powdered  alum  alone  is  also  some- 
times employed.  A  5  to  10  per  cent,  solution  of  salicylic  acid  in  equal 
parts  alcohol  and  water  will  prove  curative  in  some  instances.  Painting 
the  parts  with  solution  of  subacetate  of  lead,  pure  or  weakened,  has  also 
been  used.  If  these  milder  measures  are  unsuccessful,  stronger  remedies 
must  be  resorted  to,  such  as  the  careful  application  of  glacial  acetic  acid 
or  chromic  or  nitric  acid,  tried  in  the  order  named. 

CORNU  CUTANEUM 

Synonyms. — Cornu  humanum;  Cutaneous  horn;  Horny  excrescence;  Horny 
tumor;  Fr.,  Corne  cutan6e;  Corne  de  la  peau;  Ger.,  Hauthorn;  Hornauswuchs. 

Definition. — Cornu  cutaneum  is  a  true  horny  cutaneous  out- 
growth varying  in  size  and  shape. 

Symptoms. — Horns  are  rarely  met  with  in  human  beings,  and 
may  be  classed  as  dermatologic  oddities.  Although  resembling  animal 
horns  closely,  their  anatomic  structure  differs  in  not  containing  bone 
and  in  having  a  cutaneous  attachment,  and  therefore  more  or  less  mova- 
ble, whereas  the  former  are  located  upon  an  osseous  base.  They  show 
a  preference  for  the  hairy  scalp  and  for  the  face,  occurring  occasionally 
elsewhere,  as  on  the  trunk,  cheeks,  eyelids,  glans,  scrotum,  and  extremi- 
ties, no  part  of  the  body,  however,  being  exempt.  Occurring  on  the 
penis,  they  not  uncommonly  develop  from  acuminated  warts,  as  in  the 
remarkable  cases  recorded  by  Pick1  and  by  Brinton.2  While  generally 
solitary,  they  may  be  multiple,  and  may  occur  in  quite  large  numbers, 
as  in  a  case  reported  by  Batge,3  in  which  the  whole  lowTer  part  of  the  body 
was  studded  with  these  growths,  although,  with  the  exception  of  2, 
all  were  of  small  size.  Their  appearance  is  usually  slow  and  insidious, 
although  exceptionally  somewhat  rapid;  in  their  earliest  formation  there 
is  a  resemblance  to  a  hard  wart,  and  they  may,  in  fact,  begin  as  a  simple 
verrucous  growth.  Their  size  and  shape  are  also  subject  to  variations; 
thus  they  may  be  only  large  pin-head  in  size,  and  again  they  may  measure 
several  or  more  inches  in  length;  the  unusual  length  of  12  inches  has  been 
recorded.  Their  diameter  varies  from  |  of  an  inch  to  4  or  5  inches,  and 
is  greater  at  the  base  than  at  the  extremity.  Rodriguez's  extraordinary 
case,  quoted  by  Crocker,  growing  on  the  side  of  the  head,  was  14  inches 
around  at  the  base.  Porcher4  also  observed  a  similar  case,  on  the  side  of 
the  scalp,  the  horn  being,  however,  much  smaller. 

In  appearance  they  are  solid,  rough,  wrinkled,  and  laminated  and 

1  Pick,  Archiv,  1875,  p.  315  (with  two  colored  plates;  also  refers  to  Q  other  cases). 

2  Brinton,  Medical  News,  Aug.  6,  1887  (with  a  resume  of  15  other  cases);  Gould, 
London  Paihol.  Soc'y  Trans.,  1887,  vol.  xxxviii,  p.  355,  also  records  a  case,  associated 
with  epithelioma. 

3  Batge,  Deutsche  Zeitschrift  filr  Chirurg.,  1876,  vol.  vi,  p.  474  (also  records  another 
case  having  6  upon  the  face,  with  illustrations  and  references  to  other  cases). 

*  Porcher,  Charleston  Med.  Jour,  and  Rev.,  1855,  p.  333  (with  resume  of  other  cases 
of  cutaneous  horn  and  references). 


CORNU  CUTANEUM 


559 


round,  angular,  pointed,  straight,  or  twisted.  They  show  different 
shades  of  color,  as  gray,  yellow,  brown,  or  black.  The  base  is  concave 
or  flattened  and  is  seated  directly  upon  and  in  the  skin;  the  neighboring 
integument  may  be  normal  or  inflammatory  in  appearance,  and  some- 
times inflammatory  action  is  followed  by  suppuration,  and  the  horn  may 
be  cast  off.  As  a  rule,  their  growth  is  slow  and  they  do  not  give  rise  to 
subjective  symptoms  unless  they  are  injured  by  traumatism  or  torn  off, 
in  which  case  the  base  presents  an  ulcerating  surface,  which  may  again 
become  the  seat  of  a  horn.  After  reaching  a  variable  size  they  may  re- 
main stationary ;  or,  when  having  reached  a  certain  length,  they  may  grow 
loose  and  finally  drop  off,  usually  preceded,  however,  by  a  localized 
degenerative  process,  which  is  left  behind  and  commonly  develops  into 
epithelioma.  According  to  Lebert,  12  per  cent,  of  the  cases  have  an 


Fig.  132.— Cutaneous  horns,  showing  beginning  epitheliomatous  degeneration  of  the 

base  (after  Pancoast). 

epitheliomatous  termination.  This  development  in  its  early  stages  is 
shown  in  the  accompanying  case  (Pancoast),1  and  another  example  of  this 
tendency  is  shown  in  Gould's  patient. 

Etiology  and  Pathology.— We  are  lacking  in  positive  knowl- 
edge as  to  the  exciting  causes.  Although  usually  occurring  after  forty 
years  of  age,  they  have  been  observed  in  the  very  young;  they  are  some- 
what more  frequent  in  females  than  in  males.  The  growth  is  rare, 
although  quite  a  number  of  cases  are  now  on  record.2  It  is  not  improb- 
able that  isolated  instances  of  limited  ichthyosis  hystrix  and  keratosis 
follicularis  may  have  been  included.  They  may  have  their  startmg- 

1  Pancoast,  Photog.  Review  of  Med.  and  Surg.,  1870-71,  vol.  i,  p.  3. 

2  Wilson,  Med.-Chir.  Trans.,  1844,  vol.  xxvn    p.  52,  and  D™' ?f^S«™'J?™ 
edit,  p.  796   gives  a  summary  of  90  cases  and  references;  Bergh      Falle  von  Haut- 
SS£,fSiK  '873,  P.  185;  Lebert,  Ueber  Keratose,  Breslau   1864  £«}**»£ 
109  cases);  Hessberg,  BeUrag  zur  Kenntniss  der  Hauthorner  ^*£^"*"33S' 
Dissertation,  Gottingen,  1868,  adds  25  to  Lebert's  list;  Joseph  (Caspary  Festschrift), 
Archiv.  C.  1910,  p.  343,  adds  2  cases,  and  reviews  the  pathologic  theoi 


560 


HYPER  TR  OPHIES 


point  in  cutaneous  injuries  or  lesions,  such  as  sebaceous  cysts,  scars, 
warts,  and  other  keratoses. 

Horns,  in  their  earliest  stage  at  least,  bear  a  close  resemblance  histo- 
logically,  as  well  as  clinically,  to  warts.  They  arise  usually  from  the  deeper 
layers  of  the  stratum  mucosum,  either  from  that  lying  above  the  papillae 
or  from  that  lining  the  follicles  and  glands;  and  are  to  be  attributed  to 
a  pathologic  hypertrophic  and  cornified  condition  of  the  epidermic 
cells,  the  earliest  stage  of  their  formation  consisting,  according  to  Unna, 
in  a  simultaneous  acanthosis  and  hyperkeratosis.  The  papillae  are 
hypertrophied,  and  the  growrth  is  situated  on  the  papillae,  and  not  in- 
frequently groups  of  greatly  enlarged  papillae  extending  some  distance 
into  the  horny  mass  have  been  observed.  The  base  is  surrounded  by 
telangiectatic  blood-vessels,  which  sometimes  ramify  into  the  horn  sub- 
stance. The  horny  formation  itself  consists  essentially  of  agglutinated 


Fig.  133. — Small  beginning  cutaneous  horn,  X  about  20;  showing  broadened  base 
extending  down  into  the  corium  and  the  projecting  rounded  summit  (courtesy  of  Dr. 
B.  H.  Buxton). 

epidermic  cells,  forming  small  columns  or  rods;  in  the  columns  themselves 
the  cells  are  arranged  concentrically. 

Treatment. — The  growth,  as  a  rule,  does  not  show  a  tendency 
to  recur  if  thoroughly  removed.  It  must  not  be  overlooked  that,  if 
neglected,  epithelioma  may  develop.  Quite  frequently  it  is  accidentally 
knocked  off,  but  under  such  circumstances,  unless  the  base  is  cauterized, 
it  is  apt  to  regrow. 

The  radical  treatment  of  these  growths,  therefore,  consists  in  their 
detachment,  and  subsequently  the  destruction  of  the  base.  The  former 
is  accomplished  by  dissecting  it  away  from  the  base  or  forcibly  breaking 
it  off;  the  latter  by  means  of  any  of  the  well-known  caustics,  such  as 
caustic  potash,  chlorid  of  zinc,  and  the  galvanocautery.  A  rapid  method 
is  to  excise  the  base,  the  horn  coming  away  with  it;  this  necessitates, 
however,  considerable  loss  of  tissue. 


ICHTHYOSIS 


56l 


ICHTHYOSIS 

Synonyms. — Fish-skin  disease;  Xeroderma;  Xeroderma  ichthyoides;  Ichthyosis 
vera;  Ichthyosis  congenita;  Sauriasis;  Fr.,  Ichtyose;  Ichthyose;  Ger.,  Fischschuppen- 
ausschlag. 

Definition. — A  chronic  disease  of  the  skin  of  congenital  origin 
or  developing  in  early  life,  characterized  by  more  or  less  generalized 
dryness  and  harshness,  slight  to  plate-like  scaliness,  and  a  variable 
degree  of  follicular  papulation,  sometimes  warty  or  horn-like. 

Symptoms. — Several    grades    of    the    disease    are   encountered, 
but  commonly  classed  under  two  heads — ichthyosis  simplex  and  ich- 
thyosis    hystrix.      The    mildest 
development  of  ichthyosis  sim- 
plex is  often  referred  to  as  xero- 
derma    (also    xerosis),    in  which 
the  condition  consists  of  scarcely 
more  than  a   dry,  harsh,  some- 
what   rough-feeling    skin,    most 
pronounced  on  the  extensor  sur- 
faces of  the  extremities,  and  on 
the    back,    although    commonly 
recognizable  also  on  other  parts, 
especially   when    the  weather  is 
more  or  less  continuously   cold, 
dry,  and  windy.     There  is  usu- 
ally with  this,  or  existing  as  the 
predominant  feature,  a  slight  or 
moderate    degree     of     keratosis 
pilaris,    most     pronounced    and 
frequently    noticeable    only    on 
its  common   situations,  the  an- 
terolateral  aspects  of  the  thighs 
and    posterolateral    surfaces    of 
the    arms.      There  is  generally 
also  branny  scaliness,  sometimes 
more  decided,  and  with  a  slight 
tendency  here  and  there  to  larger 
thin    scales,   with    a    disposition 
for  the  edges  to   turn    outward 
(general  pityriasis).     Not  only  is 
the  skin  dry,  harsh,  rough,  slightly 

scaly,  and  often  with  a  dirty-gray-     Fig  r34._irhthyosis  of  average  develop- 
ish  or  unwashed  appearance,  but         '   ment  (courtesy  of  Dr.  W.  Frick). 
it  is  also  somewhat  lacking  in  sup- 
pleness and  elasticity.    There  is  a  trifling  thickening  of  the  epidermis,  and 
usually  a  slight  accentuation  of  the  lines  of  the  skin.     The  skin  of  su 
patients  is  more  susceptible  to  ordinary  irritating  influences,  and  in  wmte: 
exposed  portions  tend  to  chap  readily,  and  commonly  t 
zematous  inclination. 

36 


,j  62  HYPER  TR  OPHIES 

From  this  mild  type  there  are  many  gradations  to  the  extreme  type 
of  ichthyosis  simplex.  In  its  slighter  developments  the  scaliness  is 
more  marked  than  described,  consisting  of  thin,  film-like,  irregularly 
shaped  or  quadrilateral  scales,  most  striking  about  the  extensor  sur- 
faces of  the  region  of  the  elbows  and  knees,  but  with,  however,  more 
or  less  general  slight  development  of  keratosis  pilaris  than  observed 
in  the  mild  form— xeroderma— just  referred  to.  The  face  and  scalp, 
too,  may  show  a  slight  dryness  and  furfuraceous  scaliness.  In  more 
marked  cases  all  the  features  become  exaggerated,  the  epiderm  is  con- 
siderably thickened,  the  scales  are  thicker  and  more  plate-like,  with 
pronounced  follicular  keratosis  and  usually  a  universal  involvement  of 
the  surface,  always  most  developed,  however,  on  the  surfaces  named, 
and  in  these  cases  the  trunk  as  well  often  showing  marked  plate-like 
scaliness.  The  plate-like  scaliness  gives  the  skin  a  fish-scale  aspect, 
and  hence  the  name  ichthyosis,  or  fish-skin  disease.  In  still  more 
marked  cases  the  scales  are  noted  to  be  quite  thick,  plate-like,  usu- 
ally more  or  less  quadrilateral,  divided  by  somewhat  deep  furrows; 
and  even  the  flexor  surfaces  of  the  joints — regions  relatively  or  often 
completely  spared  in  the  milder  types — show  slight  or  moderate  involve- 
ment. The  scalp  is  dry,  scaly,  and  the  hair  often  lusterless  and  lifeless- 
looking,  the  face  rough,  dry,  and  covered  with  branny  or  film-like  scali- 
ness. The  plate-like  character  of  these  extreme  types  is  so  strikingly 
like  the  thick  scales  of  certain  fish  or  water  animals,  as  the  alligator, 
as  to  give  rise  to  the  designation,  "alligator  skin."1  In  these,  as  well  as 
in  some  of  the  less  developed  examples,  the  elasticity  and  suppleness  of 
the  skin  are  so  compromised  that  mobility  is  more  or  less  interfered  with, 
and  fissures,  often  somewhat  deep,  occur  about  the  joints.  Moreover, 
in  these  instances,  as  well  as,  in  fact,  in  milder  cases,  during  cold  weather, 
eczematous  tendency  and  complication,  especially  of  the  face,  hands, 
and  forearms,  are  usually  observed,  in  which  event  the  features  of 
this  latter  disease  are  superadded.  Some  subjects  seem  more  predis- 
posed to  the  effects  of  irritation  than  others.2 

These  several  grades  represent  examples  of  what  might  be  termed 
true  ichthyosis,  in  contradistinction  to  ichthyosis  hystrix,  about  the 
status  of  which  there  is  some  difference  of  opinion.  The  condition  of 
the  surface  varies  from  a  branny  desquamation  to  that  of  thick,  horny 
plates,  the  latter  usually  more  or  less  quadrilateral  and  roughly  diamond 
shaped.  Those  regions  where  the  integument  is  thin  and  softer,  as 
the  flexures,  neck,  face,  inner  part  of  the  thighs,  etc.,  are  always  less 
involved  than  other  parts,  and  in  many  of  the  milder  cases  are  scarcely 
or  at  all  affected.  The  scales  are  exceptionally  somewhat  shiny  and 
seemingly  translucent  (ichthyosis  nitida,  ichthyosis  nacree),  but  usually 
are  dirty  grayish,  and,  in  marked  and  extreme  cases,  often  brownish 
gray,  greenish,  or  blackish  (ichthyosis  nigricans).  Other  terms  are 
occasionally  met  with  in  literature — ichthyosis  serpentina,  or  resembling 

1  See  papers  by  G.  H.  Fox,  "The  'Alligator  Boy'— A  Case  of  Ichthyosis"  (with 
colored  plate),  Jour.  Cutan.  Dis.,  1884,  p.  97;  and  by  Yandell,  "The  'Man  Fish'  of 
Tennessee,"  Louisville  Med.  News,  1878,  p.  262. 

2  Besnier,  "Ichthyoses  irritables,"  Annales,  1889,  p.  534. 


1CHTHYOSIS 


563 


the  skin  of  a  serpent,  ichthyosis  sauroderma,  or  sauriasis,  suggestive  of 
a  crocodile  skin,  ichthyosis  scutellata,  scales  somewhat  shield  shaped. 
The  hair  and  nails  usually  show  nutritive  changes,  being  harsh  and  lus- 
terless,  the  nails  being  often  quite  fragile  and  easily  broken.  The  sweat 
and  oil  secretions  are  much  dimin- 
ished, and  sometimes  in  complete 
or  relatively  complete  abeyance. 
As  already  remarked,  there  are 
rarely  any  subjective  symptoms, 
occasionally  slight  itching,  which, 
however,  is  more  commonly  due 
to  eczematous  complications.  Fis- 
sures, when  present,  may  however, 
be  quite  painful. 

The  course  of  the  malady  in 
these  cases  is  usually  quite  char- 
acteristic, appearing  early  in  life, 
increasing  slightly  during  childhood 
and  adolescence,  and  being  less 
pronounced  during  the  warm  sea- 
son and  most  marked  in  winter. 
The  type  once  established,  whether 
mild,  moderate,  or  severe,  remains 
about  the  same  throughout  life. 
In  the  milder  cases,  during  the 
summer  weather,  owing  to  the  in- 
creased activity  of  the  sweat  and 
sebaceous  secretions,  evidences  of 
the  malady  almost  wholly  or  en- 
tirely disappear,  to  present  again 
on  the  approach  of  cooler  weather. 
In  the  severe  types  also  there  is  a 
variable  lessening  of  the  condition 
during  such  period.  The  amount 
of  scaliness  present  in  a  given  case 
depends  to  some  extent  upon  the 
patient's. habits  as  to  the  frequency 
of  general  ablutions. 


Fig.  135. — Ichthyosis  congenita.  Case 
photographed  when  four  days  old. 
Mother  pregnant  seven  times,  giving 
birth  the  fifth  and  the  last  (present  case) 
to  infants  with  congenital  ichthyosis;  the 
former  (Sherwell's  case  referred  to)  still 
living  (courtesy  of  Dr.  J.  MacF.  Win- 
field). 


The  malady  is  usually  first  noted  in  the  first  or  second  year,  although 
it  is  probably  born  with  the  individual,  but  that  during  the  first  months 
it  is  so  slight,  the  skin  so  frequently  washed,  and  owing  to  the  warmth 
of  the  body,  the  consequently  perspiratory  action,  favored  by  the  usual 
overclothing  at  that  period,  so  free,  that  it  could  be  thus  kept  in  abey- 
ance, and  its  existence  readily  overlooked.1  In  other  rarer  instances 

1  Broca  'and  other  French  observers  have  in  recent  years  called  attention  to  a 
form  of  Tchthyosis  (designated  6rvthrodermie  congenitale  ichthyosiforrne,  congenital 
SS^jSSf^SSS  observed  usually  at  birth,  but  '^^LS^ 
respects  from  the  ordinary  cases  of  ^th^  ID0«  e*>e^  M  v^rnfshed  ookinK 
the  flexures  where  it  may  be  lichenoid;  and  with  a  shiny,  reddened  varnish 
condidon  of  The  sk  n  of  the  face,  and  wrinkled  condition  of  the  skin  m  general,  with 


564  HYPERTROPHIES 

the  child  is  born  with  all  the  conditions  of  a  marked  ichthyosis  present, 
sometimes  of  pronounced  character  (ichthyosis  congem'ta,  keratoma 
diffusum,  intra-uterine  ichthyosis),  examples  of  which  have  been  reported 
by  a  number  of  observers,  among  whom  Lebert,1  Caspary,2  Hutchinson,3 
Sutton,4  Elliot,5  Sherwell,6  Winfield,7  Schwartz,8  and  others.  The 
scaliness  in  these  cases  varies  from  a  brownish,  parchment-like  exfolia- 
tion to  that  of  plate-like  character,  and  usually  with  superficial  or  deep 
rhagades,  more  or  less  ectropion,  puckering  and  fissuring  of  the  mouth 
and  other  mucous  outlets,  and  sometimes  distortion  of  the  nose  and 
ears  as  well,  constituting  the  so-called  "harlequin  fetus."  These  children 
are,  as  a  rule,  prematurely  born,  and  frequently  do  not  survive  many 
days  or  weeks.  Hebra  and  Kaposi  have  considered  all  these  cases  as 
generalized  seborrhea  (ichthyosis  sebacea),  a  view,  however,  which  is 
not  at  all  in  consonance  with  the  observations  of  others.9  It  is  not  im- 
probable that  several  maladies  may  present  somewhat  similar  conditions 
at  birth,  such,  for  instance,  as  a  pronounced  and  somewhat  persistent 
vernix  caseosa.  Some  of  the  milder  cases  presenting  at  birth  a  mem- 
branous coating  somewhat  suggestive  of  a  layer  of  collodion  or  oiled 
paper,  such  as  those  of  Hallopeau,10  Grass  and  Torok,11  and  Bowen,12 
are,  in  the  opinion  of  Bowen,  "examples  of  a  persistence  of  the  epitrichial 
layer,  which  has  usually  been  cast  off  by  the  seventh  fetal  month,  but 
in  these  instances  maintained  its  integrity  up  to  the  time  of  birth,  when 
it  enveloped  the  infants  like  a  distinct  membrane,  such  as  is  found  in 
certain  animals.  After  a  short  time  this  membrane  begins  to  peel  off 
in  large  masses  and  sheets,  leaving  the  normal  skin  below  in  a  state  of 
moderate  desquamation,  which  slowly  subsides."  Grass  and  Torok 

now  and  then  a  tendency  to  bleb  formation,  and  to  keratotic  thickening  of  the  palms, 
or  palmar  aspects  of  the  fingers,  together  with  palmar  and  plantar  hyperidrosis. 
Jadassohn,  Blatt  fur  Schweizen  Aerzte,  1911,  No.  13,  has  more  recently  recorded  3 
cases  (demonstration);  and  Fernet,  "Bullous  Ichthyosis,"  Brit.  Jour.  Derm.,  1911, 
p.  344,  reports  a  case  and  gives  a  resume  of  the  French  observations. 

'Lebert,   Ueber  Keratose,  Breslau,  1864  (reviews  9  cases). 

_2  Caspary,  "Ueber  Ichthyosis  Fcetalis,"  Archiv,  1886,  vol.  xiii,  p.  3  (2  cases,  with 
review  and  references,  colored  plate,  and  two  histologic  cuts). 

'Hutchinson,  Clinical  Lectures — Rare  Diseases  of  the  Skin,  p.  172  (Mackenzie's 
case). 

4  Sutton,  "A  Case  of  Generalized  Seborrhcea  or  'Harlequin'  Foetus,"  London  Mcd.- 
Chirurg.  Trans.,  1886,  p.  291  (with  colored  plate,  histologic  cut,  and  bibliography). 

6  Elliot,  Jour.  Cutan.  Dis.,  1891,  p.  20  (2  cases,  with  review  and  some  literature 
references). 

6  Sherwell,  ibid.,  1894,  p.  385  (with  some  literature  references). 

7  Winfield,  ibid.,  1897,  p.  516  (with  case  illustration  and  autopsy,  and  microscopic 
examination  by  Van  Cott).     See  also  Wasmuth's  recent  paper,  "Beitrag  zur  Lehre  von 
der  Hyperkeratosis  Congenita,"  Ziegler's  Beitrage,  1899,  vol.  xxvi,  p.  10  (case  illustra- 
tion, histologic  cuts). 

*  Schwartz,  Bull,  of  Lying-in  Hospital  of  New  York,  March,  1910,  reports  a  case 
with  illustration:  the  mother  had  ichthyosis;  her  first  child  died  at  the  age  of  12  days, 
with,  according  to  the  mother,  the  same  malady  (ichthyosis  congenita)  and  also  the 
4th  and  6th  children  (these  two  seen  by  Dr.  Schwartz);  the  4th  child  died  on  second 
day  after  birth,  the  6th  child  (the  case  pictured)  died  on  the  fourth  day. 

9  See  Caspary  and  Elliot's  papers. 

|°  Hallopeau  and  Watelet,  Annales,  1895,  p.  149  (case  demonstration).  ' 

1  Grass  and  Torok,  ibid.,  1895,  P-  104. 

_  "Bowen,  "The  Epitrichial  Layer  of  the  Epidermis  and  its  Relationship  to  Ichthyo- 
sis Congenita,"  Jour.  Cutan.  Dis.,  1895,  P-  485  (gives  abstract  review  of  above  two 
papers);  Meneau,  "De  1'ichthyose  foetale  dans  ses  rapports  avec  1'ichthyose  vulgaire" : 
Annales,  1903,  p.  97  (a  thorough  review  with  complete  bibliography). 


ICHTHYOSIS 


565 


take  a  somewhat  similar  view,  but  they  would  also  include  the  ichthyosis 
sebacea  of  Hebra  and  Kaposi  in  the  same  category.  In  the  3  cases 
referred  to  "the  general  health  was  not  visibly  affected  by  the  abnormality 
of  the  skin."  A  reading  of  the  literature  would  indicate  that,  while 
many,  such  as  most  of  Lebert's,  Elliot's,  Sherwell's,  Winfield's,  and  others, 
are  clearly  examples  of  congenital  or  fetal  ichthyosis,  all  reported  cases 
do  not  represent  this  malady — some  the  type  of  delayed  physiologic 
shedding  just  referred  to,  others  doubtless  generalized  seborrhea  (ich- 
thyosis sebacea,  persistent  vernix  caseosa),  and,  it  is  not  improbable, 
in  a  few  instances,  infantile  dermatitis  exfoliativa. 

Ichthyosis  hystrix  is  usually 
looked  upon,  as  already  remarked, 
as  an  infrequent  variety  of  ich- 
thyosis, but  it  has  many  features 
which  seem  to  stamp  it  as  a  prac- 
tically distinct  affection.  It  is 
rarely,  if  ever,  generalized,  but 
usually  limited  to  one  or  several 
regions;  exceptionally  it  is  true, 
it  is  more  or  less  irregularly  dif- 
fused. It  presents  in  patches  of 
various  size  and  shape,  some- 
times ill  defined,  made  up  of 
thickened,  rough,  warty-looking, 
hypertrophic,  papillary  elevations 
of  variable  size  up  to  \  inch  or 
more.  The  surface  is  uneven, 
more  or  less  corrugated,  some- 
times with  horny,  spinous  growths, 
which  may  be  of  considerable 
dimensions — hence  the  term  hys- 
trix, or  spiny,  and  also  the  term 
applied  to  extreme  cases — "por- 
cupine men"  "hedge-hog  skin," 
"rhinoceros  skin."  In  the  milder  cases  of  this  type  there  is  a  resemblance 
to  the  rough  bark  of  a  tree.  The  underlying  skin  is  harsh,  dry,  and  often 
considerably  thickened,  and  in  some  instances— suggestive  connecting 
cases  between  ichthyosis  simplex  and  ichthyosis  hystrix— the  inter- 
vening surface  is  dry,  rough,  and  scaly  to  a  variable  degree,  corresponding 
to  that  of  the  more  common  form  of  ichthyosis.  As  a  rule,  however, 
the  skin  between  or  outside  the  areas  is  normal.  In  color  the  patches 
vary  somewhat,  being  yellowish-gray,  yellowish,  or  greenish.  Some- 
times the  warty  or  spine-like  protuberances  are  cast  off  from  tim 
time,  as  in  one  of  the  celebrated  Lambert  cases,1  to  be  rapidly  repr< 

duced.  .          , 

Limited  and  peculiarly  shaped  ichthyotic-lookmg  erupticns,  h 

iTelesius  "Beschreibung  und  Abbildung  der  beiden  sogenannte  Stachelschwem- 
Menschen  aus  der  EngTischel  Familie  Lambert,"  oder  "the  Porcupine  man,  Alten- 
burg,  1802— abstract  account  by  Lebert,  loc.  cit.,  p.  126. 


Fig.  136.— Ichthyosis  hystrix  in  a  lad 
aged  twelve,  on  parts  below  the  knees  of 
mild  (ichthyosis  simplex)  type. 


5  66  H  YPER  TR  OPHIES 

tofore  included  as  cases  of  ichthyosis  simplex  and  of  ichthyosis  hystrix, 
such  as  "chronic  palmar  and  plantar  ichthyosis,"  "linear  ichthyosis," 
and  "ichthyosis  linguae,"  are  no  longer  considered  as  belonging  to  this 
malady.  Chronic  palmar  and  plantar  ichthyosis  corresponds  to  kera- 
tosis  palmaris.  et  plantaris,  linear  ichthyosis  to  linear  naevus,  and  ich- 
thyosis linguae  ordinarily  to  leukoplakia.  It  is  not  improbable,  more- 
over, that  some  cases  of  keratosis  follicularis  were  formerly  described 
under  ichthyosis.  While  ichthyosis  simplex  and  ichthyosis  hystrix 
usually  exhibit  clinical  distinctions  throughout  their  course  as  to  give 
good  ground  for  the  belief  in  their  individuality,  yet  in  exceptional  in- 
stances the  features  of  both  are  seen  to  be  present  in  the  one  case,— 
constituting  the  mixed  variety, — as  in  the  case  of  my  own  here  illustrated. 
In  this  the  hystrix  variety  of  moderate  degree  is  shown  especially  on 
the  thighs  from  the  knees  up,  as  well  as  less  markedly  in  other  places, 
while  on  regions,  as  below  the  knees  and  elsewhere,  the  dryness,  harsh- 
ness, slight  to  moderate  scaliness,  quite  characteristic  of  ichthyosis 
simplex.  In  Thibierge's  case,1  as  in  some  others  on  record,  the  mixed 
character  was  also  observed.  In  this  latter  instance,  moreover,  the 
mucous  membrane  of  the  mouth  and  nares  shared  in  the  process — an 
extremely  rare  and  almost  unknown  occurrence.  Another  exceptional 
feature  is  an  atrophic  condition  of  the  skin,  which  has  been  noted  in  a 
few  instances  by  Jadassohn,2  Hallopeau  and  Jeanselme,3  and  Audry.4 
Unusual  features  in  a  so  usually  well-marked  malady  as  ichthyosis  must 
always  be  viewed  with  suspicion.5 

Very  rarely  cases  (described  variously  as  ichthyosis  follicularis, 
ichthyosis  cornea,  pityriasis  pilaris,  follicular  xeroderma,  etc.)  are  met 
with  in  which  the  brunt  of  the  process  seems  to  be  predominantly  follicu- 
lar, presenting,  clinically,  features  of  a  marked  keratosis  pilaris,  and, 
less  strikingly,  of  keratosis  follicularis,  with  a  variable,  underlying, 
dry,  xerodermic,  or  ichthyotic  surface;  in  few  such  instances  the  malady 
is  not  general.  In  some  cases  the  projecting  follicular  spines,  after  fall- 
ing out,  leave  distinct  atrophy;  in  others,  involving  the  hairy  regions, 
there  results  more  or  less  baldness.  These  cases  are  hard  to  classify.6 

IJtiology. — The  malady  is  congenital,  and  in  most  cases  a  hered- 
itary tendency  is  noted,  the  history  of  one  or  more  direct  ancestors  or 
collateral  relatives  having  the  same  disease  being  quite  usual.  While 
the  condition  of  the  skin,  referring  more  especially  to  ichthyosis  simplex, 

1  Thibi6rge,  "Cas  extraordinaire  d'ichthyose  generalisee  avec  alterations  des  mu- 
queuses  buccale  et  nasale  des  cornees,"  Annales,  1892,  p.  717. 

2  Jadassohn,  "Ueber  Pityriasis  alba  atrophicans,"  Verhandl.  der  IV.  Deutsch.  Der- 
malolog.  Gesettsch.,  1894,  p.  392. 

3  Hallopeau  and  Jeanselme,  "Sur  une  ichthyose  avec  hypotrophie  simulant  une 
sclerodermie,"  Annales,  1895,  p.  1016  (case  demonstration). 

4  Audry,  "Sur  les  formes  atrophicantes  de  1'ichthyose  et  leur  histologie,"  Jour.  mal. 
ctttan.,  1895,  p.  265. 

5  See  also  Joseph's  paper,  "Ueber  ungewohnliche  Ichthyosisformen,"   Verhandl. 
der  IV.  Deutsch.  Dermatolog.  Gesellsch.,  1894,  p.  407  (case  illustration  and  histologie 
cut — case  suggestive  of  both  acanthosis  nigricans  and  Darier's  disease). 

6  Macleod,  "Three  Cases  of  Ichthyosis  Follicularis  Associated  with  Baldness,"  Brit. 
Jour.  Derm.,  1909,  p.  165,  goes  over  this  entire  subject,  reviewing  various  cases  reported 
(with  references) ,  and  making  a  good  attempt  to  clear  up  the  nomenclature  of  the  follic- 
ular diseases  in  which  horny  spines  or  plugs  occur. 


v  ICHTHYOSIS  567 

is  generally  noticed  only  toward  the  end  of  the  first  or  second  year, 
it  is  quite  probable,  as  already  stated,  that  it  is  in  reality  always  con- 
genital. I  am  inclined  to  share  Hutchinson's1  belief  on  this  point,  "that 
it  usually  takes  its  origin  during  intra-uterine  existence,  but  that  it  may 
be,  in  many  cases,  so  slight  at  the  time  of  birth  that  its  presence  is  en- 
tirely overlooked.  On  the  other  hand,  it  may  have  already  developed 
to  such  a  degree  of  severity  that  the  infant  is  quite  incapable  of  taking 
on  the  functions  of  life  for  itself."  These  latter  represent  those  of  the 
so-called  ichthyosis  congenita  already  described.  Exceptionally  exam- 
ples of  an  ichthyotic  condition  of  the  skin  have  been  noted  in  which  the 
development  presented  later  in  life,  but  these  are  usually  open  to  ques- 
tion, although  Crocker2  refers  to  a  suggestive  case  of  acquired  ichthyosis 
in  a  man  aged  seventy-four,  in  whom  the  sweat  function  became  less 
active  or  more  or  less  in  abeyance  ten  years  previously,  and  the  skin  then 
began  to  get  dry  and  scaly,  finally  presenting  appearances  clinically 
similar  to  those  in  the  ordinary  cases.  In  some  instances  the  hereditary 
predisposition  is  exhibited  only  in  one  or  two  of  the  children,  but  ex- 
amples of  its  occurrence  in  three  and  more  members  of  the  same  family 
have  been  recorded  from  time  to  time  by  various  observers  (Kaposi, 
Crocker,  Jeanselme,  Frick,  and  others).3  Occasionally  a  predominant 
family  tendency  to  its  appearance  in  those  of  one  sex  has  been  noted. 
Both  sexes  are,  however,  its  subjects  in  probably  about  equal  proportion, 
although  most  of  the  cases  under  my  own  observation  have  been  males. 
It  is  observed  in  all  stations  of  society.  It  is  not,  however,  a  common 
disease,  although  in  its  slight  grade  (xeroderma)  it  is  doubtless  more 
frequent  than  it  apparently  seems.  It  is  met  with  in  all  countries.  In 
districts  where  family  intermarriage  is  not  uncommon  its  relatively 
more  frequent  occurrence  is  suggestive  of  an  endemic  character,  as  in  the 
Indian  Archipelago,  especially  the  Molucca  Islands,  referred  to  by 
Hirsch,4  and  also,  according  to  Jablonowski,5  among  two  Albanian 
tribes  on  the  Adriatic  shores.  As  Hirsch  states,  however,  and  as  Jab- 
lonowski's  description  indicates,  it  is  probable  that  all  these  cases  thus 
referred  to  are  not  examples  of  this  disease.  In  fact  Henggeler6  has 
noted,  in  India,  that  most  cases  thought  to  be  ichthyosis  were  cases  of 
tinea  imbricata.  A  condition  of  the  skin  somewhat  similar  to  that  of 
ichthyosis  has  been  noted  by  Schuchardt7  in  workers  in  paraffin.  From 
the  absence  of  the  thyroid  in  his  case  of  "ichthyosis  congenita,"  Winfield 
suggests  further  observation  on  this  point  as  to  possible  etiologic  rela- 
tionship. 

Pathology.— It  is  the  common  opinion  that  ichthyosis  is  to  be 

1  Hutchinson,  Archives  of  Surgery,  1891-92,  vol.  iii,  p.  64. 

2  Crocker.  Brit.  Jour.  Derm.,  1895,  p.  217  (case  demonstration). 

3  Kaposi,  Diseases  of  the  Skin  (English  translation  by  Johnston)  p.  440  (m  a  family 
of  8  children,  5  affected);  Crocker,  Diseases  of  the  Skin,  third  edit.,  p   569  (5  "»  a 
family  of  10  children);  Jeanselme,  Annales,  1894,  P-  ™77  (4  out  of  5  children);  Fi 
Jour.  Cutan.  Dis.,  1897,  P-  19  (3  in  a  family  of  4  children)  „, 

*  Hirsch,  Handbook  Geog.  and  Histor.  Pathology,  Syd.  Soc.  Translation,  1886, 
vol.  iii,  p.  666. 

5  Jablonowski,  abs.-ref.  in  Monatshefle,  1884,  vol.  m,  p.  3»3- 

8  Henggeler,  "Ueber  einige  Tropenkrankheiten:  Tinea  Imbricata,  Monatshejte, 
1900,  vol.  xliii,  p.  325  (with  excellent  case  illustrations). 

'Schuchardt,  Volkmann's  klin,  Vortrdge,  No.  257  (Chirurgie  No.  80),  p.  2214. 


568  HYPERTROPHIES 

viewed  as  an  inherited  deformity  of  the  skin  rather  than  a  disease. 
The  pathologic  changes  were  originally  considered  seated  essentially  in 
the  epidermis,  but  later  observations,  however,  tend  to  hold  the  surface 
alterations  as  due,  partly  at  least,  to  underlying  processes  in  the  corium, 
especially  of  the  connective  tissue.  That  the  nervous  system  is  a  factor 
seems  probable  from  the  observations  concerning  examples  of  local  dry- 
ness  and  scaliness  resulting  from  nerve  injuries.  Leloir,1  who  among 
others  considers  the  disease  of  trophoneurotic  origin,  found  in  2  cases  a 
degenerative  peripheral  neuritis,  and  in  i  of  these  cases  also  degenerative 
changes  in  the  spinal  roots.  These  observations  have  not,  however, 
been  corroborated  by  others.  The  histologic  characters  have  been 
studied  by  various  observers,  the  latest  among  whom  are  Esoff,2  Unna,3 
Audry,4  Tommasoli,5  Giovannini,6  and  others.  Esoff  found  the  increased 
formation  of  epithelial  scales,  with  heightened  tendency  to  cornifica- 
tion,  and  the  greater  thickness  of  the  epidermis  due  principally  to  its 
longer  retention,  the  process  of  exfoliation  being  slowed.  Degenerative 
changes  were  also  observed  in  both  the  coil-  and  sebaceous  glands. 
Unna  states  that  there  is  deformity  of  a  weakly  developed  prickle  layer 
and  of  the  papillary  body,  together  with  a  much  thickened  horny  layer. 
The  granular  layer  is  everywhere  absent  on  the  surface  of  the  prickle 
layer,  and  there  is  absence  of  keratohyalin,  the  horny  layer  being  formed 
directly  from  the  rete,  without,  as  usual,  the  intervention  of  this  sub- 
stance. The  horny  cells  thus  formed  have  no  nuclei  and  are  homo- 
geneous, there  occurring,  in  fact,  a  special  form  of  abnormal  cornification. 
In  the  changes  in  the  tissue  of  the  cutis  the  papillary  body  is  sometimes 
more  cellular  than  normal,  the  cells  often  larger,  as  likewise  the  endo- 
thelia  and  perithelia  of  the  superficial  capillaries,  and  also  increased  in 
number.  The  collagenous  tissue  is  thickened,  and  the  lymph-spaces 
correspondingly  narrowed.  A  small  collection  of  ordinary  spindle  cells 
sometimes  surrounds  the  hair-follicles.  In  the  more  severe  cases  the 
cellular  infiltration  is  more  pronounced.  The  papillae  are  usually  more 
or  less  compressed  and  thus  lengthened,  sometimes  being  flattened. 
He  believes  that  the  findings  indicate  a  low  inflammatory  basis,  is  to  be 
ascribed  to  ichthyosis,  and  that  it  is  not  simply  a  thickening  of  the  horny 
layer.  Tommasoli  also  found  somewhat  similar  changes  in  the  cutis, 
as  well  as  the  usual  changes  in  the  epidermis.  Audry  did  not,  on  the 
contrary,  find  evidences  of  an  inflammatory  process;  the  granular  layer 
was  considerably  hypertrophied ;  the  sweat-glands  seemed  unchanged, 
but  there  was  atrophy  of  the  sebaceous  glands.  In  a  case  investigated 
by  Giovannini  the  predominant  changes  were  observed  about  the 
periphery  of  the  sweat-gland  ducts,  with  mitosis  of  the  epithelial  cells 
of  the  ducts. 

'Leloir,  Arch,  de  Physiolog.,  1881,  p.  405. 

2  Esoff,  "Beitrag  zur  Lehre  von  der  Ichthyosis,  etc.,"  Virchow's  Archil),  1877,  p. 
417  (with  histologic  cuts  and  references). 

3  Unna,  Histo pathology,  p.  322  (with  histologic  cuts). 

4  Audry,  "Critique  anatomique  de  quelques  keratonoses,"  Annales,  1893,  p.  384. 
'Tommasoli,  "Sur  1'histopathologie  et  la  pathogenic  de  1'ichthyose,"  Annales, 

J893i  P-  537  (with  literature  references). 

6  Giovannini,  Giorn.  della  R.  Accad.de  Med.  di  Torino,  Dec.,  1893,  p.  653 — abstract 
in  Annales,  1894,  p.  1176. 


ICHTHYOSIS 


569 


The  process  consists,  in  the  simplex  variety,  of  an  accumulation 
and  thickening  of  the  epidermis,  but  especially  of  the  horny  layer,  and 
often  a  somewhat  thinned  condition  of  the  rete.  The  formerly  con- 
sidered papillary  hypertrophy  is  apparent,  more  than  real,  the  irreg- 
ularities resulting  from  a  dipping-down  of  the  horny  strata,  the  papillae 
being  thus  compressed  and  elongated.  In  fact,  the  papillae  themselves 
often  show  atrophy.  Slight  evidences  of  inflammatory  action  are  some- 
times found  in  the  cutis,  and  the  glandular  structures  in  marked  cases, 
usually  after  long  continuance  of  the  malady,  undergo  degenerative 
changes.  There  is,  as  a  rule,  poor  development  of  the  panniculus  adiposa. 
The  associated  keratosis  pilaris,  often  most  marked  in  some  of  the  milder 
types,  presents  but  little,  if  any,  essential  variation  from  that  form  which 
occurs  independently. 

In  ichthyosis  hystrix,  according  to  Schourp,1  the  direct  transition 
from  rete  cells  into  horny  cells  without  material  intermediate  change 
is  also  noted.  Kaposi  (loc.  tit.}  states  that  the  anatomic  conditions  in 
this  form  of  the  disease  do  not  differ  from  those  in  old  warts:  enor- 
mously elongated  papillae,  above  which  the  horny  layer  is  piled  up  in 
thick,  stratified  coats.  There  is  moderate  cell-infiltration  of  the  papillae, 
with  dilated  vessels. 

Diagnosis. — The  features  of  ichthyosis  are  usually  so  character- 
istic that  no  difficulty  arises  in  the  diagnosis.  The  harsh,  dry  skin, 
with  thickened  epidermis,  and  furfuraceous  to  plate-like  scaliness,  with 
frequently  follicular  elevations  (keratosis  pilaris)  or  warty-looking 
growths,  its  greater  development  upon  the  extensor  surfaces,  and  the 
absence  of  inflammatory  symptoms,  constitute  a  picture  quite  readily 
recognized.  Moreover,  there  is  the  history  of  the  affection  dating  back 
to  infancy  or  earliest  childhood,  and  its  amelioration,  or  in  mild  type 
complete,  or  almost  complete,  disappearance  during  the  summer  weather, 
as  corroborative  evidence.  It  is  to  be  borne  in  mind,  however,  that  in 
some  instances,  especially  in  cold,  snappy,  windy  weather,  eczematous 
complications,  more  particularly,  however,  of  exposed  parts,  is  occasion- 
ally observed,  and  this  fact  should  not  be  permitted  to  mislead.  The 
local  character  of  the  ichthyotic-looking  skin  in  elephantiasis,  as  well  as 
the  other  associated  symptoms,  will  prevent  this  latter  being  confused 
with  true  ichthyosis.  The  same  may  be  said  as  to  the  exceptional  in- 
stances of  eczema  verrucosum  of  the  region  of  the  lower  leg  and  ankle. 

The  features  of  ichthyosis  hystrix  are  usually  still  more  pronounced 
and  characteristic,  and  an  error  is  scarcely  possible.  It  should  not  be 
confused  with  linear  naevus. 

Prognosis.— There  is  generally  a  slight,  but  often  not  mate- 
rial, increase  in  the  condition  up  to  the  age  of  youth  or  early  adult  life, 
after  which  it  remains  practically  stationary,  with  sometimes  trifling 
improvement.  The  type  once  established,  it  practically  remains  un- 
changed, the  mild,  moderate,  and  severe  varieties  each  continuing  as 
such.  The  outlook  for  the  patient  as  regards  a  cure  is  unfavorable,  as 
may  be  inferred  from  what  has  already  been  said,  but  the  process  in 
ichthyosis  simplex  may  usually  be  kept  more  or  less  in  abeyance,  o 
1  Schourp,  "Ueber  Ichthyosis  hystrix,"  Dermatolog.  CentraMaU,  1898,  p.  242. 


570 


//  YPER  TR  OPHIES 


rendered  endurable  by  proper  measures.  The  disease  continues  through- 
out life,  and,  so  far  as  I  know,  but  two  exceptions  to  this  are  on  record- 
by  Hebra1:  in  one  instance  of  an  ichthyosis  simplex  in  a  girl  of  eight, 
which  disappeared  permanently  in  consequence  of  an  attack  of  measles; 
the  other,  the  hystrix  variety,  after  an  attack  of  variola.  It  is  not  im- 
possible that  if  treatment  were  begun  in  early  life  and  perseveringly  con- 
tinued, in  the  milder  varieties  at  least,  a  favorable  result  might  be 
brought  about. 

Treatment. — The  treatment  of  ichthyosis  is  essentially  external, 
but  first  a  few  remedies  occasionally  administered  internally  should 
be  referred  to.  Of  the  several  so  employed,  those  which  seem  at  times 
to  have  a  favorable,  though  temporary,  influence  are  pilocarpin  and 
thyroid  extract.  In  several  instances  it  has  seemed  to  me  that  pilo- 
carpin or  jaborandi,  administered  in  dosage  sufficient  to  stimulate  the 
sweat  secretion,  has  tended  to  make  the  skin  more  supple  and  the 
scaliness  less  marked.  Thyroid  is  a  preparation  that  deserves  trial, 
in  view  of  the  favorable,  though  admittedly  temporary,  influence  re- 
ported by  Don,2  Bramwell,3  Abraham,4  and  a  few  others.  Hardaway5 
believes  that  he  has  seen  some  effect  in  mild  cases  from  the  adminis- 
tration of  two  or  three  Garrod's  sulphur  tablets  daily.  Fagge6  recom- 
mended antimonial  wine.  In  those  of  impaired  nutrition  cod-liver  oil 
seems  to  be  of  some  slight  service.  Sherwell7  thought  the  administration 
of  linseed  to  be  of  advantage.  After  all,  the  treatment  which  must 
always  be  adopted  in  these  cases,  if  certainty  of  amelioration  or  relief 
is  desired,  consists  in  external  measures,  and  these,  if  properly  followed 
up  and  continued,  will  often  bring  about  the  appearance  of  an  apparently 
normal  skin.  When  this  is  effected,  treatment  is  to  be  continued,  but 
much  less  rigorously.  There  are  especially  two  objects  to  be  kept  in 
mind  in  the  management  of  these  cases — removal  of  the  scaliness  and 
the  maintenance  of  a  soft  and  pliable  condition  of  the  skin.  For  the  first, 
frequent  baths  will  often  suffice.  These  baths  will,  according  to  the 
severity  of  the  case,  be  either  plain  warm  baths,  alkaline  baths,  or  hot- 
water  baths  with  the  free  use  of  sapo  viridis — the  same,  in  fact,  as  used 
in  psoriasis.  Steam  and  hot-air  baths  may  also  be  had  recourse  to  for 
rapidity  of  action  or  in  cases  in  which  there  is  considerable  firm  epidermic 
thickening.  After  each  bath  the  skin  should  be  rubbed  or  anointed  with 
a  mild  salve  or  oil.  In  the  mildest  cases  the  baths  alone  will  serve  to 
keep  the  skin  in  an  apparently  normal  state;  in  the  others,  and  always 
in  the  more  severe  cases,  an  oily  application  should  be  made  after  each 
bath.  A  weak  glycerin  lotion,  from  \  dram  to  2  drams  (2.-S.')  to  the 
ounce  (32.)  of  water,  oil  of  sweet  almonds,  cold  cream,  benzoated  lard, 
petrolatum,  or  the  like  will  answer  for  this  purpose.  The  addition  of 

1  Hebra  and  Kaposi,  Hantkranklteiten,  1876,  vol.  ii,  p.  41. 

2  Don,  Brit.  Med.  Jour.,  1897,  ii,  p.  1334. 

3  Bramwell,  Brit.  Jour.  Derm.,  1894,  p.  205. 

4  Abraham,  ibid.,  1896,  p.  106  (discussion). 

5  Hardaway,  Manual  of  Skin  Diseases,  second  ed.,  p.  261. 

8  Fagge,  quoted  by  Pye-Smith,  Diseases  of  the  Skin,  p.  284. 

7  Sherwell,  "The  Use  of  Linseed  and  Linseed  Oil  as  Therapeutic  Agents  in  Diseases 
of  the  Skin,"  Arch.  Derm.,  1878,  p.  303. 


POR  OKERA  TO  SIS  5  7 1 

lanolin  in  the  proportion  of  from  15  to  30  per  cent,  to  one  of  the  oint- 
ments named  will  sometimes  prove  an  advantage.  In  most  cases  the 
incorporation  of  from  10  to  40  grains  (0.65-2.6)  of  salicylic  acid  to  the 
ounce  (32.)  of  ointment  will  be  found  more  effective.  A  satisfactory 
ointment  is  one  consisting  of  10  to  40  grains  (0.65-2.6)  of  salicylic  acid, 
glycerin  20  minims  (1.35),  lanolin  2  drams  (8.),  benzoated  lard  and  pe- 
trolatum, each,  3  drams  (12.).  The  quantity  of  salicylic  acid  depends 
upon  the  amount  and  rapidity  of  scale  accumulation.  The  addition 
of  resorcin,  3  to  10  per  cent.,  is  an  advantage;  this  drug,  applied  in  oint- 
ment of  3  per  cent,  strength  in  mild  cases,  and  5  to  20  per  cent,  in 
markedly  developed  cases,  has  been  strongly  recommended  by  Andeer1 
and  indorsed  by  Jamieson.2  The  latter  considers  it  superior  to  the  sul- 
phur ointment  plan.  Unna3  speaks  well  of  a  course  of  treatment  con- 
sisting of  the  daily  application  of  sulphur  ointment  of  variable  strength, 
usually  5  to  10  per  cent.,  and  also  of  ichthyol  applications,  10  per  cent., 
with  water  or  in  ointment,  and  frequent  baths;  he  refers  to  several  cases 
in  which  the  good  results  remained  for  several  months  or  longer  after 
active  measures  had  been  discontinued.  Occasional  sulphur  vapor 
baths  in  conjunction  with  the  milder  ointment  and  bath  plan  will 
sometimes  prove  of  additional  benefit. 

In  ichthyosis  hystrix,  alkaline,  steam,  hot-air,  and  sulphur  baths, 
together  with  the  use  of  the  strong  salicylic  acid  ointment,  will,  in  the 
milder  varieties,  usually  suffice  to  clear  off  the  horny  accumulation. 
Sometimes,  however,  the  formation  is  so  hard  and  adherent  that  the 
application  of  salicylic  acid  plasters,  10  to  25  per  cent,  strength,  is  re- 
quired, and  in  extreme  cases  it  may  be  necessary  to  have  recourse  to 
caustics  or  to  the  knife. 

POROKERATOSIS 

Synonyms. — Hyperkeratosis  eccentrica;  Keratodermia  eccentrica;  Hyperkeratosis 
figurata  centrifuga  atrophicans;  Fr.,  Porokeratose;  Hyperkeratose  figured  centrifuge 
atrophiante. 

Under  this  title  Mibelli4  called  attention  to  a  rare  and  undescribed 
variety  of  hyperkeratosis,  presenting  in  small,  eccentrically  developing 
areas.  Simultaneously  appeared  also  a  description  of  the  malady  by 
Respighi,5  and  since  these  first  cases  new  reports  have  been  made  by 
the  same  observers  and  by  Hutchins,6  Reisner,7  Joseph,8  Gilchrist,9 

1  Andeer,  "Resorcin  bei  Ichthyosis,"  Monalshefic,  1884,  vol.  iii,  p.  365. 

2  Jamieson,  Diseases  of  the  Skin. 

3  Unna,  "Aphorismen  iiber  Schwefeltherapie  und  Schwefelpraparate,    Monalshefle, 

^MibeliiPGiorn.  tool.,  1893,  p.  313;  Monatshefle,  Nov.  i,  1893;  International  Atlas 
of  Rare  Skin  Diseases,  1893,  vol.  ix,  plate  xxvir,  Annales,  1905 ;,  p. ^503. 

6  Respighi,  Giorn.  Ual.,  1893,  p.  356,  and  1895,  p.  69,  and  Mono tshefte  (translation 
of  first  paper)   1894,  vol.  xviii,  p.  70  (with  case  illustration  and  histologic  cuts).    < 

•  Hutchins,  Jour.  Cutan.  Dis.,  1896,  p.  373  (with  case  illustration  and  a  review  ol 
the  published  cases,  with  references). 

7  Reisner,  Ein  Fall  von  Porokeratosis,  Inaug.  Dissertation,  btrassburg,  iSob-          . 
"M.  Joseph,  Archiv,  1897,  vol.  xxxix,  p.  335  (case  illustration  and  n  hist 

cuts ;  re  vie  w  of  other  published  cases  and  references) . 

'Gilchrist  (preliminary  paper),  Bull.  Johns  Hopkins  Hosp.,  1897,  P-  107;  (mar 
paper)  Jour.  Cutan.  Dis.,  1899,  P-  U9  (with  case  illustrations;  n  cases  in  one  family 
(four  generations);  5  histologic  cuts  and  bibliography). 


572 


H  YPER  TR  OPHIES 


G.  W.  Wende,1  and  Rasch.2  The  disease  is  extremely  slow  and  insidious, 
appearing  first  as  a  trifling,  superficial  but  slightly  elevated,  warty- 
looking  formation,  or  as  thin,  callous  spots.  These  gradually  enlarge, 
sometimes  months  or  years  elapsing  before  reaching  conspicuous  dimen- 
sions. The  spots  extend  by  a  peripheral  thickened  "seam,"  "dike," 
or  "wall,"  and,  usually  leave  an  atrophic,  generally  slightly  or  moderately 
calloused,  center.  In  some  cases  the  inclosed  portion  consists  of  some- 
what atrophic  glossy  epidermis,  in  others  a  trifle  thickened,  but  per- 
ceptibly depressed,  and  sometimes  presenting  a  dotted  appearance. 
The  border  is  rather  sharply  defined  against  the  outlying  sound  skin, 
and  is  hard  or  horny  in  character,  with  often  a  linear  horny  ridge,  in  the 
middle  line  of  which  there  is  a  narrow  sulcus,  and  in  this  very  often  a 
thin,  horny,  thread-like  or  cord-like  elevation,  somewhat  irregularly  di- 


Fig.  137. — Porokeratosis  (courtesy  of  Dr.  G.  W.  Wende). 

viding  the  sulcus  into  two  lateral  halves.  In  this  thus  inclosed  line  are 
often  found  here  and  there  round,  millet-seed  or  smaller  sized  blackish 
epidermic  concretions,  which  can  be  picked  out  (Hutchins).  Occasion- 
ally, too,  these  or  similar  concretions  or  minute  wart-  or  papillary-like 
corneous  projections  are  found  imbedded  in  the  inclosing  horny  lateral 
elevations  of  the  seam  or  border,  as  well  as  within  the  atrophic  hardened 
inclosed  portion.  Sometimes  the  border  is  distinctly  wall-like,  its  in- 
closing side  rather  sharply  perpendicular,  and  the  other  side  rapidly, 
but  not  precipitously,  merging  into  the  surrounding  skin.  In  contour 

1  G.  W.  Wende,  Jour.  Cutan.  Dis.,  1898,  p.  505  (with  case  illustration  and  histologic 
cut  and  bibliography). 

2  Rasch,  Pester  med.-chirurg.  Presse,  1898,  p.  626 — abs.  in  Jour.  Cutan.  Dis.,  1898, 
p.  547;  Heidingsfeld,  Jour.  Cutan.  Dis.,  Jan.,  1905,  reviews  the  subject  and  gives  com- 
plete bibliography;  Brocq  and  Pautrier,  Tribune  Medicale,  June  22,  1907,  case,  young 
woman,  patches  on  face,  nucha,  left  hand,  and  forearm  (early  references). 


POR  OKERA  TOSIS 

the  areas  are  sometimes  fairly  well  rounded,  but  often  somewhat  wavy 
others  of  irregular  squarish  shape,  and  others  still  more  irregular  in  out- 
line. The  inclosed  portion  almost  always  shows  slight  or  moderate 
epidermic  thickening  and  variable  atrophy,  with  slight  scaliness  or  fairly 
smooth;  but  occasionally  it  is  but  little  changed,  having  a  faintly  atrophic 
appearance,  and  the  hairs  may  or  may  not  have  disappeared.  The 
color  of  this  part  may  be  grayish  white,  dirty  gray,  sometimes  with  a 
brownish  hue,  and  exceptionally,  more  especially  in  ill-developed  spots, 
a  pinkish  tinge.  The  "seam,"  "wall,"  or  "dike"  may  be  dirty  gray  or 
brownish  gray,  and  is  usually  quite  pronounced,  horny,  and  elevated; 
in  others— ill-defined  spots— it  may  appear  simply  as  a  loose  rim  of 
epidermis,  made  up  of  one  or  several  layers,  and  the  free  edges  directed 
inward  and  slightly  upward.  In  one  and  the  only  instance  under  my 
own  care  there  was  but  a  single  patch,  of  years'  duration,  and  seated 
on  the  dorsal  surface  of  the  hand,  between  the  metacarpal  bones  of  the 
thumb  and  forefinger;  the  patch,  about  an  inch  to  an  inch  and  a  half  in 
diameter,  was  irregularly  rounded,  with  a  pronounced  wavy  elevated 
border,  with  an  ill-developed  irregular  and  broken  sulcus,  more  or  less 
studded  with  hard  concretions  or  seed-wart-like  epidermic  accumula- 
tions. The  inclosed  portion  was  depressed,  somewhat  horny,  slightly 
scaly,  uneven,  and  with  here  and  there  the  imbedded  minute,  warty- 
looking  concretions  just  referred  to.  The  broken  character  of  the  dike 
or  wall  is  not  unusual,  although  it  is  often  continuous. 

The  favorite  regions  are  the  hands  and  feet,  more  especially  the 
dorsal  aspects,  but  also  not  uncommonly  on  the  palmar  and  plantar 
surface  as  well.  The  patches  occur  on  other  parts,  however,  as  the  face, 
limbs,  and  trunk.  But  one  or  several  may  be  present,  or  there  may 
be  many  in  various  sizes  and  of  somewhat  general  distribution.  As  a 
rule,  they  do  not  exceed  one  to  several  inches  in  diameter,  and  sometimes 
remain  much  smaller.  There  is  usually  slight,  continuous  extension,  but 
sometimes,  after  reaching  a  certain  development,  they  remain  practically 
stationary;  where  several  contiguous  patches  coalesce  a  considerable  area 
may  result.  As  a  rule,  there  are  no  subjective  symptoms,  although  in 
some  cases  variable  itching  has  been  noted.  The  sweat  and  sebaceous 
secretions  of  the  affected  areas  are  more  or  less  in  abeyance.  While 
the  integument  alone  is  usually  the  seat  of  the  malady,  Respighi  and 
Ducrey1  have  shown  that  it  is  not  at  all  uncommon  for  lesions  to  be 
seen  on  the  mucous  membranes  of  the  mouth  also;  in  3  of  the  4  cases 
observed  by  them,  the  lesions  occurring  here  appearing  as  opalescent, 
rounded,  or  irregularly  rounded  patches,  each  inclosed  by  a  distinct 
white  raised  line  or  border,  sometimes  interrupted,  and  surrounding 
which  there  is  usually  a  slight  zone  of  hyperemia.  Its  course  here,  as 
on  the  skin,  is  slow  and  chronic,  and  apparently  gives  rise  to  no  incon- 
venience. Mibelli2  also  found,  in  an  extensive  case,  lesions  in  the  mouth 
as  well  as  on  the  glans  penis. 

1  Respighi  and  Ducrey,  Annales,  1898,  pp.  i,  609,  and  734 — an  exhaustive  account 
of  the  disease, — clinical  and  histologic, — 3  case  illustrations,  and  48  histologic  cuts. 

2  Mibelli,  Archiv,  1899,  vol.  xlvii,  pp.  i  and  231;  review  of  the  disease,  5  case  illus- 
trations, and  6  histologic  cuts. 


574  H  YPER  TR  OPHIES 

Btiology  and  Pathology. — But  little  is  known  as  to  the  cause 
of  the  disease,  although  a  hereditary  tendency  was  indicated  in  Res- 
pighi's  case,  as  the  father  of  the  patient  had  similar  lesions;  the  hered- 
itary factor  has  been  convincingly  shown  by  Gilchrist  in  his  report  of 
ii  cases  in  one  family — in  4  generations.  Respighi  and  Ducrey  also 
report  an  instance  of  the  malady  occurring  in  several  generations.  It  is 
a  rare  disease,  the  cases  of  Hutchins,  Gilchrist,  Wende,  and  my  own1 
apparently  being  all  that  have  been  recorded  in  this  country.  It  is 
seemingly  not  so  rare  in  Italy,  but  is  scarcely  known  in  England,  France, 
and  Germany.  It  is  met  with  in  both  sexes  and  at  all  ages,  but  it  has 
its  beginning  more  frequently  in  early  life.  There  is  no  direct  evidence  to 
prove  that  the  disease  is  parasitic,  although  in  30  experimental  inocula- 
tions made  by  Wende  on  4  different  individuals  one  proved  successful, 
but  as  this  was  on  the  affected  patient,  it  is  not  wholly  conclusive;  it  is 
possible  that  the  local  irritation  produced  may  have  been  sufficiently 
potential  in  a  predisposed  skin,  although  it  is  true  in  this  instance  the 
inoculation,  made  on  the  unaffected  hand,  was  positive  only  after  10 
unsuccessful  attempts.  Respighi's  experiments  in  transplantation  were 
without  result.  Examinations  made  for  micro-organisms  have  been 
uniformly  negative.  The  predominance  of  parts  subject  to  pressure 
and  friction  as  sites  of  the  eruption,  as  the  hands  and  feet,  appears  to 
indicate  that  these  factors  may  be  contributory. 

Histologic  examinations  were  made  by  almost  all  the  observers 
named,  and  their  conclusions  in  the  main  agree  that  the  malady  is  a 
special  form  of  hyperkeratosis,  and  affecting  chiefly  the  lower  horny 
and  upper  rete  layers,  although  all  parts  of  the  epidermis,  especially 
about  the  sweat-gland  ducts,  which  are  often  plugged  up  with  horny 
epithelium,  share  in  the  process.  The  hair-follicles  and  sebaceous 
glands  also  show  involvement.  The  papillary  layer  of  the  derma  is 
almost  obliterated  in  the  central  area  (Respighi).  Tommasoli2  was 
inclined  to  question  the  individuality  of  the  affection  and  the  identity 
of  the  various  cases  reported,  believing  that  they  were  unusual  exam- 
ples of  other  keratoses,  such  as  ichthyosis,  linear  naevus,  etc.,  but  the 
clinical  features,  as  well  as  the  histologic  findings,  and  the  behavior 
and  course  of  the  disease,  as  Mibelli3  convincingly  showed,  are  strikingly 
different  from  any  other  known  malady. 

Prognosis  and  Treatment.— The  malady,  as  will  have  been 
seen,  is  a  persistent  one,  with  but  little,  if  any,  tendency  to  spontaneous 
disappearance,  but  beyond  the  disfigurement  which  it  causes  need  give 
rise  to  no  anxiety.  Occasionally  some  of  the  efflorescences  may  dis- 

1 1  saw  this  case  in  1887  or  1888,  on  two  occasions  only,  but  was  puzzled  by  it  and 
did  not  recognize  its  nature,  intending  to  publish  it  later;  the  papers  of  Mibelli  and 
Respighi  appearing  subsequently  showed  me  that  I  had  missed  an  opportunity  of  pri- 
ority. Recently  (1909)  Dr.  H.  H.  Rutherford,  U.  S.  A.,  was  kind  enough  to  send  me  a 
photograph  of  a  case  in  a  young  soldier  aged  twenty-six,  showing  an  elongated  area 
at  base  of  thumb,  extending  on  the  dorsal  surface  of  hand;  it  began  at  the  age  of  sixteen 
as  a  small,  warty  pimple,  which  gradually  scaled  off  and  became  callous,  with  a  thick- 
ened seam  bordering  it. 

•  Tommasoli,  Comment,  din.  d.  mal.  cut.  e.  gen.  ur.,  1894,  ii,  No.  i. 

3  Mibelli,  "Ueber  die  Porokeratose  (Antwort  auf  eine  Kritik),"  Monatshefte,  1895, 
vol.  xx,  p.  309  (with  references). 


ANGIOKERA  TOMA 


575 


appear  (Joseph).    The  lesions  on  the  palms  and  soles  are  sometimes 
rendered  painful  by  the  constant  pressure,  friction,  etc. 

The  treatment  of  the  affection  is  somewhat  uncertain  as  to  result 
unless  surgical  measures  are  employed.  Joseph  was  not  able  to  obtain 
any  result  from  salicylic  acid  and  other  keratolytics,  but  with  excision 
there  was  no  recurrence.  Gilchrist  found  that  the  lesions  always  re- 
turned after  thorough  curetting  and  subsequent  application  of  silver 
nitrate,  a  plan  which  was  tried  first.  Excision  proved  satisfactory,  but 
naturally  left  scars.  In  2  of  his  cases  the  electric  needle  was  used  with 
excellent  results,  causing  very  little  scarring,  and  there  was  no  return. 

ANGIOKERATOMA1 

Synonyms.— Keratoangioma;  Lymphangiectasis  (Colcott  Fox);  Fr.,  Verrues 
telangiectasiques  (Dubreuilh);  Tuberculides  angiomateuses  (Leredde);  Ger..  Angio- 
keratom. 

Definition. — An  affection  usually  of  the  extremities,  occurring, 
for  the  most  part,  in  those  subject  to  chilblains,  and  characterized  by 
the  appearance  of  telangiectases  which  subsequently  develop  into  warty- 
looking  elevations. 

Symptoms.— The  descriptions  of  Cottle,  Mibelli,  Pringle,  Zeisler, 
Fordyce,  and  others  have  given  a  pretty  clear  picture -of  the  symp- 
tomatology of  this  rare  malady.  It  generally  follows  one  or  more 
attacks  of  chilblains,  minute  vascular  dilatations  or  telangiectases  sub- 
sequently arising.  They  are  pin-point  to  pin-head  in  size,  discrete,  or 
in  close  proximity  or  crowded  together.  At  first  they  may  be  pinkish 
in  tinge,  later  becoming  darker  and  even  with  a  dark-purplish  hue  or 
color,  the  central  point  usually  being  the  darkest;  occasionally  the  color 
partakes  of  a  reddish  brown.  The  backs  of  the  fingers  and  the  dorsal 
surface  of  the  toes,  and  especially  toward  the  basal  portions,  are  the 
favorite  sites;  the  lesions  may  occasionally  appear  on  the  palmar  sur- 
faces also.  Exceptionally  they  are  seen  elsewhere,  as  in  Fordyce's  and 
Button's  cases,  in  which  the  lesions  were  confined  to  the  scrotum,  and 
in  Anderson's  patient,  of  more  or  less  general  distribution.  In  Zeis- 
ler's  case,  in  addition  to  the  ordinary  lesions  on  the  hands  and  feet, 
the  auricles,  forearms,  and  legs  were  the  seat  of  pedunculated  vascular 
tumors  and  naevus-like  patches.  The  fingers  and  hands  have  been, 
however,  the  most  frequent  localization. 

1  Literature:  Cottle,  St.  George's  Hosp.  Reps.,  1877-78,  vol.  ix,  p.  758,  with  colored 
illustration;  Pringle,  Brit.  Jour.  Derm.,  1891,  pp.  237,  282,  and  309  (with  2  colored 
plates  and  histologic  cut,  and  a  re'sume  of  previously  reported  cases) ;  Zeisler,  Trans. 
Amer.  Derm.  Assoc.for  1893  (abstract;  full  paper  not  published);  Fordyce,  Jour.  Cutan. 
Dis.,  1896,  p.  83  (with  a  colored  plate  and  5  excellent  photomicrographs,  and  complete 
literature  references  to  above  reports  and  those  of  Mibelli  (1889),  Crocker  (1888  and 
1891),  Colcott  Fox  (1886  and  1889),  Dubreuilh  (1889  and  1893),  Audry  (1893), 
Deydier  (1892),  Brocq  (1892),  Thibie>ge  (1892),  Joseph  (1892  and  1894),  Tommasoli 
(1893),  Renault  (1894);  Dubreuilh,  Annales,  1896,  p.  1202;  Mibelli,  Monaishffte,  1897, 
vol.  xxiv,  p.  428;  Wisniewski,  Archiv,  1898,  vol.  xlv.,  p.  357  (with  2  colored  histologic 
cuts,  review  of  the  subject,  and  references);  W.  Anderson,  Brit.  Jour.  Derm.,  1898,  p. 
113  (general  distribution,  with  almost  complete  immunity  of  the  hands  and  feet;  2  cuts 
showing  distribution,  and  i  of  histology);  Dore,  ibid.,  1903,  p.  23  (with  chilblain  circu- 
lation, erythema  pernio,  and  erythema  induration);  R.  L.  Sutton,  Jour.  Amer.  Med. 
Assoc.,]u\y  15,  1911,  p.  189  (a  clinical  and  histopathologic  study  of  angiokeratoma 
of  the  scrotum  with  case  illustration,  review,  and  references). 


576 


H  YPER  TR  OPHIES 


After  a  while  the  telangiectases  show  slight  elevation,  and  the 
surface  may  become  rough  and  irregular  and  somewhat  horny,  and 
present,  more  especially  when  close  or  bunched  together,  a  warty 
aspect,  the  resemblance  to  small  warty  growths  leading  Dubreuilh  to 
designate  the  malady  "telangiectatic  warts."  Closely  lying  vascular 
dilatations  sometimes  practically  fuse  together,  forming  a  slightly  raised 
patch,  a  fractional  part  of  an  inch  in  diameter,  with  small  projecting 
or  irregular  horny  elevations,  the  reddish  or  purplish  color  being  most 
marked  peripherally.  Different  stages  of  the  process  are  usually  to  be 
seen,  from  the  passive,  livid  congestion  of  chilblains  to  the  well-marked 
warty  character.  As  a  rule,  the  color  may  partly,  rarely  completely,  be 


Fig.  138. — Angiokeratoma. 

made  to  disappear  on  pressure.  The  condition  is  commonly  worse 
during  the  cold  season,  at  which  time  new  points  are  more  apt  to  appear. 
Thus  the  malady  tends  to  become  more  widespread,  the  growths  show- 
ing no  signs  of  retrogression.  There  are  no  subjective  symptoms,  and 
beyond  the  disfigurement,  the  malady  gives  rise  to  no  trouble,  although 
the  larger  projecting  growths,  if  roughly  knocked,  may  show  a  disposition 
to  bleed. 

Etiology  and  Pathology.— The  disease  is  rare,  although  some- 
what similar  scattered  single  lesions,  lacking  distinct  horny  characters, 
are  occasionally  seen  on  the  hands  and  upper  trunk.  The  malady 
usually  begins  in  childhood  or  youth,  although  in  Fordyce's  patient., 


ANGIOKERA  TO  MA 


577 


aged  sixty,  it  had  apparently  begun  much  later,  and  Zeisler's  case-a 
male-began  when  aged  forty-nine.  The  female  sex  seems  to  furnish 
the  majority  of  cases.  In  some  instances  more  than  one  member  of 
the  family  has  exhibited  the  disease;  according  to  DubreuihV  Mibelli 
saw  6  cases  in  the  same  family,  and  Pringle2  saw  4-all  males  Local 
circulatory  weakness,  as  that  resulting  from  chilblains,  is  apparently  an 
important  factor  in  most  instances,  although  in  the  2  cases  reported  by 
*  ordyce  and  Anderson  this  preliminary  feature  was  wanting;  in  Fordyce's 
case,  however,  the  patient  had  a  double  varicocele,  indicating  a  tendency 
to  blood-vessel  dilatation.  In  some  instances,  however,  there  was  no 
apparent  cause. 


Fig.  139. — Angiokeratoma  (X  about  100),  showing  cavernous  space  filled  with 
blood-corpuscles  and  divided  by  fibrous  septa;  hypertrophy  of  the  corneous  layer  and 
rete  (courtesy  of  Dr.  J.  A.  Fordyce). 

Mibelli,  who  gave  the  present  accepted  name  to  the  malady,  was 
the  first  to  investigate  the  pathologic  histology,  since  which  time  his 
findings  have  for  the  most  part  been  corroborated  by  Pringle,  Joseph, 
Audry,  Wisniewski,  Fordyce,  Unna,  and  others.  The  primary  patho- 
logic change  is  a  vascular  one,  the  keratosis,  a  secondary  phenomenon. 
The  lesions,  quoting  Fordyce's  words,  consist  of  lacunar  spaces  filled 
with  blood,  occupying  the  papillary  portion  of  the  derma,  some  of  which 
are  found  inclosed  in  the  rete;  and  these  cavernous  spaces  are  evidently 
the  essential,  and  probably  primary,  feature  of  the  disease.  It  is 
probable,  as  Mibelli  and  Pringle  suggest,  and  in  which  opinion  Fordyce 

1  Dubreuilh,  loc.  cil. 

2  Pringle,  Brit.  Jour.  Derm.,  1913^.40  (case  demonstration);  4  rases,  father  and 
three  sons,  quite  typical  on  the  hands,  and  to  a  less  degree  on  the  feet  also. 

37 


578  HYPERTROPHIES 

is  inclined  to  coincide,  that  the  lacunar  dilatations  result  from  changes 
in  the  papillary  vessels,  superinduced  by  causes  which  impair  the  con- 
tractility of  the  vessel-walls,  the  most  common  being  attacks  of  chil- 
blains. Fordyce's  investigations  lead  him  to  coincide  in  Pringle's 
hypothesis  that  the  blood-spaces  in  the  rete  Malpighii  are  caused  by  a 
downgrowth  of  the  cells  of  this  layer,  producing  a  constriction  of  the 
terminal  loops  and  their  resulting  distention.  In  addition  to  these  several 
changes,  there  is  a  slight  inflammatory  infiltration  to  the  underlying 
derma  and  thickening  of  the  corneous  layer.  Differing  from  other 
observers,  Mibelli  and  Audry  found  also  some  dilatation  of  the  lymph- 
spaces. 

Diagnosis. — The  primary  minute  telangiectases  and  subsequent 
warty  tendency,  with  the  associated  dark-red  or  purplish  color  and 
the  localization,  together  with  often  a  history  of  previous  exposure  to 
severe  cold,  with  consequent  chilblains,  are  usually  sufficiently  diag- 
nostic. The  vascular  dilatation  is  entirely  wanting  in  ordinary  warts, 
and  the  growth  and  appearance  of  the  latter  different. 

Prognosis  and  Treatment. — The  malady  is  persistent,  with 
no  tendency  to  involution.  The  treatment  consists,  as  successfully  em- 
ployed by  Pringle,  of  electrolysis,  each  lesion  receiving  attention,  the 
needle  being  attached  to  the  negative  pole,  and  a  current  of  2  or  3  mil- 
liamperes  used.  Measures  should  be  advised  as  to  proper  hand  and 
foot  covering  in  cold  weather,  and  the  maintenance  of  circulatory  tone 
by  exercise  and  suitable  tonics  if  indicated. 

SCLERODERMA1 

Synonyms. — Hide-bound  skin;  Sclerema;  Scleriasis;  Sclerema  adultorum;  Derma- 
tosclerosis;  Fr.,  Scl6rodermie;  Sclereme  des  adultes;  Ger.,  Sklerodermie. 

Definition. — A  chronic  disease,  characterized  by  a  circumscribed 
localized,  or  general  and  more  or  less  diffuse,  usually  pigmented,  rigid, 
stiffened,  indurated,  or  hide-bound  condition  of  the  skin. 

The  manifestation  differs  materially  in  extent  and  character,  in 
some  cases  being  more  or  less  diffused,  hard,  hide-bound,  and  with  usually 
considerable  pigmentation,  and  in  others  consisting  of  rather  sharply 
circumscribed  patches  or  bands  of  a  somewhat  lardaceous  appearance, 
and  often,  especially  the  rounded  areas,  with  a  pinkish  border.  The 
former  is  the  variety  usually  known  as  diffuse  symmetric  scleroderma; 
the  latter,  as  circumscribed  scleroderma  or  morphea.  Duhring  main- 
tains that  morphea  is  distinct  from  scleroderma,  and  it  must  be  confessed 
that  the  extremes  of  these  two  types  bear  practically  no  clinical  resem- 
blance, one  to  the  other,  but  other  cases  approach  more  closely  and  merge 
into  each  other,  some  cases  presenting  the  typical  conditions  of  both. 

1  Some  valuable  recent  literature :  Lewin  and  Heller,  Die  Sklerodermie,  Berlin,  1895 
(a  review  of  the  entire  subject,  embracing  508  collected  cases) ;  Osier,  Jour.  Cutan.  Dis., 
1898.  pp.  49  and  127  (a  report  of  8  cases  of  diffuse  scleroderma,  with  review  comments 
on  the  disease,  especially  diagnosis  and  treatment  with  thyroid  extract) ;  Dercum,  Jour, 
of  Nervous  and  Mental  Dis.,  July,  1896  (3  cases)  and  (on  scleroderma  and  rheumatoid 
arthritis— with  reports  of  2  cases),  ibid.,  October,  1898;  Meneau,  Jour.  mal.  cutan.,  1898, 
p.  145;  Colcott  Fox,  Brit.  Jour.  Derm.,  1892,  p.  101,  also  contributes  an  interesting 
historic  paper  bearing  upon  early  observations  of  English  observers  on  the  disease. 


SCLERODERMA 


579 


Symptoms. — The  diffuse  type  may  begin  insidiously  or  rapidly. 
In  the  former  event  the  first  symptom  noted  is  a  slight  stiffness  of  the 
part  involved,  which  may  at  first  be  extremely  limited.  On  examina- 
tion, variable  swelling  or  infiltration  is  usually  noted,  the  surface  is  some- 
what tense  looking,  and  sometimes  shining;  at  other  times  there  is  noted, 
along  with  the  first  symptoms,  more  or  less  yellowish-brown  or  brownish 
pigmentation,  and  which  may,  indeed,  be  the  first  manifestation  ob- 
served by  the  patient.  As  a  rule,  there  are  no  subjective  symptoms 
complained  of  in  the  early  stages,  except  in  some  cases  occasional  neural- 
gic or  rheumatic  pains.  The  division  between  the  affected  and  the 
healthy  skin  is  not  well  defined,  one  insensibly  disappearing  into  the  other. 


1^^^^^^^^^^^^^^^^^^=^=^==^=== 

Fig.  140—  Scleroderma— band  or  ribbon  type,  extending  full  length  of  the  arm. 
Several  "morphea"  patches  on  back. 

The  process  gradually  extends,  and,  after  the  course  of  weeks  or  some 
months  or  several  years,  finally  involves'  one  or  more  regions  or  the 
greater  part  of  the  entire  surface.  It  may  be  limited  to  the  arms  or  the 
lower  extremities,  extending  sometimes  on  to  the  trunk;  or  the  face, 
neck,  and  immediately  adjacent  parts  are  the  seat  of  the  induration. 
When  well  established  the  integument  is  brawny  or  leathery,  hard  to  the 
touch,  stiff,  rigid,  and  cannot  be  lifted  up  into  folds.  It  is  usually  appar- 
ently agglutinated  with  the  subjacent  tissues,  and  the  entire  part 
or  less  immobile. 

In  the  rapidly  spreading  or  acute  type,  the  process  is  commonly 
ushered  in  by  more  or  less  edematous  infiltration,  with  or  without 


580  HYPERTROPHIES 

preceding  chills,  fever,  or  other  constitutional  disturbance.  The  tissues 
and  skin  are  tense  and  generally  glossy,  and  in  some  instances  may  pit 
slightly  upon  pressure,  although,  as  a  rule,  owing  to  the  tenseness  and 
beginning  hardening,  this  is  not  readily  produced.  In  these  edematous 
or  infiltrating  cases  the  skin  is  often  whitish  or  waxy,  somewhat  similar 
to  the  appearances  observed  in  ordinary  edema.  The  disease  rapidly 
extends,  and  soon  a  greater  part  of  the  entire  surface  is  invaded.  The 
infiltration  or  edema  disappears  as  the  integument  becomes  hard  and 
rigid,  and  practically  the  same  picture  is  presented  as  in  the  insidious 
form:  the  skin  is  dry,  sometimes  harsh,  sometimes  smooth,  hide- 
bound, stiff,  and  hard  and  more  or  less  pigmented,  and  not  infre- 
quently with  some  shriveled  epidermic  scaliness.  In  some  instances, 
in  places,  especially  the  lower  leg,  there  is  slight  wart-like  papillary 
hypertrophy. 

If  the  limbs  are  involved,  they  are  stiff  and  immobile,  and  later 
become  shrunken  and  withered,  the  underlying  muscles  also  atrophying, 
and  the  whole  region — skin,  tissue,  muscle,  and  bone — seems  glued 
together  and  atrophic.  In  some  cases  (Thibierge)1  the  muscles  are 
noted  to  be  atrophic,  even  where  there  is  no  overlying  sclerodermic 
areas.  If  the  face  is  the  part  involved,  the  countenance  is  immobile, 
expressionless,  the  wrinkles  and  lines  obliterated,  and  the  mouth  slightly 
or  firmly  rigid.  In  fact,  the  integument  has  a  wooden  or  petrified  look. 
Atrophic  changes  may  take  place  here  also,  but  not  so  commonly  as  with 
the  extremities.  When  seriously  involving  the  latter,  joint  symptoms 
of  an  arthritic  or  rheumatoid  arthritic  character  are  noted,  and,  in  addi- 
tion to  the  enormous  shrinking  and  atrophy  which  sometimes  ensue,  even 
to  the  extent  of  reducing  the  arm  of  an  adult  to  almost  that  of  a  child, 
the  joints  become  ankylosed,  the  fingers  bent  and  fixed,  resulting  in  a 
veritable  sclerodactylia,  an  associated  condition  to  which  Ball  called 
attention,  and  well  shown  in  cases  more  recently  reported  by  Osier,2 
Dercum.3  Elliot,4  Uhlenhuth,5  and  others.6  Both  the  fingers  and  toes 
may  be  the  seat  of  these  changes,  as  in  some  of  the  cases  just  referred  to 
and  in  one  referred  to  by  Kalischer.7  Sometimes  such  distortion  is 
preceded  by  pain,  occasionally  cyanosis,  and,  in  fact,  many  of  the  other 
symptoms  of  Raynaud's  disease  (Bouttier,  Chauffard,  and  others).8 
Ulcerations  are  apt  to  form  over  the  knuckle  prominences,  and  the  whole 
condition  be  a  painful  and  troublesome  one.  In  such  cases  and  in 
others  often  the  first  troublesome  symptom  noted  is  slight  ulceration 

1  Thibi6rge,  "Contribution  a  1'etude  des  lesions  musculaire  dans  la  sclerodermie," 
Revue  de  Med.,  1890,  p.  291,  calls  special  attention  to  the  characters  of  the  muscular 
atrophy  observed  and  refers  to  other  literature  cases;  Bloch,  Berlin,  klin.  Wochenschr., 
1899,  p.  307,  has  added  a  case  of  bone  and  muscle  atrophy  to  those  already  reported; 
also  case  reported  by  Adler,  ibid.;  and  one  by  Nixon,  Bristol  Medico-Chirurg.  Jour., 
Dec.,  1903,  and  refers  to  case  by  Dreschfeld  (Manchester  Med.  Chronicle,  1897,  p.  263). 

2  Osier,  loc.  cit.  3  Dercum,  loc.  cit. 

4  Elliot,  Jour.  Cutan.  Dis.,  1899,  p.  575. 

5  Uhlenhuth,  Berlin  klin.  Wochenschr.,  1899,  p.  207. 

8  Gordonier,  Amer.  Jour.  Med.  Sci.,  1889,  vol.  xcvii,  p.  15,  reports  a  case  and  re- 
views others. 

7  Kalischer,  Wien.  med.  Rundschau,  1899,  p.  65. 

8  Bouttier,   "De  la  Sclerodermie,"   These  de  Paris,  1886;    Chauffard,    abs.-ref., 
Annales,  1897,  p.  895;  also  noted  by  Osier,  Dercum,  and  others. 


SCLER  O  DERM  A  581 

of  the  finger-ends;  Jacoby's1  case  began  in  the  form  of  open  sores, 
the  different  finger-tips  being  successively  attacked,  and  Eichhoff2 
observed  an  instance  somewhat  similar,  but  in  which  the  apparent 
exciting  factor  of  the  atrophic  and  destructive  process  was  a  favus 
of  the  nails.  In  some  cases,  especially  those  in  which  the  subcutaneous 
tissues  and  muscles  have  atrophied,  the  hardened  skin  may  tend  to  ulcer- 
ate over  sharp  bony  prominences. 

The  disease  may,  however,  begin  on  any  region,  and  the  most  fre- 
quent one  is  that  of  the  neck,  although  shoulders,  back,  chest,  arms,  and 
face  are  not  uncommon  sites.  It  may  limit  itself  somewhat,  or  it  may 
gradually  or  quickly  involve  almost  the  entire  surface.  As  a  rule,  it  is 
extensive.  It  may  be  somewhat  irregular  in  its  distribution,  but  it  is 
usually  symmetric — in  a  case  described  by  Britton,3  the  disease  was  not 
only  diffused  over  most  of  the  surface,  but  its  symmetric  character  was 
perfect;  and  in  one  recently  noted  by  Bruns,4  the  disease  involved  both 
lower  extremities,  extending  upward  and  stopping  short  level  with  the 
second  sacral  vertebra.  Not  only  may  the  skin  be  involved  more  or  less 
extensively,  but  the  mucous  membrane  of  the  mouth  as  well,  and  this 
has  also  been  observed  even  when  the  integumentary  involvement  was 
limited.  Sometimes,  too,  the  teeth  loosen  and  fall  out  (Dercum).  In 
some  cases  the  scleroderma  presents  in  wide  strips  or  bands,  and  occa- 
sionally associated  with  circumscribed  areas  of  more  or  less  typical 
morphea,  and  in  exceptional  instances,  in  addition  to  the  sclerodermic 
changes,  there  are  noted  associated  alopecia  and  leukoderma.8 

As  a  rule,  there  are  no  distinctive  or  special  constitutional  symptoms 
in  scleroderma;  some  of  the  less  extensive  cases  and  most  of  those  of 
wide  distribution  are  ushered  in  by  chills,  fever,  and  other  evidences 
of  general  disturbance.  There  are  not  infrequently,  however,  concomit- 
ant or  developing  rheumatic  symptoms  and  occasionally  those  of  rheu- 
matoid arthritis.  Pigmentation  is  sometimes  marked,  and  sometimes 
suggestive  of  Addison's  disease;  in  exceptional  instances  this  latter  has 
been  reported  to  coexist.  Local  pain,  occasionally  cramp-like  in  char- 
acter, heat  or  burning,  and  a  sense  of  numbness,  and,  as  already  referred 
to,  edema  are  sometimes  precursory  and  early  accompanying  symptoms. 
The  sweat  secretion  of  the  involved  region  is  diminished,  and  usually 
entirely  suppressed.  Sensibility  of  the  parts  is  rarely  affected,  but  there 
is  itching  in  some  cases.  Changes  in  the  thyroid  gland  have  also  been 
observed  in  some  instances  (Singer,  Jeanselme,  Ditscheim,  Grunfeld, 
Osier,  Uhlenhuth,  James,  Samouilson,  and  others),  but  usually  in  asso- 
ciation with  coexistent  Graves'  disease.  In  extreme  types,  especially 
when  the  face  is  involved,  from  stiffening  and  often  contraction  c 
the  mouth,  proper  nourishment  is  interfered  with,  and  the  patient 
suffers  from  inanition.  From  hardening  and  contraction 

1  Jacoby.  Philada.  Med.  Jour.,  April  15,  1899. 

2  Eichhoff,  Archiv,  1890,  vol.  xxii,  p.  857  (with  cut). 

3  Britton,  Brit.  Jour.  Derm.,  1891,  p.  227. 

4  Bruns,  Deutsche  med.  Wochenschr.,  1899,  p.  487-  ,       n 

•  Eddowes,  Brit.  Jour.  Derm.,  1899,  P-  325,  exhibited  ^^ 
Britain  and  Ireland  a  case  presenting  general  alopecia,  leukoderma, 
morphea  patches. 


582  HYPERTROPHIES 

integument  of  the  chest  breathing  is  also  seriously  interfered  with  in 
some  cases. 

The  course  of  the  disease  is  essentially  chronic,  sometimes  exten- 
sion being  slow,  at  other  times  rapid.  In  some  cases  there  is  occa- 
sional retrogression,  which  may  even  go  on  to  complete  recovery,  but 
before  such  a  fortunate  conclusion  there  may  occur  one  or  more  exacer- 
bations, usually  foreshadowed  by  chilliness  or  chills  and  other  systemic 
disturbance.1  The  edematous  cases  are  more  likely  to  lead  to  atrophic 
changes — Crocker  believes  this  to  be  the  result  in  all  of  them. 

Circumscribed  Scleroderma — Morphea  (known  formerly  as  Keloid 
of  Addison). — The  disease  may  present  some  variations.  The  typical 
examples,  those  which  seem  wholly  different  from  scleroderma,  begin, 
as  a  rule,  by  the  appearance  of  light-pinkish  or  hyperemic,  usually  oval 
or  rounded,  small  coin-sized  patches.  There  may  be  slight  elevation 


Fig.  141. — Circumscribed  scleroderma  (morphea)  in  a  man  aged  thirty;  consisting 
of  two  symmetric  areas  shown,  which  were  waxy  or  lardaceous  in  appearance,  quite 
firm  to  the  touch,  and  with  a  slight  peripheral,  pinkish  border,  although  this  was  not  at 
all  marked  and  discernible  only  upon  close  inspection.  Duration  one  year  and  of 
gradual  appearance. 

or  an  appearance  of  scarcely  perceptible  puffiness.  The  color,  in  the 
course  of  some  days — a  variable  time — fades  out,  and  the  patch  is  ob- 
served to  be  encircled  with  a  faint  rosy  or  pinkish  zone,  which,  on  close 
examination,  is  found  to  be  made  up  of  minute  capillaries,  while  the  area 
itself  is  whitish  or  ivory-like,  or  lardaceous,  and  seems  inlaid  in  the  skin. 
It  is  usually  on  a  level  with  the  surface,  or  it  may  be  slightly  depressed; 
it  often  has  a  polished  look,  and  it  is  either  somewhat  soft  to  the  touch, 
and  when  pinched  up  not  materially  different  from  the  surrounding 
skin,  or  it  is  noted  to  be  firm,  hard,  leathery,  and  even  brawny.  On 
close  inspection  very  often  the  surface  is  observed  to  be  coursed  over  by 

1  An  interesting  paper  and  review  in  this  connection:  Kanoky  and  Sutton,  "A  Com- 
parative Study  of  Acrodermatitis  Chronica  Atrophicans  and  Diffuse  Scleroderma,  with 
Associated  Morphea  Atrophica,"  Jour.  Cutan.  Dis.,  Dec.,  1909  (illustrated,  bibliog- 
raphy). 


SCLERODERMA 


583 


minute  blood-vessels,  sometimes  forming  a  faint  network.  Later 
instead  of  a  smooth,  shining  surface,  there  may  be  slight,  thin,  shriveled 
epidermic  coating.  Beyond  the  faint  pinkish,  or  sometimes  lilac 
colored,  border,  a  slight  yellowish  or  yellowish-brown,  often  mottled 
irregularly  diffused  pigmentation  is  noticeable,  which  may  extend  some' 
distance  from  the  patch. 


Fig.  142. — Circumscribed  scleroderma  (morphea)  in  a  middle-aged  working- 
woman;  disease  limited  to  the  patch  shown  on  the  leg.  Duration  about  one  year.  The 
pinkish  or  lilac  border  present  in  most  cases  is  shown  by  the  dark  peripheral  shading. 
The  inclosed  area  is  whitened  and  lardaceous  in  appearance.  The  two  small  ulcera- 
tions  are  accidental,  due  to  traumatism. 

In  some  instances  the  patches,  instead  of  being  pinkish  or  rosy, 
begin  as  whitish  or  bluish-white  (Handford1)  areas,  later  becoming  yel- 
lowish. In  exceptional  instances  the  erythematous  stage  usually 
noticed  is  prolonged.  As  a  rare  example  of  this  latter  was  one  under 
Cavafy's2  observation,  in  which  the  legs  were  for  months  the  seat  of 

1  Handford,  Illus.  Med.  News,  June  22,  1889,  p.  265,  records,  in  a  report  of  2  cases, 
a  case  of  this  kind  (with  colored  plate  and  histologic  cut). 

2  Cavafy,  Brit.  Jour.  Derm.,  1896,  p.  275. 


584  HYPERTROPHIES 

erythematous  areas  of  obscure  nature,  but  which  finally  began  to 
harden,  the  erythema  disappearing  and  giving  place  to  lardaceous 
patches.  In  other  instances,  instead  of  the  typical  characteristic  patches, 
there  appear  several  or  more  small  or  large  scar-like  spots,  sometimes 
slightly  depressed;  the  skin  is  atrophic  or  thin,  and  often  with  neighbor- 
ing telangiectases  of  reddish  or  bluish  color.  Pigmented  areas,  true 
sclerodermic  areas,  pit-like  atrophic  depressions,  and  atrophic  lines  are 
also  present  in  some  cases.1  Or,  instead  of  lesions  of  these  characters, 
the  disease  may  present  in  irregularly  rounded  areas,  or  short  or  long 
bands,  hard  and  brownish,  sometimes  with  the  peculiar  pinkish  capillary 
border  or  with  abrupt  termination  in  the  skin  beyond,  which  may  or 
may  not  be  pigmented.  Occasionally  a  band  extends  almost  the  entire 
length  of  a  limb,  and  may  be  elevated  or  countersunk.  In  these  cases 
paroxysmal  attacks  of  cramp-like  pain  are  now  and  then  noted. 

The  course  of  the  typical  lesions  of  morphea  is  variable — usually 
slow  and  chronic  in  character;  they  frequently  enlarge  slowly,  and  if 
close  together,  coalescence  results,  and  large  areas  may  be  covered. 
Very  often  after  reaching  the  diameter  of  a  few  inches  they  remain 
stationary  for  an  indefinite  time,  either  with  a  gradual  tendency  to 
enlargement  or  to  retrogression  and  disappearance.  In  some  cases 
decided  atrophic  changes  ensue,  and  the  final  result  is  akin  to  that  ob- 
served in  diffuse  scleroderma:  the  skin  is  shriveled  and  thin,  and  some- 
times hard  and  fibrous,  the  tissues  beneath  gradually  atrophy,  and  the 
parts  agglutinated  together,  finally  forming  irregular,  smooth  or  fur- 
rowed, sunken,  contracted  scars,  sometimes  of  keloidal  aspect  or  nature. 
In  rare  instances  ulceration  takes  place,  usually  in  parts  of  the  involved 
area  only. 

Morphea  patches  may  develop  upon  any  region,  but  its  most  com- 
mon sites  are  the  upper  trunk,  face,  neck,  abdomen,  and  the  arms  and 
thighs;  as  a  rule,  but  several  areas  are  seen,  but  it  may  be  widespread 
over  several  regions,  as  in  extensive  cases  described  by  Morrow-2  and 
Cavafy,3  in  which  there  were  numerous  large  areas  from  the  hips  down 
on  both  legs,  and  with  more  or  less  perfect  symmetry.  Ordinarily  patches 
of  the  disease  are  irregularly  distributed,  sometimes  presenting  on  but 
a  single  region;  occasionally  the  distribution  corresponds  to  that  of  the 
cutaneous  nerves,  and  exceptionally  the  manifestation  has  been  strictly 
limited  to  the  fifth  nerve,  as  in  Anderson's4  case,  in  which  the  entire 
region  of  the  distribution  of  the  three  divisions  of  the  right  fifth  nerve 
was  the  seat  of  sclerodermic  changes,  including  the  mucous  membrane 
of  the  mouth  and  the  upper  part  of  the  pharynx.  Barrs5  observed  a 
case  in  which  the  disease,  upon  both  arms  and  left  leg,  followed  very 
accurately  the  nerve-fields. 

In  rare  instances,  closely  analogous  to  the  last,  as  in  a  case  also 

1  Duhring,  Amer.  Jour.  Med.  Sri.,  Nov.,  1892,  reports  an  interesting  case  of  asso- 
ciated morphea  patches  and  atrophic  lines  and  spots. 

2  Morrow,  Jour.  Ciitan.  Dis.,  1896,  p.  419  (with  3  illustrations)  and  discussion 
(White  and  Duhring),  p.  446. 

3  Cavafy,  loc.  at. 

4  W.  Anderson,  Brit.  Jour.  Derm.,  1898,  p.  46. 
8  Barrs,  ibid.,  1891,  p.  152. 


SCLERODERMA 


585 


reported  by  this  last  observer  (Barrs),  as  well  as  by  others  previously, 
the  disease  seems  to  limit  itself,  chiefly  at  least,  to  one  side  of  the  face 
(hemiatrophia  facialis  or  unilateral  atrophy  of  the  face),  but  not  infre- 
quently with  one  or  several  characteristic  patches  elsewhere.  With 
these  cases,  however,  the  atrophic  "shrinking"  influence  of  the  disease 
is  especially  noticeable,  not  only  the  skin,  but  the  subcutaneous  tissue 
muscles,  and  even  the  bones  becoming  involved,  and  great  deformity 
sometimes  resulting. 

Etiology. — Both  types  of  scleroderma  are  infrequent — the  dif- 
fused type  >rare,  the  circumscribed  variety — morphea — much  less  so. 
It  is  met  with  in  both  sexes,  but  with  a  considerable  preponderance 
on  the  female  side,  and  this,  I  believe,  is  even  more  pronounced  in 
morphea.  In  Lewin  and  Heller's  statistics,  out  of  435  cases,  292  were 
females.  It  is  chiefly  observed  in  those  between  the  ages  of  fifteen 
and  forty-five,  but  no  age  except  early  infancy  is  exempt,  as  it  has  been 
met  with  both  in  the  very  young  (the  youngest  patient  recorded  being 
thirteen  months  old)  and  the  very  old.  Various  causes  have  been  as- 
signed, but  there  remains  much  to  be  learned  before  anything  definite 
can  be  stated  on  this  score.  Rheumatism,  chills,  exposure  to  cold  and 
wet,  prolonged  sun-exposure,  thyroid  disease,  exhaustion  from  any  cause, 
emotional  and  other  nervous  disturbances,  filaria  sanguinis  (Bancroft), 
arterial  disease,  and  many  other  factors  are  named  as  of  etiologic  in- 
fluence. Some  cases  have  apparently  had  their  start  in  some  local 
irritation  or  injury,  another  example  of  which  is  recently  recorded  by 
Leslie  Roberts.1  In  some  instances,  however,  the  patients  at  the  time 
of  the  attack  are  apparently  in  good  health,  and  when  the  involvement 
is  not  unusually  extensive,  the  general  condition  may  remain  compara- 
tively undisturbed;  this  is  especially  so  in  most  cases  of  morphea. 
Zambaco2  is  inclined  to  view  the  disease  as  an  anomalous  or  modified 
form  of  leprosy. 

The  rheumatic  origin  of  the  disease  has  the  frequent  occurrence 
of  rheumatic  and  rheumatoid  arthritic  symptoms  to  support  it,  such 
symptoms  sometimes  antedating  the  sclerodermic  changes,  and  in  other 
cases  being  concurrent.  These  facts  are,  however,  in  my  judgment, 
more  especially  as  to  rheumatoid  arthritis,  merely  an  added  evidence 
in  favor  of  the  neurotic  cause  of  the  disease,  which,  upon  the  whole, 
has  the  greatest  support.  That  changes  in  the  thyroid  gland  are  noted 
in  some  cases  has  already  been  remarked  upon,  usually,  however,  in 
association  with  Graves'  disease,  but  also  in  some  instances  in  which 
this  latter  did  not  exist,  usually  atrophic  in  character,  as  reported  by 
several  observers,  more  recently  by  Hektoen,3  Uhlenhuth,4  James,5  and 
others.6 

1  Roberts,  Brit.  Jour.  Derm.,  1900,  p.  118. 

2  Zambaco,  Trans.  First  Internal.  Leprosy  Congress. 

3  Hektoen,  Jour.  Amer.  Med.  Assoc.,  June  26,  1897,  vol.  xxvin,  p.  1240. 

4  Uhlenhuth,  Berlin  klin.  Wochenschr.,  1899,  p.  207. 

5  James,  Scottish  Med.  and  Surg.  Jour.,  May,  1899. 

6  Samouilson    "De  la  Coexistence  de  la  scl6rodermie  et  des  alterations  des  , 
thyroideTS'^  Paris,  July  21,  ,898,  considers. the  subject  at  length i  and I  reviews 
the  literature,  with  the  conclusion  that  the  disease  is  sometimes  due  loan  gmagn 
resulting  from  abnormal  action  of  the  thyroid  gland;  Leven,  Dermatolog,  Centralblatt, 


ij  86  H  YPER  TR  OPHIES 

In  favor  of  its  being  a  neurosis  are  the  occasional  nerve  distribu- 
tion, its  frequent  symmetric  arrangement,  the  occasional  preceding  or 
concurrent  finger  symptoms,  suggesting  Raynaud's  disease,  the  occasional 
local  sensory  symptoms,  the  sometimes  noted  coexistence  of  alopecia 
and  leukoderma,  the  pigmentary  changes,  the  muscle  and  bone  atrophy, 

etc. 

Pathology. — Knowing  so  little  regarding  the  essential  causes 
which  provoke  the  disease,  it  is  difficult  to  formulate  a  satisfactory 
explanation  of  the  pathologic  changes  which  take  place  in  the  cutaneous 
structures.  As  Osier  succinctly  states,  as  already  in  part  intimated  in 
etiology,  the  disease  is  variously  regarded  as  a  trophoneurosis  dependent 
upon  changes  in  the  nervous  system — a  perversion  of  nutrition  analogous 
to  myxedema,  and  due  to  disturbance  of  the  thyroid  function;  a  sclerosis 
following  widespread  endarteritis;  a  primary  slow  hyperplasia  of  the 
collagenous  intercellular  substance  of  the  corium — fibromatosis;  or  a 
primary  affection  of  the  lymph-channels,  central  or  peripheral.  Lewin 
and  Heller,  from  their  valuable  studies,  are  led  to  view  the  disease  as  a 
neurosis — an  angioneurosis,  trophoneurosis,  or  angiotrophoneurosis.  As 
Crocker  states,  most  of  the  symptoms  can  be  referred  to  obstruction, — 
arterial,  lymph,  and  venous, — and  that  the  variable  character  of  changes 
observed  in  different  cases  depends  upon  which  of  the  vascular  sys- 
tems is  most  involved.  According  to  Unna,  the  first  changes  are  in 
the  connective  tissue,  especially  its  intercellular  substance.  It  is 
probable  that  the  primary  pathogenic  influence  is  to  be  found  in  the 
central  nervous  system,  although  many  (Chiari,  Spieler,  Dinkier,  and 
others)  have  failed  to  find  such  evidence;  but,  on  the  other  hand,  West- 
phal,1  Jacquet  and  de  Saint-Germain,2  Schulz,3  and  Steven4  have  noted 
degenerative  and  sclerotic  changes  in  the  brain,  spinal  cord,  or  sympa- 
thetic, but  there  was  no  uniformity,  and  the  exact  relationship  cannot, 
therefore,  be  definitely  stated.  Brissaud5  believes  it  takes  its  origin  in 
some  disturbance  of  the  sympathetic.  In  Schulz's  case,  in  which  there 
was  considerable  general  pigmentation,  one  suprarenal  body  was  found 
somewhat  diseased. 

The  anatomic  changes  observed  in  the  diffuse  type  (Neumann, 
Kaposi,  Auspitz,  Schwimmer,  Fagge,  and  others)  are  essentially  in  the 
corium  and  subcutaneous  tissues.  Pigmentation,  it  is  true,  is  found  in 
the  rete,  and  not  infrequently  in  the  corium  also,  especially  in  the  papil- 

Feb.,  1904  (associated  development  of  thyroid);  Roques,  "Le  Traitement  opothera- 
pique  de  la  sclerodermie,"  Annales,  July  1910,  p.  383,  reviewing  the  subject,  found 
a  larger  proportion  with  defective  thyroids;  full  review  of  literature;  bibliography; 
Alderson,  "The  Skin  as  Influenced  by  the  Thyroid  Gland,"  California  State  Jour,  of 
Med.,  June,  IQII,  (gives  a  brief ,  but  good  review  of  recorded  thyroid  gland  influences). 

1  Westphal  (2  cases — i  autopsy),  Charite-Annalen,  Berlin,  1876,  vol.  iii,  p.  341. 

2  Jacquet  and  de  Saint-Germain,  Annales,  1892,  p.  508. 

3  Schulz,  "Sclerodermie,  Morbus  Addisonii  und  Muskelatrophie,"  Neurologisches 
Centralblatt,  1889,  pp.  345.  386,  and  412,  with  references. 

4  Steven,  Glasgow  Med.  Jour.,  Dec.  1898;  editorial  review  of  same  in  Lancet,  1899, 
vol.  i,  p.  43;  clinical  account  of  case  in  Internal.  Clinics,  July,  1897,  vol.  ii,  p.  195, 
with  4  illustrations  (an  interesting  case  leading  to  pronounced  hemiatrophy  of  the  face, 
body,  and  extremities,  with  deformity  and  fibrous  ankylosis  of  the  joints). 

8  Brissaud,  La  Presse  medicale,  1897,  p.  285— full  abstract  in  Brit.  Jour.  Derm., 
J897,  P-  367 — reviews  the  various  theories  (with  many  references). 


SCLERODERMA 


587 


lary  layer.  Both  in  the  true  skin  and  subcutaneous  connective  tissue 
there  is  a  marked  increase  of  connective-tissue  element,  with  thickening 
and  condensation.  The  fat  atrophies  and  gives  place  to  connective 
tissue.  The  vessels  are  found  surrounded  by  masses  of  small  cells  of 
unknown  origin,  and  are  thereby  diminished  in  caliber;  the  latter  is  also 
due  to  thickening  of  the  media  and  intima.  The  glandular  structures 
are  irregularly  surrounded  by  these  cell-masses,  but  are  primarily  other- 
wise unchanged;  in  the  later  stages,  however,  they  are  atrophied.  Ex- 
cepting the  presence  of  these  cells  there  are  no  inflammatory  signs. 
The  papillae  are  usually  normal  in  size,  although  in  some  cases  in  which  a 
papillomatous  tendency  is  noted  hypertrophy  is  observed.  The  con- 
nective tissue  and  elastic  tissue  of  the  corium  are  increased,  densely 
packed,  and  the  entire  cutaneous  structure  is  converted  into  a  dense 
mass.  The  histologic  changes  in  the  circumscribed  form,  studied 
carefully  by  Crocker,  vary  relatively  little  from  those  of  the  diffused 
type  in  its  early  stage,  both  having  the  same  anatomic  basis,  the  cell 
exudation  bringing  about  the  first  change — narrowing  of  the  vessels, 
fibrillar  tissue  formation,  and  atrophic  changes;  the  pinkish  or  violaceous 
zone  is  due  to  collateral  hyperemia  around  an  anemic  area.  Duhring 
found  in  a  soft,  pliable,  whitish  patch  of  some  months'  duration  a  con- 
densation of  the  connective  tissue  of  the  corium,  with  a  shrinkage  of  the 
papillary  layer. 

Diagnosis. — In  well-marked  cases  of  diffused  scleroderma  the 
characters — rigidity,  stiffness,  hardness,  and  hide-bound  condition  of 
the  skin,  with  usually  more  or  less  pigmentation — are  quite  distinctive 
and  scarcely  admit  of  error.  In  the  less  marked  and  obscure  examples 
possible  confusion  might  occur  with  Raynaud's  disease,  the  brawny 
induration  sometimes  observed  in  scorbutus,  myxedema,  and  leprosy, 
but  the  features  and  mode  of  onset  of  these  several  affections  are  clearly 
different.  The  nervous  phenomena,  the  usually  preceding  and  long- 
continued  and  often  periodic  stasic  and  anemic  conditions  of  the  favorite 
limited  regions  in  Raynaud's  disease,  are  differential  points  of  value, 
and  together  with  the  absence  of  any  tendency  to  extensive  hardening 
or  thickening  will  usually  serve  to  prevent  a  mistake  in  this  direction. 
The  localization  of  the  brawny  hardness  of  scurvy,  the  purpuric  element, 
and  other  symptoms  are  distinct  from  those  of  scleroderma.  The 
edematous  stage  observed  in  some  cases  presents  a  similarity  to  myx- 
edema, but  the  distribution  and  mode  of  onset  of  the  latter,  the  absence 
of  sclerotic  and  other  features,  are  different.  Leprosy  can  scarcely  be 
confounded  with  diffuse  scleroderma,  the  sensory  disturbances  usually 
present  and  often  preceding  the  development  of  the  cutaneous  symptoms 
in  the  former,  the  absence  of  tendency  to  brawny  hardening,  the  history 
of  the  case,  and  the  exposure  to  the  disease  are  points  to  be  considered. 
The  malady  can  scarcely  be  mistaken  for  xeroderma  pigmentosum. 
Sclerema  neonatorum,  a  somewhat  allied  disease,  is  an  affection  of 
earliest  infancy,  whereas  scleroderma  has  never  been  noted  before  the 
second  year  of  life. 

The  early  white  plaques  of  morphea— circumscribed  scleroderma— 
in  some  cases  resemble  closely  similar  areas  not  infrequently  seen  in 


HYPERTROPHIES 

leprosy,  but  the  symptoms  and  characters  of  the  latter  already  noted  are 
of  different  nature.  The  morpheic  white  areas  may  also  bear  resem- 
blance to  vitiligo,  but  in  the  latter  the  sole  essential  symptom  is  loss  of 
pigment— no  thickening  or  other  change  in  the  skin.  In  women  a  mis- 
take between  carcinomatous  skin  invasion  of  the  breast  (cancer  en 
cuirasse)  and  the  circumscribed  sclerodermic  disease  has  been  made,  but 
careful  investigation  should  prevent  error. 

Prognosis.— The  outcome  in  a  given  case  of  either  variety  as 
regards  cure  is  uncertain;  the  diffused  type  is  often  fatal,  usually  from 
some  intercurrent  affection  superinduced  by  the  patient's  condition. 
In  those  in  which  the  chest  is  practically  incased  in  an  unyielding  armor, 
and  the  mouth  narrowed  and  fixed,  and  the  jaws  firm,  interfering  with 
respiration  and  nutrition,  the  prospect  is  unfavorable.  According  to 
Meneau,  the  scleroderma,  progressive  in  character,  beginning  at  the 
extremities  and  spreading  to  other  parts,  is  generally  fatal.  On  the  other 
hand,  in  many  extensive  cases  and  seemingly  unfavorable,  if  decided 
atrophic  changes  have  not  occurred,  recovery  takes  place. 

The  circumscribed  form — morphea — is  a  relatively  mild  affection, 
often  persisting,  it  is  true,  and  in  some -cases,  almost  indefinitely,  but  is 
not  necessarily  dangerous,  and  very  often,  after  some  months  or  a  year 
or  two,  either  as  the  result  of  treatment  and  sometimes  spontaneously, 
complete  recovery  ensues.  Considerable  deformity  may,  however, 
result  in  the  rarer  instances  in  which  atrophy  takes  place. 

Treatment. — The  patient's  general  health  must  receive  proper 
attention,  and  such  tonics  as  quinin,  strychnin,  iron,  arsenic,  sodium 
salicylate,  and  cod-liver  oil  have  an  important  influence  in  some  cases. 
Of  these,  several — arsenic,  sodium  salicylate,  and  cod-liver  oil — have  in 
my  experience  been  the  most  valuable,  and  probably  possess  more  than 
a  simple  tonic  and  alterative  value.  My  own  observations,  however, 
have  concerned,  for  the  most  part,  the  circumscribed  forms  of  the  disease. 
In  extensive  cases,  in  addition  to  those  remedies  named,  the  adminis- 
tration of  pilocarpin,  properly  supported  with  stimulants  and  tonics, 
and  its  action  on  the  sweat-glands  promoted  by  warm  clothing  or  bed- 
covering,  is  of  some  value  when  the  sweat  secretion  is  markedly  in 
abeyance.  Recently  thyroid  extract  has  been  advocated,  but  the  re- 
ports are  at  variance.  Osier  has  not  been  favorably  impressed  with  its 
use,  although  still  recommending  its  trial.  The  cases  mentioned  by 
Lewin  and  Heller,  in  which  this  treatment  was  adopted,  were  not  ma- 
terially influenced,  and  this  was  also  the  experience  of  Uhlenhuth, 
Dreschfeld,1  and  some  others.  On  the  other  hand,  Marsh,2  Lustgarten,3 
Gayet,4  Eddowes,5  Roques,6  and  others  have  seen  betterment  take  place. 
As  yet,  therefore,  the  exact  value  of  this  remedy  remains  to  be  deter- 
mined— it  should,  however,  be  tried,  in  all  diffused  cases  at  least. 

The  local  treatment  most  efficacious  consists  essentially  in  the  use 

1  Dreschfeld,  Medical  Chronicle,  1896-97,  vol.  vi,  p.  263. 
-  Marsh,  Med.  News,  1895,  vol.  Ixvi,  p.  427. 

3  Lustgarten,  Jour.  Cutan.  Dis.,  1895,  p.  27  (brief  reference  only). 

4  Gayet,  Jour.  mat.  cutan.,  Jan.,  1900. 

5  Eddowes,  Brit.  Jour.  Derm.,  1899,  p.  325. 

6  Roques,  loc.  tit. 


SCLEREMA   NEONATORUM  589 

of  friction  with  oils  or  ointments  and  massage.  The  applications  should 
usually  be  of  mild  character,  or  in  limited,  obstinate,  non-irritable  areas, 
quite  stimulating.  As  a  mild  ointment  may  be  mentioned  one  contain- 
ing salicylic  acid  10  grains  (0.65),  cacao-butter  2  drams  (8.),  lanolin 
2  drams  (8.),  petrolatum  4  drams  (16.);  or  i  or  2  per  cent,  salicylated 
'oil  can  be  used.  In  the  hard,  thickened,  sclerodermic  areas  in  the  cir- 
cumscribed form  I  have  used  with  advantage  an  oil  consisting  of  i  or 
2  parts  of  oil  of  turpentine  with  6  parts  oil  of  sweet  almonds;  and  an  oint- 
ment of  2  parts  oil  of  turpentine,  i  part  beta-naphthol,  2  parts  oil  of 
sweet  almonds,  and  10  parts  lanolin;  and  in  the  tough  band  areas  on  the 
extremities,  sometimes  associated  with  paroxysmal  pain,  an  ointment 
containing  5  or  10  grains  (0.35-0.65)  of  menthol  and  \  dram  (2.)  of  chloro- 
form to  the  ounce. 

In  the  typical  soft  or  moderately  hard  areas  of  morphea,  especially 
in  the  earliest  stages,  the  mild  applications  are  to  be  used,  the  stronger 
sometimes  tending  to  produce  irritation.  Electric  treatment,  consist- 
ing of  general  and  local  galvanization,  has  been  commended  by  some 
observers;  with  the  former  I  have  had  no  experience,  but  the  latter, 
using  a  current  of  2  to  10  milliamperes,  with  friction  movements  of  the 
two  electrodes — labile  application — has  seemed  to  me  of  some  advantage; 
likewise  the  use  of  the  static  battery  roller  electrodes  made  over  the  part, 
while  covered  with  the  clothing  or  some  fabric.  In  the  past  few  years 
favorable  statements  have  been  made  of  electrolysis  in  the  treatment  of 
circumscribed  patches  by  Brocq,1  Darier  and  Gaston,2  and  Allen.3 
I  have  had  no  experience  with  this  method.  It  is  employed  in  the  same 
manner  as  in  the  removal  of  superfluous  hairs:  current  strength  between 
\  to  10  milliamperes,  according  to  sensitiveness  of  the  patient  and  the 
integumentary  conditions;  the  stronger  current  in  the  more  infiltrated 
areas,  if  the  patient  bears  it,  and  in  such  cases,  too,  the  duration  of  the 
application  somewhat  longer  than  in  the  softer  and  less  infiltrated  patches. 
Brocq  employs  as  supplementary  to  the  electrolytic  procedure  the  ap- 
plication of  mercurial  plaster,  which,  I  believe,  should  have  a  share  in 
the  credit  for  the  good  results  claimed  by  him.  X-ray  treatment  is  some- 
times especially  valuable  in  the  morphea  type  of  the  disease. 

SCLEREMA  NEONATORUM 

Synonyww.-Scleroderma  neonatorum;  Sclerema  of  the  newborn;  Underwood's 
disease;  Fr.,  Sclereme  des  nouveau-nes;  Algidite  progressive;  Lendurcissement  8th- 
repsique  (Parrot);  Ger.,  Das  Sklerem  der  Neugeborenen;  Das  Fettskle 

Symptoms.— This  rare  disease  of  infancy,  first  described  by  Un- 
derwood,4 shows  itself  usually  at  or  shortly  after  birth,  and  as  a  rule, 
first  manifests  itself  upon  the  lower  extremities,  and  more  or  less  rapidly 
invades  other  parts,  in  most  cases  the  general  involvement  ensuing 
within  three  or  four  days.  In  some  instances  jaundice  has  been  asso- 
ciated. The  skin  is  at  first  generally  whitish  and  waxy  in  appei 

1  Brocq,  Annales,  1898,  No.  2. 

2  Darier  and  Gaston,  ibid.,  1897,  p.  451- 

3  Allen,  Jour.  Cutan.  Dis.,  Jan.,  1899.  P-  4°. 

<  Underwood,  Diseases  of  Children,  1874,  p.  7&. 


590 


H  YPER  TR  OPHIES 


it  later  becomes  faintly  livid  or  mottled,  and  is  hard,  stiff,  leathery 
and  tense,  and  the  surface  cold.  It  does  not  pit  upon  pressure.  Fusion 
or  agglutination  with  the  subjacent  parts  is  noted,  and  in  consequence 
of  this  or  as  a  result  of  induration  of  the  integument,  or  of  both,  the 
infant  is  as  if  frozen  or  hewn  from  marble;  it  is  unable  to  move  or  suckle, 
respires  feebly,  and  usually,  already  weakened  by  intestinal  disorders, 
pneumonic  or  circulatory  disturbance,  the  pulse  falls,  the  temperature 
drops  to  several  degrees  below  normal,  and  it  perishes  in  a  few  days  or 
one  or  two  weeks.1  In  those  cases  in  which  it  appears  to  be  congenital 
or  develops  immediately  at  birth,  death  usually  results  in  one  or  two 
days.  In  extremely  exceptional  instances  the  disease,  after  involving 
a  small  portion  of  the  surface,  retrogresses,  the  involved  tissues  soften, 
regain  their  elasticity,  and  recovery  ensues;  or  it  may  remain  stationary, 
for  a  time  at  least,  and  resemble  somewhat  scleroderma  in  the  adult.2 

Etiology. — Fortunately  the  malady  is  extremely  rare,  appearing 
within  the  first  ten  days  of  life;3  and  the  cases  recorded  have  for  the 
most  part  been  in  emaciated  or  atrophic  infants  in  maternity  wards 
or  foundling  asylums.  Both  Underwood  and  Parrot  consider  it  an 
institution  disease,  often  in  overcrowded  rooms,  and  associated  with 
bad  hygiene  and  improper  feeding.  Some  cases  seem  to  be  congenital; 
others  develop  in  a  day  or  two  after  birth  without  recognizable  cause; 
in  others  it  appears  several  days  after  birth,  apparently  as  a  result  of  con- 
stitutional diseases  which  rapidly  depress  or  drain  the  vitality  and  bring 
on  collapse,  such  as  diarrhea,  lung  affections,  cardiac  weakness,  etc. 
According  to  J.  L.  Smith,4  a  considerable  proportion  of  infants  with  this 
disease  are  prematurely  born. 

Pathology. — Although  the  disease  had  been  previously  de- 
scribed by  Underwood  and  a  few  others  more  than  a  hundred  years 
ago,  it  was  not  until  Parrot's5  observations  that  the  confusion  between 
this  affection  and  cedema  neonatorum  was  dissipated,  although  there 
is  yet  a  not  uncommon  belief  that  these  two  affections  are  allied,  and 
that  they  may  be  also  closely  related  respectively  to  the  sclerous  and 
edematous  types  of  scleroderma,  a  view  which  has,  I  believe,  much  in 
its  favor.  Langer6  looks  upon  the  malady  as  due  to  solidification  of 
the  fat,  resulting  from  the  temperature  depression,  the  fat  of  the  new- 
born containing  relatively  so  much  palmatin  and  stearin,  which  readily 

1  In  a  case  reported  by  L.  W.  Meyers,  Jour.  Cutan.  Dis.,  1909,  p.  87,  there  was 
slight  elevation  of  temperature;  disease  began  on  third  day  on  the  buttocks  and  thighs 
and  then  spread,  child  dying  on  the  twenty-fifth  day. 

2  Barr,  Brit.  Med.  Jour.,  May  4,  1889;  Bunch,  Brit.  Jour  Derm.,  1898,  p.  145 
(case  demonstration) ;  Pringle,  ibid.,  1899,  p.  290  (case  demonstration);  and  W.  Brown- 
ing, Jour.  Cutan.  Dis.,  1900,  p.  563,  report  interesting  cases  of  somewhat  limited  and 
peculiar  character. 

3  Money,  Lancet,  1888,  vol.  ii,  p.  811,  records  2  cases,  sisters,  developing  one  or 
two  months  after  birth,  associated  with  paralysis,  death  ensuing  two  or  several  months 
later;  another  sister  had  previously  died  from  the  same  disease,  also  developing  late  and 
lasting  a  few  months  before  death  ensued.     The  only  other  child — a  boy  of  two  and 
one-half  years — had  so  far  remained  free.     I  am  not  sure  that  these  cases  belong  to  this 
disease;  they  are  apparently  connecting  cases  between  this  affection  and  some  cases 
of  scleroderma,  as  observed  in  the  adult. 

4  J.  L.  Smith,  Diseases  of  Children. 

5  Parrot,  Clinique  des  Nouveau-nes,  L'Athrepsie,  Paris,  1877. 
'Langer,  Wien.  med.  Presse,  1881,  pp.  1375  and  1412. 


(EDEMA   NEONATORUM  50! 

solidifies  when  the  body-heat  drops  below  normal— a  view  which  scarcely 
accords  with  the  anatomic  findings  of  Parrot  and  Ballantyne l  who 
found  practically  a  "dried-out"  skin,  some  thickening  of  the  layers  and 
diminution  of  the  fat,  and  no  true  sclerosis  and  no  serous  effusion,  the 
drying  out  being  due  to  the  diarrhea.  Wiederhofer2  and  Soltmann3' also 
practically  accept  the  belief  that  the  draining  of  the  tissues  by  serum  loss 
is  of  pathologic  import.  Northrup,  quoted  by  Smith,  and  others  found 
histologically  nothing  especially  abnormal. 

Prognosis  and  Treatment.— Apparently  only  cases  in  which 
the  sclerema  is  not  general  or  complete  recover,  and  these  are  rare, 
a  fatal  end  being  the  almost  invariable  result.  Treatment  consists 
in  measures  to  increase  the  body-heat  and  the  administration  of  proper 
alimentation  and  stimulants,  by  tubes  passed  through  nose  or  mouth 
to  the  pharynx  and  stomach,  or  by  the  rectum,  or  both. 

OEDEMA  NEONATORUM 

Synonyms. — Edema  of  the  newborn;  Ger.,  Das  Sklerodem. 

Symptoms. — The  characteristic  symptoms  of  this  affection  are 
edema  and  variable  hardness  or  induration,  in  both  these  respects  cor- 
responding somewhat  to  the  edematous  type  of  scleroderma  in  the  adult. 
It  begins  almost  invariably  on  the  legs,  very  exceptionally  on  other  parts, 
such  as  the  face  or  trunk,  and,  as  a  rule,  in  the  first  day  or  two  of  life. 
It  is  sometimes  preceded  by  drowsiness,  or  this  develops  with  the  cuta- 
neous phenomena.  Beginning  usually  on  the  lower  part  of  the  legs,  it 
gradually  creeps  upward,  and  about  the  same  time  the  hands  are  likely 
to  show  involvement,  and  then  other  parts.  It  .is  rarely  general.  Ex- 
ceptionally it  is  limited  to  the  lower  porton  of  both  extremities,  especially 
the  hands  and  feet  (J.  L.  Smith).  To  the  touch  the  parts  are  either  some- 
what rigid,  due  to  enormous  serous  infiltration,  or  they  are  soft  and 
doughy,  and  pit  upon  moderate  pressure.  The  skin  is  of  a  yellowish, 
dusky,  or  livid  color,  and  sometimes  glossy  or  shining.  The  general 
symptoms  of  drowsiness,  feeble  circulation,  and  weakened  respiratory 
action  usually  increase;  the  temperature  is  noted  to  be  below  the  normal, 
and  sooner  or  later,  with  some  exceptions,  from  some  intercurrent  affec- 
tion or  complication  superinduced  by  the  patient's  condition,  such  as 
diarrhea,  pulmonary  disease,  nephritis,  with  collapse,  lead  rapidly  to  the 
end. 

Its  chief  differences  from  sclerema  neonatorum  are  the  edematous 
infiltration,  always  most  marked  in  dependent  regions,  the  absence  of 
pronounced  integumentary  sclerosis  and  articular  immobility,  the  pitting 
upon  pressure,  and  less  general  rigidity,  and  its  less  generalized  distribu- 
tion. 

1  Ballantyne,  Brit.  Med.  Jour.,  Feb.  22,  1890,  p.  403,  and  editorial  comment,  p. 

2  Wiederhofer,  in  Gerhardt's  Handbuch  der  Kinderkrankheiten,  1880,  vol.  iv,  2. 

3  Soltmann,  Eulenberg's  Real-Encyclopadie,  1899,  vol.  xxii,  p.  482  (excellent  con- 
tribution both  as  to  sclerema  neonatorum  and  oedema  neonatorum,  with  full  bibliog- 
raphy). 


592  HYPERTROPHIES 

Etiology.— It  develops  in  the  first  few  days  of  life.  The  causes 
seem  to  vary  in  different  cases,  although,  as  a  rule,  feeble,  ill-nourished, 
premature  infants,  with  marked  cardiac  weakness,  are  its  usual  subjects, 
and  especially  in  the  children  of  ill-fed  and  insufficiently  nourished 
mothers.  Pulmonary  atelectasis,  nephritis  (Elsasser,  Henoch),1  heredi- 
tary syphilis  (Soltmann2),  erysipelas  (J.  L.  Smith),  incomplete  establish- 
ment of  respiration  (Dumas),  exposure  to  cold  immediately  after  birth 
(Crocker3),  have  been  variously  considered  as  influential  in  some  cases. 
On  the  other  hand,  in  Blacker's4  case  there  seemed,  an  entire  absence  of 
recognizable  factors. 

Pathology. — Ballantyne5  ascribes  cedema  neonatorum  to  dis- 
turbances of  the  cardiac,  pulmonary,  renal,  or  vascular  system,  believing 
it  akin  to  anasarca  in  the  adult.  Dumas,  from  his  studies  and  observa- 
tions, considers  the  disease  as  a  symptom  of  phlegmasia  alba  dolens, 
which  is  developed  during  the  first  days  after  birth,  but  that  the  venous 
thrombosis  is  more  frequently  located  in  the  inferior  vena  cava  than  it  is 
in  the  adult.  Jarisch6  believes  the  various  observations  made  and  the 
autopsy  findings,  so  often  diverse,  point  rather  to  the  condition  being  a 
symptom  or  a  part  of  other  grave  diseases,  rather  than  an  independent 
malady.  At  all  events,  it  consists  essentially  of  an  edema — a  serous 
transudation  into  the  subcutaneous  tissue.  The  fat  is  found  to  be  some- 
what dense,  crumbly,  or  granular,  and  not  infrequently  of  a  yellowish 
or  brownish  color.  Autopsies  have  disclosed  in  some  instances  pulmo- 
nary disease,  venous  thrombosis,  nephritis,  enlarged  liver,  etc. 

Prognosis  and  Treatment. — According  to  Soltmann,  at  least 
80  to  90  per  cent,  of  the  cases  die.  Treatment  is  essentially  the  same 
as  in  sclerema  neonatorum — increasing  and  maintaining  the  body-heat, 
sufficient  and  proper  nourishment,  and  stimulants.  Dumas  advises, 
as  a  preventive  measure,  suitable  care  to  establish  thoroughly  the  respi- 
ratory function  in  the  newborn  at  the  moment  of  birth,  and  not  too 
hasty  ligation  of  the  cord. 

ELEPHANTIASIS7 

Synonyms. — Elephantiasis  Arabum;  Pachydermia;  Barbadoes  leg;  Morbus  elephas; 
Elephant  leg;  Elephantiasis  indica;  Bucnemia  tropica;  Spargosis;  Fr.,  Elephantiasis. 

Definition. — A  chronic  endemic  or  sporadic  disease  of  the  skin 
and  subcutaneous  tissues,  usually  of  the  leg  or  genitalia,  characterized 

1  Quoted  by  J.  Lewis  Smith,  Diseases  of  Children. 

2  Soltmann,  loc.  cit. 

3  Crocker,  Diseases  of  the  Skin. 

4  Blacker,  Brit.  Jour.  Derm.,  1898,  p.  87  (case  demonstration). 
2  Loc.  cit. 

8  Jarisch,  Haulkrankheilen,  1900,  p.  824. 

'Literature:  P.  Manson,  Tropical  Diseases,  London,  1898;  chapter  on  "The 
Filariae  Sanguinis  Hominis  and  Filaria  Disease,"  in  Davidson's  Hygiene  and  Diseases 
of  Warm  Climates,  Edinburgh  and  London,  1893.  Manson's  earlier  contributions  on 
this  subject  are  practically  reviewed  in  these  publications,  and  references  to  the  prin- 
cipal observations  of  other  writers  are  made.  W.  M.  Mastin,  "The  History  of  Filaria 
Sanguinis  Hominis;  its  Discovery  in  the  United  States,"  Annals  of  Surgery,  Nov.,  1888; 
Esmarch  and  Kulenkampff,  Die  Elephantiasistichen  Formen,  Hamburg,  1885,  with 
numerous  illustrations;  full  bibliography  is  given  by  Hyde,  Morrow's  System,  vol.  iii 
(Dermatology),  p.  451. 


ELEPHANTIASIS 


593 


by  enlargement  and  deformity,  lymphangitis,  swelling,  edema,  thickening, 
induration,  pigmentation,  and  more  or  less  papillary  growth.  In  the 
description  following  the  term  non-parasitic  will  be  applied  to  those 
cases  not  due  to  filaria. 

Symptoms. — The  malady  usually  begins,  in  the  endemic  variety, 
and  less  commonly  in  sporadic  cases  also,  with  general  symptoms  of 
fever  (elephantoid  fever),  chilliness,  often  nausea,  and  sometimes  vom- 
iting, and,  in  some  instances,  more  or  less  rheumatic  pain,  especially 
about  the  lumbar  region.  Along  with  these,  concomitantly  or  precur- 
sorily,  there  is  an  erysipelatous  or  pseudo-erysipelatous  inflammation 
of  the  part,  with  swelling,  pain,  heat,  redness,  and,  as  a  rule,  lymphan- 
gitis. There  may  be  considerable  edema,  varying  somewhat  in  different 
cases,  and  not  infrequently,  especially  if  there  is  marked  lymphatic 
involvement,  more  or  less  discharge  of  a  clear  or  milky  character.  The 
inflammation,  in  some  cases,  takes  its  origin  in  a  local  lesion,  such  as  a 
slight  cutaneous  abrasion,  injury,  or  scar;  but  in  the  large  majority  of 
instances  manifests  itself  without  any  recognizable  local  cause.  The 
part  is  considerably  enlarged,  sometimes  tense,  and  only  pitting  upon 
pronounced  pressure;  or  the  condition,  and  especially  after  a  few  days, 
is  more  of  the  nature  of  an  edema,  somewhat  doughy,  and  which  pits 
quite  readily.  In  several  days  the  acuteness  of  the  symptoms,  both 
general  and  local,  has  abated,  the  former  often  entirely  disappeared,  and 
gradually  the  swelling,  tenderness,  and  redness  subside,  and,  after  a  few 
weeks  or  longer,  as  a  result  of  treatment  or  spontaneously,  the  affection 
is  apparently  at  end,  except  that  the  region  involved  is  observed  to  be 
somewhat  larger  than  before  the  onset.  This  enlargement  is,  however, 
in  most  cases,  often  scarcely  perceptible  after  the  first  attack;  later,  with 
each  succeeding  seizure,  it  becomes  more  and  more  noticeable.  The 
period  of  freedom  or  quiescence  varies  from  several  weeks  to  some  months. 

The  amount  of  increase  depends  measurably  upon  the  duration  and 
severity  of  the  attack,  the  latter  in  some  being  slight  and  relatively 
transitory,  in  others  intensely  acute  and  protracted.  Exceptionally  it 
is  of  slight  character,  but  practically  continuous,  and  the  enlargement, 
though  trifling,  is  steadily  progressive.  After  months  or  one  or  more 
years  the  enlargement  or  hypertrophy  becomes  conspicuous,  the  part 
is  chronically  swollen,  edematous,  and  hard;  the  skin  thickened,  the 
normal  lines'and  folds  exaggerated,  the  papillae  enlarged  and  prominent, 
and  with  often  more  or  less  fissuring  and  pigmentation.  This  goes  on, 
there  is  gradual  increase  in  size,  the  parts  in  some  instances  reaching 
enormous  proportions;  the  skin  becomes  rough  and  warty,  eczematous 
inflammation  is  often  superadded,  and,  sooner  or  later,  ulcers,  superficial 
or  deep,  either  spontaneously  or  from  injury  or  from  varicose  veins, 
form— which,  together  with  the  crusting  and  moderate  scalmess,  and 
sometimes  with  intermittent  or  continuous  lymph-like  discharge,  prese 
a  striking  and  characteristic  picture.  In  a  minority  of  cases,  me 
especially  until  the  disease  is  well  advanced,  the  surface  remains  com- 
paratively smooth.  The  course  of  the  malady,  when  once  thoroughly 
established,  is  usually  steadily,  although  often  scarcely  perceptibly, 
progressive;  but  there  are  in  most  cases  periods  of  comparative  inactivity, 


38 


HYPERTROPHIES 

or,  after  reaching  a  certain  development,  the  disease  may,  for  a  time  at 
least,  remain  stationary.  The  accumulated  crusts,  composed  of  epider- 
mis, discharge,  blood  and  dirt,  undergo  variable  change  or  decomposition, 
and  there  is  emitted  an  offensive,  and  often  penetrating,  odor. 

The  general  and  local  symptoms  in  the  endemic  variety  are  essentially 
similar  whatever  the  part  attacked,  varying  in  intensity  in  different 
patients.  In  the  scrotal  or  genital  form  there  is  often  a  good  deal  of 
pain  in  the  parts  themselves  and  along  the  spermatic  cords.  In  both 
the  leg  and  genital  cases  the  inguinal  glands  are  enlarged  to  a  varying 
degree,  and  sometimes  tender  and  painful.  In  the  non-parasitic  cases, 
usually  met  with  outside  of  the  endemic  districts  or  countries,  the  general 
symptoms  are  rarely  marked,  and  often  absent,  depending  upon  the  in- 
tensity of  the  erysipelatous  inflammation.  In  these  latter  this  inflam- 
mation seems  to  be  similar  to,  or  identical  with,  ordinary  erysipelas, 
and  according  to  extent  and  severity  will  the  constitutional  involvement 
be  insignificant  or  pronounced.  In  others,  both  of  the  endemic  and  non- 
parasitic  kinds,  the  disease  is  insidious,  slowly  progressive,  and  without 
systemic  disturbance.  Much  depends  upon  the  character  of  the  case, 
its  extent,  and  the  nature  of  the  operative  cause  or  causes,  as  will  be 
referred  to  under  etiology  and  pathology. 

The  regions  involved  in  elephantiasis  are  most  commonly  the  legs 
(elephantiasis  cruris)  and,  less  frequently,  in  the  severe  forms  at  least, 
the  genitalia  (elephantiasis  genitalium).  Other  parts  may,  however, 
be  the  seat  of  the  disease,  as  more  or  less  generalized,  as  in  Felkin's  case,1 
the  arm  and  hand  (Crocker,  Mackenzie,  Hoyer,  and  others),2  the  side 
of  the  face  (Richards,  Hebra  and  Kaposi,  Moncorvo,  and  others),3 
eyelids  (Gorand),4  and  other  regions.  It  is  probable,  though,  that  many 
of  these  cases  of  anomalous  localization  are  not  true  examples  of  the  dis- 
ease, but  rather  unusual  forms  of  fibroma  or  the  allied  condition,  derma- 
tolysis.  In  elephantiasis  of  the  leg  quite  frequently  but  one  leg  is  in- 
volved, and  the  right  more  commonly ;  in  the  endemic  variety,  however, 
both  legs  are  often  invaded.  In  some  cases,  more  particularly  the  spo- 
radic, it  may  be  limited  to  the  foot  and  ankle,  for  a  time  at  least.  A  ver- 
rucous  surface  is  not  uncommon  on  the  dorsum  of  the  foot,  usually  cov- 
ered with  horny  epidermis  or  sodden  accumulation.  Generally,  how- 
ever, the  whole  leg  up  to  the  middle  thigh  shows  variable  enlargement, 
being  most  marked  on  the  lower  part,  where  it  may  reach  three  or  more 
times  the  normal  circumference.5  While  in  some  cases,  more  particularly 
of  moderate  development,  it  is  smooth,  or  relatively  so,  and  well  shapen, 
as  a  rule  it  is  rough  and  irregular  or  warty,  scaly,  crusted,  and  much  de- 

1  Felkin,  Edinburgh  Med.  Jour.,  1889,  vol.  xxxiv,  part  ii,  p.  779. 

2  Crocker,  Diseases  of  the  Skin,  also  refers  to  Mackenzie's  case;  Hoyer,  Buffalo  Med. 
and  Surg.  Jour.,  1885-86,  vol.  xxv,  p.  452  (with  illustration). 

3  Moncorvo,  Pediatrics,  1897,  p.  481. 

4  Gorand,  Annales  de  la  Polydinique  de  Bordeaux,  April,  1892,  p.  105  (3  cases); 
Schuster  (Gussenbauer's  clinic),  Prager  med.  Wochenschr.,  1880,  p.  201,  reports  a  case 
of  elephantiasic  nose  enlargement,  developed  after  an  injury,  associated  with,  however, 
fibroma tous  or  fibroneuromatous  general  integumentary  lesions;  a  tabulation  of  a 
number  of  cases  of  localized  elephantiasis  with  literature  references  is  given;  these 
cases  can  scarcely  be  called,  however,  elephantiasis,  as  this  term  is  generally  understood. 

5  McCall  Anderson,  Jour.  Cutan.  Med.,  1868,  vol.  i,  p.  180,  records  a  case  in  which 
the  calf  circumference  reached  27  inches. 


ELEPHANTIASIS  595 

formed,  often  deserving  the  term  elephant  leg,  by  which  it  is  sometimes 
described.  The  disease  varies  considerably,  however,  as  to  growth,  and 
cases  of  all  degrees  of  severity  are  met  with,  from  the  comparatively 
insignificant  to  the  extreme  condition  which  hinders  the  patient  from 
getting  about. 

Elephantiasis  of  the  genital  region  may  involve  the  entire  parts  or 
only  the  scrotum  or  the  penis.  Almost  invariably,  however,  even  when 
the  hypertrophic  changes  are  conspicuously  pronounced  on  one  part, 
the  other  is  enlarged  also,  but  to  relatively  less  extent.  The  enlarge- 


Fig   i43.-ElephantiasiS)  with  marked  papillary  growth  (almost  of  ichthyosis  hystrix 
type)  and  pigmentation. 


ment  varies  from  insignificant  to  enormous  dimensions,  in  one  instance 
the  scrotal  growth  weighing  no  pounds  (Clot-Bey).1  The  neighboring 
lymphatic  glands  are  usually  enlarged. 

The  malady,  when  limited  to  the  genitaha,  varies  very  little,  if  at 
all,  from  that  of  the  legs,  but  is  probably  much  more  insidious  anc 
progressive,  with  less  tendency  to  extreme  acute  exacerbations  than 
the  disease  of  the  latter  region.  There  is  often  considerable 

gives  no  reference  as  to  source. 


HYPERTROPHIES 

lymphatic  discharge,  and  the  enormous  tumor,  sometimes  hanging  as 
far  down  as  below  the  knees,  is  a  source  of  great  discomfort,  a  dragging 
feeling,  and  often  pain.  Eczemas  and  ulcerations  are  frequently  added, 
and  increase  the  patient's  misery  still  further.  In  women  the  brunt  of 
the  disease,  when  involving  the  genitalia,  usually  falls  upon  the  labia 
majora;  the  clitoris  and  other  parts  may,  however,  and  almost  always 
in  extreme  cases,  share  in  the  hypertrophic  process.  The  condition  may 
be  a  slight  one,  and  give  rise  to  but  little  discomfort,  or  it  may  eventually 
be  excessive. 

Lymph-scrotum  (varix  lymphaticus;  lymph  tumors;  naevoid  elephan- 
tiasis; milky  exudation  of  the  scrotum)  is  to  be  looked  upon  as  a  form 
of  elephantiasis,  probably  occupying  a  middle  ground  between  this 
latter  and  chyluria.  According  to  Manson,  the  characteristic  feature 
of  this  affection  is  the  presence,  on  the  surface,  of  dilated  lymphatics 
and  lymphatic  vesicles,  which  often  rupture  and  discharge  coagulable 
lymph.  There  is  a  certain  amount  of  hypertrophic  enlargement,  and 
often  with  attacks  of  erysipelatous  inflammation  and  elephantoid  fever. 
Manson  believes  that  the  three  diseases — elephantiasis,  lymph-scrotum, 
and  chyluria — and  their  varieties  may  be  considered  as  but  accidental 
modifications  of  the  same  pathologic  conditions  and  etiologically  identical. 

Elephantiasis  telangiectodes,  which  is  also  known  as  naevoid  elephan- 
tiasis and  telangiectatic  elephantiasis,  is  a  hypertrophic  development, 
which,  according  to  Virchow,  has  a  congenital  origin,  and  which  sub- 
sequently undergoes  hypertrophy.1  The  elephantiasic  enlargement  may 
be  slight  or  may  attain  considerable  dimension.  The  hypertrophic 
growth  is  thought  by  Virchow  to  be  due  to  the  overnutrition  of  the  part, 
resulting  from  the  underlying  increase  of  the  vascular  supply,  the  deep 
vessels  often  attaining  considerable  size.  In  some  cases  the  tissue  and 
vessels  enlarge  progressively,  and  while  the  surface  is  not  necessarily 
changed,  occasionally  increased  vascular  supply  ensues  superficially  and 
a  reddish  aspect  is  presented. 

Acromegaly2  is  a  hypertrophic  condition,  first  clearly  presented  in 
Marie's  classic  paper,  which  deserves  brief  mention  in  connection  with 
elephantiasis.  The  bones  and  soft  parts,  especially  of  the  face,  feet, 
and  hands,  undergo  thickening  and  increase  in  volume,  in  extreme  case 
almost  giant-like  in  appearance.  The  affection  is  usually  slow  and  in- 
sidious, the  individual  scarcely  knowing  when  the  process  began.  The 
arms  and  legs,  especially  toward  the  distal  ends,  share  materially  in  the 
hypertrophic  enlargement,  and  all  parts,  even  the  trunk  (as  in  one  of 
Dercum's  cases),  may  be  involved  also.  In  the  face,  the  lower  jaw, 

^Merrill  Ricketts,  Jour .  Cutan.  Dis.,  1889,  (with  illustration),  reports  an  inter- 
esting case  involving  the  chin,  lower  lip,  and  contiguous  lower  part  of  the  cheeks,  in 
which  increased  growth  did  not  ensue  until  adult  life  was  reached. 

2  Literature:  Paul  Marie,  Revue  de  med.,  1886,  p.  297,  and  Marie  and  Marinesco 
(pathologic  anatomy),  Trans.  Internal.  Cong.,  Berlin,  1890;  Arnold,  Virchow's  Archiv, 
vol.  cxxxv,  p.  i;  Souza-Leite,  De  I'Acromegalie,  Paris,  1890 — abs.  of  49  cases;  trans- 
lation by  Syd.  Soc'y,  London;  F.  A.  Packard,  Amcr.  Jour.  Med.  Sci.,  June,  1892,  p. 
657;  Collins,  Jour.  Nervous  and  Mental  Dis.,  Dec.,  1892  (digest  of  cases  since  Souza- 
Leite's  publication),  and  Feb.,  1893  (bibliography);  Dercum,  Amer.  Jour.  Med.  Sci., 
Mar.,  1893;  Church  and  Hessert,  Med.  Record,  1893,  vol.  xliii,  p.  545;  W.  G.  Shallcross, 
Pliilada.  Med.  Jour.,  April  20,  1901. 


ELEPHANTIASIS  597 

cheek  bones,  nose,  supra-orbital  prominences,  and  ears  usually  stand 
out  prominently.  In  the  hands  the  parts  are  often  huge,  broad,  and  flat, 
the  fingers  markedly  increased  in  volume,  and  the  ends  blunt.  The 
nails  are,  as  a  rule,  thick  and  flat,  but  not  usually  widened;  as  Bramwell1 
remarks,  the  nails  appear  to  be  small  in  proportion  to  the  size  of  the 
fingers,  and  in  most  cases  grooved  longitudinally.  The  hairs  on  the 
affected  regions  are  frequently  stronger,  and  exceptionally  there  is  a 
tendency  to  more  or  less  general  hairy  development  (Weir  Mitchell). 
The  skin,  more  particularly  of  the  face  and  extremities,  is  more  or  less 
thickened,  and  not  readily  pinched  up  into  folds,  and  often  exhibits 
pigmentary  spots;  occasionally  more  or  less  general  pigmentation  de- 
velops (Weir  Mitchell).  The  sweat  function  is  usually  increased.  Ac- 
cording to  Souza-Leite,  headache  is  a  frequent  concomitant.  The  cause 
of  the  disease  is  not  known;  Marie's  suggestion  of  involvement  of  the 
pituitary  body  and  its  enlargement  has  been  noted  in  a  number  of 
autopsies,  but  in  other  cases  it  has  been  found  to  be  wholly  normal. 
Klebs's  idea  that  it  might  be  due  to  persistence  and  enlargement  of  the 
thymus  gland  is  also  without  sufficient  corroborative  data  to  give  it 
standing.  In  fact,  postmortem  findings  have  shown  in  isolated  instances 
enlargement  of  one  or  other  of  the  various  glandular  structures,  as  well 
as  nerve  and  cerebral  lesions,2  but  a  judicial  review  of  the  cases  leaves 
nothing  substantial  as  to  its  nature  and  causes. 

Anatomically  there  is  practically  no  change  noted  in  the  epidermis 
except  pigmentation  of  the  prickle  layer,  but  both  cutis  and  hypoderm 
are  thickened,  essentially  consisting  of  collagenous  hypertrophy  (Unna). 
Degeneration  of  muscles,  blood-vessels,  and  nerves  has  also  been  observed, 
the  walls  of  the  arteries  and  veins  and  the  sheaths  of  the  nerves  are  thick- 
ened. 

Etiology.— Elephantiasis  occurs  in  all  parts  of  the  world,  but  is 
much  more  frequent  in  tropical  climates,  where  it  is  more  or  less  endemic. 
In  the  endemic  districts  it  is  chiefly  in  malarial  regions,  in  the  lowlands, 
and  also  along  the  seacoast  and  sea  islands.  Manson  has  shown  that 
the  mosquito  is  a  probable  factor— an  intermediate  host,  the  filaria 
hominis  sanguinis,  being  the  essential  agent.  Poor  food,  unhygienic 
living,  and  similar  conditions  are  doubtless  of  contributory  influence. 
It  is  rare  in  the  well-to-do  and  wealthy  classes.  It  is  not  contagious, 
nor  is  it  hereditary.  In  endemic  districts,  it  is  true,  owing  to  the  facts 
of  the  common  exposure  to  the  same  influences,  the  disease  is  often  seen 
in  two  or  more  members  of  the  family;  according  to  Richards,3  in  a  large 
percentage  of  cases  (about  75  per  cent,  in  his  tabulation)  the  disease  was 
present  in  one  or  both  parents.  Occasional  instances  of  the  coexistence 
of  leprosy  and  elephantiasis  have  been  observed  (Richards),  although  the 
association  is  purely  an  accidental  one,  the  two  diseases  being  in  no  way 
related  The  malady  is  seen  in  both  sexes  and  at  all  ages,  but  is  much 
more  frequent  in  early  adult  and  middle  life,  although  it  is  occasionally 

1  Bramwell  Atlas  of  Clinical  Medicine,  189.3,  vol.  ii,  p.  104. 

» In  WaWo's  case,  Brit.  Med.  Jour.,  March  22,  1890,  cavities  were  found  both  ,n 

""^vTcSSardrchapter  on  "Elephantiasis  Arabum,"  in  Fox  and  Farquhar's 
Endemic  Skin  and  Other  Diseases,  London,  1876. 


5  98  H  YPER  TR  OPHIES 

observed  in  childhood,  and  in  some  instances  as  a  congenital  affection.1 
The  disease  is  largely  confined  to  males,  the  proportion  being  about  3  to 
i,  and  the  darker  races  are  the  more  susceptible. 

While  the  filaria — for  which  Manson  suggests  the  name  of  filaria 
hominis  nocturna,  inasmuch  as  it  is  found  circulating  in  the  blood  only 
at  night — is  to  be  accepted  as  an  important,  if  not  the  sole,  factor  in  the 
endemic  disease,  there  are,  however,  many  cases  which  present  essentially 
the  same  symptomatology  which  are  entirely  independent  of  this  agent.2 
In  fact,  whatever  gives  rise  to  inflammation  or  obstruction  of  the  lym- 
phatics and  veins  may  lead  to  this  hypertrophic  development.  For 
example,  disease  and  enucleation  of  the  inguinal  glands  have  been  known 
to  be  followed  by  elephantiasis,  of  varying  degree,  of  the  genitalia,  both 
in  men  and  women,  of  which  many  cases  have  been  reported  in  recent 
years  by  Lassar,3  Riedel,4  Brouardel,5  Koch,6  and  many  others.  Ob- 
struction produced  by  various  tumors,  neoplasms,  ulcerations,  chronic 
skin  diseases,  phlegmasia  dolens,  syphilis  (Francis),7  gonorrhea  (Hum- 
bert, Farner,  and  others),8  and  sometimes  following  local  injury  (Berry, 
Hutchinson,  and  others).9 

Pathology. — The  pathologic  changes  are  the  result,  as  already 
intimated,  of  lymphatic  obstruction,  and  this  may  be  due  to  various 
causes.  According  to  Manson,  Lewis,  Bancroft,  Sabouraud,  and  others 
there  remains  no  doubt  that  in  the  endemic  cases  the  obstruction  is  due 

1  Barwell,  London  Path.  Soc'y  Trans.,  1881,  p.  282  (unilateral — head  and  face; 
bones  and  soft  parts;  with  illustration);  Spietschka,  Archiv,  1891,  vol.  xxiii,  p.  745  (a 
case  involving  both  legs,  with  illustration  and  literature  references) ;  Nonne,  Virclww's 
Archiv,  1891,  vol.  cxxv,  p.  189  (4  cases  from  same  family,  in  which  it  had  prevailed 
for  several  generations;  6  illustrations);  Coley,  N.    Y.  Med.  Jour.,  June  20,  1891  (of 
face  and  scalp,  with  illustration — apparently  allied  to  fibroma  or  dermatolysis;  good 
result  from  operation);  Uthemann,  Deutsche  med.  Wochenschr.,  1895,  p.  826  (penis  and 
scrotum — apparently  beginning  at  age  of  four — two  illustrations,  showing  condition 
and  result  of  operation) ;  Busey,  Congenital  Occlusion  and  Dilatation  of  Lymph  Channels, 
New  York,  1878;  Moncorvo,  loc.  cit.,  reports  2  new  cases  and  refers  to  10  others  pre- 
viously reported  by  him;  Jopson,  Arch.  Pediatrics,  1898,  vol.  xv,  p.  173,  records  2 
cases,  brothers,  aged  one  and  one-half  and  four,  involving  feet  and  legs;  father  had 
suffered  from  a  similar  affection  in  childhood,  which  was  later  outgrown;  gives  brief 
review  of  the  subject,  with  references. 

2  Shattuck,  "./Etiology  of  Elephantiasis,"  Boston  Med.  Jour.,  1910,  clxiii,  No.  19,  p. 
718,  states  that  "filaria  is  an  important  factor  in  the  production  of  endemic  elephanti- 
asis of  some  regions,  but  is  not  essential  to  the  occurrence  of  the  endemic  type  of 
disease." 

3  Lassar,  Dermatolog.  Zeitschrift,  1894,  p.  550. 

4  Riedel,  Langenbeck's  Archiv,  1894,  Bd.  xlvii,  p.  216. 

5  Brouardel,  Annales,  1896,  p.  863. 

*  Koch,  Archiv,  1896,  vol.  xxxiv,  p.  203  (Koch  describes  a  number  of  cases  of  vary- 
ing enlargement  in  women,  and  gives  references  to  the  contributions  of  Virchow,  Mayer, 
Neisser,  Jacobi,  Lesser,  Fritsch,  and  Schroeder). 

7  A.  G.  Francis,  Brit.  Jour.  Derm.,  1894,  p.  225,  gives  notes  of  several  cases  asso- 
ciated with  tertiary  syphilis;  McDonagh,  ibid.,  1912,  p.  24  (case  demonstration — 
syphilitic  elephantiasis  of  the  scrotum  (syphilitic  lymphangitis),  with  histolog.  exami- 
nation; free  from  streptococcic  or  staphylococcic  infection. 

8  Humbert,  La  Semaine  Med.,  May  25,  1894  (case  presentation — penis,  consequent 
upon  a  gonorrheal  lymphangitis);  Farner,  Centralbl.  fur  Gynakologie,  1885,  No.  17, 
abs.  in  Munch,  med.  Wochenschr.,  May  7,  1895  (female  genitalia — apparently  originat- 
ing from  an  acute  gonorrhea). 

9  Berry,  Provincial  Med.  Jour.,^  1889,  vol.  viii,  p.  284  (hand  and  forearm — 2  illus- 
trations— following  a  burn);  Hutchinson,  Clinical  Jour.,  1895-96,  p.  29  (brief  report — 
developed  after  a  crush  of  foot;  leg  subsequently  amputated;  later  development  in 
other  leg). 


ELEPHANTIASIS  599 

to  the  filaria,  probably  both  directly  by  their  presence  in  numbers  block- 
ing up  the  lymph-channels,  and  indirectly  by  the  inflammatory  condi- 
tions of  these  vessels  or  glands  which  they  may  provoke.  According  to 
Manson,  only  the  embryo  filaria  is  found  circulating,  the  parent  filaria 
living  in  some  part  of  the  lymph-trunk,  discharging  its  ova  into  the  lymph- 
streams,  which  find  their  way  into  some  of  the  glands,  in  which  they  find 
lodgment,  and  are  subsequently  hatched  out,  and  then  enter  the  general 
circulation.  Manson's  investigations  would  make  it  seem  probable 
that  the  mosquito  abstracts  some  of  the  embryos  from  the  blood  of  an 
affected  individual,  and,  after  undergoing  some  development,  these 
finally  find  their  way  into  the  drinking-water,  and  are  thus  conveyed  to 
man.  In  consequence  of  obstruction  varices  of  the  lymphatics,  glandu- 
lar structures,  and  veins  result,  in  varying  degree,  in  anastomes  by  which 
the  embryos  get  into  the  blood,  and  in  some  cases  there  is  rupture  of  such 
formations  and  discharge  of  lymph  upon  the  surface. 

Many  of  the  non-parasitic  cases,  —  almost  all  those  of  our  own 
country,  for  instance,  Unna1  believes,  result  from  repeated  attacks 
of  strep  togenes  inflammation  (erysipelas,  phlegmon,  lymphangitis),  and 
independent  of  any  circumscribed  stagnatory  cause.  The  persistent 
recurrent  attacks  bring  on  doughy  soft  edema,  and  which  later  becomes 
harder,  with  tissue  increase  and  progressive  enlargement.  He  is  of  the 
opinion,  therefore,  that  true  sporadic  cases  may  be  said  to  develop 
from  incompletely  healed  erysipelas  attacks,  those  which  leave  behind 
disturbances  of  circulation,  and  the  products  of  which  are  not  completely 
absorbed  nor  all  the  streptococci  destroyed;  to  this  variety  he  would 
give  the  name  elephantiasis  streptogenes  or  elephantiasis  nostras. 
Examinations  of  this  variety  of  the  disease  by  Sabouraud2  disclosed 
during  the  erysipelatous  attacks  the  presence  of  streptococci  of  Fehleisen. 
With  each  attack  or  exacerbation,  as  Sabouraud  remarks,  there  is  a  fresh 
advance  of  edema,  and  that  each  new  edematous  infiltration  is  probably 
followed  by  local  organization  of  the  emigrated  embryonal  cells  into  con- 

nective tissue. 

The  anatomic  studies  (Virchow,  Kaposi,  Mosely  and  Morison, 
Marcacci,  Crocker,  and  others)  of  the  disease  agree  substantially  as 
to  the  findings.  The  seat  of  the  changes  is  essentially  the  subcutaneous 
tissue,  and  the  bulk  of  the  enlargement  is  made  up  of  hypertrophic 
connective  tissue.  On  section  the  tissues  are  found  quite  firm,  with  a 
whitish  or  yellowish  surface,  usually  exuding  a  lymph-like,  yellowish, 
sometimes  gelatinous,  fluid.  In  addition  to  the  connective-tissue  hy- 
pertrophy the  whole  integument  is  thickened,  sometimes  moderately,  in 
other  cases  markedly  so.  As  is  to  be  inferred  from  the  clinical  verrucous 
appearances  in  some  cases,  there  is  often  papillary  hypertrophy,  the 
papilla  being  elongated  and  broadened.  There  is  often  also  increase 
in  pigment  matter;  in  the  case  examined  by  Mosely  and  Monson»  (a 
negress)  a  large  amount  of  pigment  granules,  chiefly  in  heaps,  was  founc 
in  the  corium  beneath  the  line  of  the  papilla;.  There  is,  in  adc 


pp.  592  and  629!  3  Mosely  and  Monson,  Medical  News,  April  23,  it 


6oo  H  YPER  TR  OPHIES 

enlargement  of  blood-vessels  and  lymphatics.  Secondarily,  after  pro- 
longed duration  of  the  disease,  the  underlying  muscles  undergo  atrophy 
and  fatty  degeneration,  and  the  bones  may  show  enlargement,  uni- 
formly or  irregularly. 

Diagnosis.— The  diagnostic  characters  of  beginning  elephanti- 
asis are  the  recurrent  erysipelatous  inflammation  and  the  gradual  en- 
largement of  the  parts.  To  these,  in  the  endemic  or  filaria  variety,  and 
in  some  of  the  non-parasitic  sporadic  cases,  the  concurrent  febrile  dis- 
turbance is  an  added  factor.  The  appearances,  later  in  the  course  of  the 
disease,  such  as  increased  size,  thickening,  induration,  often  varicosities 
of  lymphatic  and  venous  nature,  papillary  hypertrophy,  etc.,  are  so  dis- 
tinctive that  a  mistake  is  scarcely  possible.  The  filaria  variety  admits 
of  ready  recognition  by  careful  examination  of  the  blood  drawn  during 
the  night,  the  parasites  being  quite  characteristic;  in  some  cases,  how- 
ever, they  are  not  so  abundant,  and  at  least  several  examinations  should 
be  made  before  an  absolute  conclusion  is  reached. 

Prognosis. — While  the  subjects  of  the  disease  are  necessarily 
rendered  more  or  less  miserable  by  the  weight  of  the  parts  and  hindrance 
to  locomotion,  life  itself  is  rarely  endangered.  In  the  endemic  parasitic 
variety  much  depends,  as  also  in  non-parasitic  cases,  upon  the  stage  at 
which  the  patient  comes  under  observation;  in  the  first  months  of  its 
development  there  is  a  possibility,  and  according  to  some  writers  a  prob- 
ability, that  the  disease  can  be  checked  or  held  in  abeyance;  when  well 
established,  rarely  more  than  palliation  is  to  be  expected,  although  some 
cases  are  on  record  where  remarkable  benefit  followed  therapeutic 
measures.  In  elephantiasis  of  the  genitalia,  more  especially  in  the  male 
and  when  of  the  scrotum,  the  results  of  surgical  removal  are  satisfactory. 

Treatment. — In  the  endemic  or  filaria  variety  of  disease  the 
general  treatment  during  the  febrile  attacks  and  the  cutaneous  exacerba- 
tions, really  resolves  itself  into  the  ordinary  measures  indicated  by  the 
symptoms — saline  purge  or  aperients,  quinin  in  full  dosage,  with  or  with- 
out strychnin,  and  iron,  according  to  circumstances,  and  sleep-producing 
drugs,  if  needed,  such  as  opiates,  phenacetin,  sulphonal,  and  the  like. 
The  general  management  of  the  exacerbations  in  the  non-parasitic  cases 
depends  upon  the  severity  of  the  erysipelatous  outbreak,  differing  but 
little,  if  any,  from  the  above,  when  such  attacks  are  severe;  locally  the 
ordinary  applications  useful  in  erysipelatous  inflammations,  and,  if  very 
painful,  fomentations  of  lead-water  and  laudanum.  Rest  in  the  re- 
cumbent position  is  useful  in  all  cases,  more  perceptibly  so  in  the  ad- 
vanced disease.  An  important  measure  in  staying  the  progress  of  the 
malady,  and  even  curing  it,  as  attested  by  Fayrer,  is  removal,  in  the  early 
stages,  from  the  endemic  region  to  one  in  which  the  disease  does  not  pre- 
vail. In  the  endemic  variety  Thomasz1  some  years  ago  reported  brilliant 
results,  in  the  early  stages,  from  calcium  sulphid,  i  to  2  grains  (0.065- 
0.13)  twice  daily,  but  I  have  not  been  able  to  find  a  report  of  such  treat- 
ment by  others,  either  favorable  or  unfavorable.  Lawrie's2  hopefulness 

Thomasz,  Ceylon  Med.  Jour.,  Aug.,  1888,  p.  i. 

2Lawrie,  Lancet,  1891,  vol.  i,  p.  364  (2  cases),  and  1892,  vol.  ii,  p.  1247  (letter 
communication,  referring  to  another  case). 


MYXEDEMA  6oi 

as  to  thymol,  in  2-  to  5-grain  doses  (0.135-0.32)  three  or  four  times  daily, 
based  on  its  apparently  successful  action  in  2  cases  of  chyluria  due  to 
filariae,  and  therefore  probably  useful  in  elephantiasis,  has  been  negatived 
by  the  experience  of  Manson,  Crombie,  Williams,  and  others.1  The 
constitutional  treatment  of  elephantiasis  during  the  intermission  between 
the  acute  exacerbations  is  symptomatic — tonics,  cod-liver  oil,  etc.,  if 
indicated. 

In  elephantiasis  of  the  leg,  along  with  rest,  certain  local  measures 
have  a  valued-absolute  cleanliness,  massage,  and  compression.  Hard- 
away2  warmly  suggested  or  indorsed  the  reducing  influence  exerted  by 
the  rubber  bandage  well  applied.  Conjointly  with  such  measures  the 
use  of  the  continuous  and  interrupted  electric  currents  is  strongly  rec- 
commended  by  Aranjo.3  Ligation  of  the  main  artery  of  the  limb 
(Carnochan,  Wernher,  Bryant,  Erickson,  Leonard,  and  others)4  has  often 
been  followed  by  material  reduction  in  the  size  of  the  part,  and  some- 
times with  alleged  cure.  Nerve  section  has  also  been  practised  by  Mor- 
ton and  others  with  decided  improvement  in  a  few  cases,  but  there  is 
great  risk  of  secondary  trophic  and  sensory  disturbances.  As  a  measure 
of  relief  Curl5  speaks  favorably  of  the  results  of  removing  wedge-shaped 
strips  of  skin  and  subcutaneous  tissue  from  time  to  time;  in  this  manner 
the  leg  being  considerably  reduced  in  size.  The  treatment  of  elephan- 
tiasis of  the  genitalia  is  operative,  and  recorded  results,  chiefly  regarding 
the  male  genitalia  (Osgood,  Fayrer,  Charles,  and  others),  are  extremely 
favorable,  and  have  become  more  so,  and  practically  without  danger, 
under  the  surgery  of  to-day.6 

MYXEDEMA 

Synonyms. — Cretinoid  edema  (Gull);  Fr.,  Myxced£me;  Cachexie  pachydermique 
(Charcot);  Athyroidie  (Besnier);  Ger.,  Myxcedem. 

Definition. — A  constitutional  affection,  chiefly  in  women,  in- 
duced by  atrophy  or  ablation  of  the  thyroid  gland,  and  characterized 
by  cretinoid  changes  and  edematous  swelling,  and  thickening  and  indu- 
ration of  the  skin  and  subcutaneous  tissues. 

Symptoms. — This  somewhat  rare  malady,  which  was  first  clearly 
described  by  Sir  William  Gull7  in  1873,  is  usually  of  slow  and  insidious 
development,  the  earliest  symptoms  presenting,  as  a  rule,  being  those 
of  ill-defined  general  poor  health,  with,  more  especially,  an  anemic  con- 
dition and  disinclination  to  physical  or  mental  exertion.  These  become 

1  Quoted  by  Manson,  Davidson's  Hygiene  and  Diseases  of  Warm  Climates,  p.  835, 
with  references. 

2  Hardaway,  St.  Louis  Courier  of  Medicine,  May,  1879. 

3  Silva  Aranjo,  Atlas  des  Maladies  de  la  Peau,  Rio  de  Janeiro,  1889,  p.  3;  Mon- 
corvo  et  Silva  Aranjo,  "Du  traitement  de  1'ephantiasis  par  I'electricite',    Journal  de 
Therapeutique,  1882,  vol.  ix,  p.  i. 

4  Leonard,  Brit.  Med.  Jour.,  1879,  vol.  i,  p.  934,  states  that  he  has  found  statistics 
(but  references  and  particulars  not  given)  of  69  cases;  of  these,  40  were  cured  (3  by 
digital  compression),  13  improved  (3  temporarily),  and  16  unsuccessful. 

5  Curl,  Jour.  Cutan.  Dis.,  1905,  p.  402. 

"Havelock  Charles,  Indian  Med.  Record,  1897,  vol.  Ixn,  p.  165  reports  a  series  of 
60  cases  successfully  treated  (abstract  in  Sajous'  Annual  and  Analytical  Lydopadta, 
1899,  vol.  iii,  p.  91). 

7  Gull,  London  Clin.  Soc'y  Trans.,  1874,  vol.  vu,  p.  180. 


602  HYPERTROPHIES 

more  marked,  and  then  consist  of  sluggishness  of  movement,  unsteadiness 
of  gait,  slow  and  halting  speech,  and  mental  hebetude.  The  subject 
becomes  mentally  dull  and  listless,  the  temperature  subnormal,  and  often 
shows  glycosuria  or  albuminuria.  At  the  same  time  is  noted  atrophy 
in  the  thyroid,  the  gland  partly  or  almost  wholly  disappearing  or  under- 
going fibrous  change. 

Along  with  these  constitutional  symptoms  the  skin  also  becomes 
the  seat  of  peculiar  changes.  It  becomes  yellowish  and  waxy  in  appear- 
ance, thickened,  firmly  edematous,  and  swollen,  particularly  the  face, 
neck,  and  the  extremities.  The  face  is  noted  to  be  enlarged  and  rounded, 
more  or  less  moon-shaped,  the  lips,  nose,  and  eyelids  are  swollen,  thick- 
ened, and  variably  indurated,  giving  the  coarsened  features  an  immobile 
or  fixed,  expressionless  aspect.  As  a  result  of  these  tumefactive  changes 
there  is  only  a  slit-like  opening  between  the  puffy  and  swollen  eyelids, 
the  nostrils  are  broadened  and  thickened,  and  the  lower  lip  everted  and 
pendulous.  There  is  often  an  ill-defined,  dull-red  flush  on  the  cheeks, 
although,  as  a  whole,  the  countenance  is  of  a  dead  yellowish  or  waxy 
appearance.  The  neck  also  undergoes  similar  changes,  especially  the 
supraclavicular  region,  where  there  may  be  a  cushion-like  accumulation 
of  fat.  The  hands  show  like  conditions,  becoming  massive,  deformed, 
and  shapeless,  the  fingers  so  swollen  and  thickened  as  to  give  it  a  broad- 
ened, spade-like  aspect.  The  entire  surface  more  or  less  shares  in  this 
peculiar  development,  the  regions  of  the  joints  especially  showing  the 
thickening  and  edema-like  infiltration,  and  often  to  such  an  extent  as 
seriously  to  compromise  the  natural  suppleness  and  mobility  of  the 
parts.  In  some  instances  there  is  variation  in  the  degree  of  swelling, 
and,  according  to  Ord,1  this  is  particularly  so  with  the  face,  and  generally 
having  a  relationship  with  the  intensity  of  the  general  symptoms,  espe- 
cially the  nervous  symptoms,  partial  amelioration  of  the  swelling  being 
followed  by  headache  and  neuralgia,  and  its  increase  or  recurrence  by 
relief  of  the  severity  of  the  nervous  phenomena. 

The  skin  is  usually  dry  and  rough,  with,  in  some  places,  a  trans- 
lucent look.  It  is,  as  a  rule,  harsh  and  hard  to  the  touch,  with  often  a 
fine  branny  scurfiness,  occasionally  lamellar,  and  perspiration  is  lessened 
or  wholly  absent.  The  hair  likewise  becomes  harsh,  dry,  and  scanty, 
and  there  may  finally  be  partial  or  almost  complete  scalp  alopecia.  In 
addition,  especially  later  in  the  malady,  the  skin  may  be  more  or  less 
pigmented,  in  areas  or  generalized,  as  in  Addison's  disease,  although 
rarely  to  so  pronounced  an  extent  or  depth.  The  soft  parts  of  the  buccal 
cavity,  especially  the  tongue  and  uvula  and  the  arches,  share  in  the 
swollen,  edematous  process.  The  edema,  while  apparently  similar  in 
appearance  to  the  edema  of  renal  disease,  differs  in  being  firm  and  not 
pitting  on  pressure;  nor  is  it  influenced  by  position. 

Etiology  and  Pathology.— The  disease  is  rare  and  chiefly  seen 
in  adult  life,  usually  about  the  middle  period,  and  is  predominantly 
confined  to  the  female  sex.  While  in  many  respects  the  disease  is 
etiologically  obscure,  it  is  now  known  that  it  is  connected  with  atrophy 

1  W.  M.  Ord,  "Myxedema  and  Allied  Disorders,"  Brit.  Med.  Jour.,  1808,  ii,  p. 
1473- 


MYXEDEMA  603 

or  loss  of  the  thyroid  gland.  This  is  disclosed  by  clinical  observation 
as  well  as  by  the  fact  that  the  condition  (so-called  "sporadic  cretinism") 
is  noted  sporadically  in  congenital  deficiency  of  the  gland  and  also  fol- 
lowing, in  a  large  proportion  of  instances,  its  partial  or  complete  surgical 
removal.  According  to  the  analytic  study  of  the  committee  (Ord, 
Cavafy,  Goodhart,  Horsley,  Mackenzie,  and  others)  of  the  London 
Clinical  Society,1  it  developed  in  69  out  of  408  instances  in  which  the  gland 
was  completely  extirpated,  and  in  no  case  in  which  removal  was  not  com- 
plete. Billroth,2  on  the  other  hand,  has  never  noticed  the  occurrence  of 
myxedema  after  the  extirpation  of  goiter.  Moreover,  question  has  been 
raised  by  some  observers  as  to  the  identity  of  true  myxedema  and  that 
condition,  the  so-called  "cachexia  strumipriva"  of  Reverdin  and  others, 
which  develops  after  the  extirpation  of  goiter.  Aggregate  observations, 
however,  fortified  as  they  are  by  the  investigations  of  the  London  Clinical 
Society  Committee  and  those  of  Hun  and  others,  do  not  afford  substan- 
tial support  to  this  doubt. 

Ord,  who  gave  the  malady  the  name  of  myxedema,  found  that  the 
edematous  infiltration  was  due  to  a  proliferation  and  deposit  of  mucin 
in  the  superficial  connective  tissue,  the  amount  present  estimated  to  be 
fifty  times  the  normal  quantity.  According  to  Hun,  however,  the  con- 
nective-tissue spaces  in  the  corium  were  pushed  asunder  by  a  fluid  which 
was  not  mucin.  This  observer  also  found  a  general  atheromatous 
endarteritis,  although  this  is  not  in  accord  with  the  observations  of 
Caspary,  Grawitz,  and  others  (quoted  by  Kaposi).  There  is,  however, 
fairly  general  agreement  as  to  the  involvement  of  the  nervous  system, 
and  Charcot  considered  the  implication  of  the  nerve-centers  as  the  pri- 
mary factor,  and  the  other  pathologic  changes  as  secondary  to  this. 
The  thyroid  gland,  with  rare  exceptions,  has  always  been  found  atro- 
phied. Kaposi  (loc.  tit.)  has  stated  that  various  observers  (not  named) 
were  unable  to  demonstrate  clinically  atrophy  of  the  thyroid  gland; 
Adami,3  on  the  contrary,  as  more  in  consonance  with  common  belief,  was 
not  able  to  find  an  account  of  any  autopsy  upon  cases  diagnosed  clinically 
as  myxedema  in  which  the  gland  was  found  normal  or  but  little  affected. 

Diagnosis.—  This  is  rarely  a  matter  of  difficulty  if  the  case  is 
at  all  developed,  as  the  aggregate  symptoms  are  striking  and  charac- 
teristic; there  is  merely  a  faint  similarity,  never  a  puzzling  resemblance, 
to  some  cases  of  acromegaly,  as  in  the  latter  the  bones  are  greatly  en- 
larged and  there  is  also  lacking  the  rounded  or  moon-shaped  face,  that 
of  acromegaly  being  an  elongated  oval.  The  nervous  symptoms  and 
the  changes  in  the  thyroid  are  also  distinctive  of  myxedema. 
ady  can  scarcely  be  confused  with  the  edema  of  renal  disease  or  with 
the  infiltrated  nodular  swelling  of  leprosy. 

i  "Report  on  Myxedema"  London  Clin.  Soc'y  Trans.,  supplement  to  vol.  xxi, 
1888  (a  most  exhaustive  and  comprehensive  investigation). 


-  «.  A*. 

P.    196. 


604  H  YPER  TR  OPHIES 

Prognosis  and  Treatment. — The  course  of  myxedema  is  per- 
sistent, progressive,  and  chronic,  and  if  untreated  usually  leads  sooner 
or  later  to  the  development  of  a  grave  mental  and  physical  disorder, 
marasmic  condition,  and  a  fatal  ending.  Fortunately,  since  the  dis- 
covery of  the  value  of  thyroid  extract,  a  greater  control  has  been  exer- 
cised over  the  disease,  as  noted  by  Bircher,  Beatty,  Putnam,  Osier, 
Murray,  and  others.1  The  dose  should  at  first  be  small  and  cautiously 
increased,  as  emphasized  by  2  instances  in  patients  suffering  from  heart 
disease,  under  Murray's  observation,  in  which  death  from  syncope 
immediately  due  to  exertion  followed  the  prolonged  administration  of 
thyroid  for  myxedema. 

DERMATOLYSIS 

Synonyms. — Loose  skin;  Cutis  laxa;  Cutis  pendula;  Pachydermatocele  (Mott); 
Chalazodermia;  Fr.,  Dermatolysie;  Chalazodermie. 

Definition. — A  rare  disease,  consisting  of  hypertrophy  and  loose- 
ness of  the  skin  and  subcutaneous  connective  tissue,  with  a  tendency  to 
hang  in  folds.2 

Symptoms. — The  hypertrophic  form  of  dermatolysis  may  be 
congenital  or  acquired,  and  may  be  limited  to  a  small  or  large  area,  or 
develop  simultaneously  at  several  regions.  The  development  may  be 
so  extensive  that  the  integument  hangs  in  large  folds,  although  ordinarily 
it  is  much  less  marked.  All  parts  of  the  skin,  including  the  follicles, 
glands,  and  subcutaneous  connective  tissue,  share  in  the  hypertrophy. 
The  skin  and  tissues  are,  however,  soft  and  pliable,  and  sometimes  show 
variable  elasticity.  The  follicular  openings  are  often  enlarged,  and 
occasionally  contain  comedo-like  sebaceous  plugs.  The  enlargement  of 
the  follicles,  and  of  the  natural  folds  and  rugae,  usually  present  to  a  varia- 
ble degree,  gives  rise  to  an  uneven  surface,  but  soft,  and  sometimes  slightly 
unctuous  to  the  touch.  There  is  also  ^.  tendency  to  increased  pigmenta- 
tion, the  integument  becoming  more  or  less  brownish.  It  will  be  seen 
that  the  condition  bears  a  close  resemblance  to  certain  cases  of  fibroma, 
but  its  looseness  and  absence  of  any  "body"  or  tumor-like  formation, 

1  Bircher,  "Das  Myxodem  und  die  cretinische  Degeneration,"  Volkmann's  Samm- 
lung  klinische  Vortrage,  No.  357  (Chirurgie,  No.  no)  (a  thorough  exposition  of   the 
malady,  with  case  citations,  review,  references,  and  illustrations);  Putnam,  Amer.  Jour. 
Med.  Sci.,  1893,  vol.  cvi,  p.  125;  Osier  (case  resembling  Bright's  disease),  Montreal 
Med.  Jour.,  1896-97,  vol.  xxv,  p.  642;  Murray,  "The  Pathology  of  the  Thyroid  Gland," 
Lancet,  1899,  vol.  i,  pp.  667  and  747  (a  valuable  contribution). 

2  For  examples  of  extreme  development,  as  well  as  its  occasional  resemblance  and 
identity  to  pendulous  fibroma,  the  reader  is  referred  to  the  following  cases,  some  of 
which  are  mentioned  by  Professor  Duhring  (Diseases  of  tlte  Skin,  third  edit.,  p.  421); 
Keen,  Photo.  Rev.  of  Med.  and  Surg.,  1871-72,  vol.  ii,  p.  45  (neck  and  shoulders,  hanging 
down  to  the  buttocks;  illustration);  Mott,  London  Med.-Chirurg.  Soc'y  Trans.,  1854, 
vol.  xxxvii,  p.  155  (5  cases,  some  of  which  doubtful,  with  2  illustrations);  Fritsche, 
London  Clin.  Soc'y  Trans.,  1873,  vol.  vi,  p.  160  (2  cases  with  i  illustration  and  sup- 
plementary note  by  Tilbury  Fox);  John  Bell,  Principles  of  Surgery,  edit.,  1808,  vol.  iv 
(Eleanor  Fitzgerald  case — 2  illustrations,  op.  pp.  32  and  34);  Stokes,  Dublin  Jour. 
Med.  Sci.,  1876,  p.  i  (scalp  case — apparently  a  soft  fibroma;  with  illustration);  Cooke's 
case  (described  by  Duhring  (loc.  cit.),  and  also  by  Wilson,  Lectures  on  Dermatology, 
1874-75,  P-  J63 — the  latter  also  describes  Bell's  case)  (left  hip  and  thigh,  and  hanging 
in  folds  to  the  knee,  like  the  legs  of  a  pair  of  loose  Turkish  trousers) ;  Alibert,  Monogra- 
phic des  Dermatoses,  1855,  vol.  ii,  p.  719,  also  pictured  in  La  Pratique  Dermatologie, 
vol.  i,  p.  695  (face — numerous  folds  entirely  concealing  the  visage);  Wright,  London 
Patholog.  Soc'y  Trans.,  1864-65,  vol.  xvi,  p.  269  (on  neck — 2  illustrations). 


DERMATOLYSIS  6Or 

it  seems  to  me,  entitle  it  to  a  separate  consideration.  It  is  usually  slowly 
progressive,  although  it  may,  after  reaching  variable  development 
remain  stationary.  There  are  no  subjective  symptoms,  and,  except 
for  its  weight  and  inconvenience,  gives  rise  to  no  discomfort  It  may 
be  seated  about  the  face,  arms,  neck,  head,  thighs;  in  fact,  on  almost 
any  part  of  the  body.1 

The  looseness  and  inelasticity  of  the  integument  (wrinkled  skin, 
loose  skin)  common  to  advancing  years  (see  also  Atrophia  senilis),  and 
also  resulting  from  the  disappearance  of  fatty  accumulations  and  follow- 
ing the  overdistention  of  pregnancy,  etc.,  may  here  be  briefly  referred 
to.  In  these  instances  the  skin  is  not  hypertrophied  nor  thickened, 
but  is  somewhat  loose  or  wrinkled,  to  a  variable  degree,  from  slight  to 
quite  pronounced,  as  if  too  large  for  the  enveloped  part.  In  the  senile 
form,  which  is  usually  upon  the  face,  or  most  marked  on  this  region, 
there  is  sometimes  a  trifling  increase  in  the  pigmentation.  Its  elasticity 
is  usually  lost,  and  if  picked  up  between  the  fingers  returns  but  slowly 
to  its  place. 

Etiology  and  Pathology  .—Its  etiology  is  obscure.  As  already 
remarked,  it  is  congenital  in  some  instances,  and  occasionally  it  has  been 
noted  to  be  hereditary,  as  in  Graf's  case,2  involving  the  left  side  of  the 
neck  and  lower  eyelids,  and  which  had  occurred  in  several  generations, 
developing  between  the  fortieth  and  fiftieth  years.  In  the  congenital 
cases  there  is  usually  increased  growth  subsequently,  generally  most 
marked  beginning  with  puberty.  It  is  undoubtedly  allied  to  fibroma, 
with  which  it  is  by  most  authors  considered  to  be  identical,  and  also 
possesses  some  analogy  to  elephantiasis  (Hebra  and  Kaposi),  and,  in 
some  instances,  to  mollusciform  and  lipomatous  nsevi  and  elephantiasis 
telangiectodes,  or  angio-elephantiasis.  These  various  growths,  though 
usually  decided  variants  clinically,  have  a  suggestive  family  resemblance. 
In  acquired  dermatolysis  the  process  sometimes  takes  its  start  at  the 
site  of  an  injury  or  slight  traumatism,  as  noted  by  Bell,  Crocker,  Demar- 
quay,3  and  others.  This  has  led  some  writers  to  believe  the  affection 
to  be  trophoneurotic  in  origin.  There  is  much  confusion  as  to  the  his- 
topathologic  findings,  owing  to  the  fact  that  in  many  instances  they  have 
been  based  upon  the  formations  known  as  mollusciform  naevus  and  fibro- 
ma. According  to  Duhring,  "the  growth  consists  of  a  simple  hypertrophy 
of  the  integument,  including  all  its  parts,  especially  of  the  subcutaneous 

1  Cutis  verticis  gyrata  (Unna).     Brief  reference  may  be  made  here  to  a  peculiar  con- 
dition of  the  scalp  skin,  first  described  by  Jadassohn,  subsequently  by  Unna,  and  by 
von  Veress  (Dcrmatolog.  Zeitschr.,  B.  xv,  Heft  n);  the  skin  of  the  crown  and  back  of 
the  head  is  found  to  be  in  furrows,  giving  an  appearance  reminiscent  of  the  gyri  and 
sulci  over  the  surface  of  the  cerebrum.     All  cases  have  been  males  and,  with  one  ex- 
ception, dark-haired  subjects.     Its  etiology  is  unknown,  on  the  one  hand  being  con- 
sidered as  consecutive  to  chronic  inflammation,  and  on  the  other  as  a  slow  develop- 
ment of  a  congenital  abnormality.     Audry  (Annales,  1909,  p.  257)  and  Vorner  (Dcrma- 
tolog. Wochensch.,  March,  16,  1912,  liv,  p.  309)  have  each   recently  reported  a  case; 
Vorner  believes  it  always  free  from  inflammatory  signs,  and  believes,  therefore,  that 
von  Veress'  case  and  also  Vignolo  Lutati's  case  should  not  be  considered  as  representing 
the  condition. 

2  Graf,  Casper's  Wochenschrifl,  1836,  p.  225,  quoted  by  Esmarch  and  Kulenkampff, 
Die  Elephanliaschen  Formen,  Hamburg,  1885,  p.  204. 

3  Demarquay,  Bull,  de  Soc.  de  Chirurg.,  1864,  p.  343. 


606  HYPERTROPHIES 

connective  tissue.  Under  the  microscope  it  is  seen  to  consist  largely 
of  soft  fibrous  or  lipomatous  tissue,  or  of  both  in  varying  proportions." 

Prognosis  and  Treatment.  —  There  is  no  tendency  to  spontane- 
ous disappearance  in  this  affection;  on  the  contrary,  there  is  usually  a  dis- 
position to  increase  and  extend,  although  often,  after  a  time,  or  at  periods, 
there  is  a  relative  or  complete  cessation  of  growth.  The  treatment, 
when  desirable  from  the  extent  and  situation  of  the  hypertrophic  mass, 
consists  in  excision,  bringing  the  skin  together  with  sutures,  the  scar  left 
being  linear  and  comparatively  insignificant. 

For  the  senile  and  similar  wrinkling  or  looseness  of  the  skin,  referred 
to  above,  for  which,  more  especially  that  occurring  about  the  face, 
advice  is  sometimes  sought,  a  variable  degree  of  benefit  can  usually  be 
brought  about  by  careful  massage,  the  application  of  the  faradic  and 
galvanic  currents,  and  sometimes  also  by  the  employment  of  slightly 
stimulating  remedies,  such  as  a  2  to  5  per  cent,  salicylic  acid  or  resorcin 
salve;  and,  occasionally,  by  plaster-like  applications  which  bring  about 
a  slight  or  moderate  reactionary  redness  or  dermatitis  and  consequent 
exfoliation.  A  preparation  that  can  be  used  for  this  last  is  that  which 
is  referred  to  in  the  treatment  of  acne  as  the  "peeling  paste,"  of  one-third 
to  full  strength  there  given.  It  should  be  constantly  worn  from  one  to 
several  days  or  longer,  according  to  the  action,  and  then  a  mild  salve 
applied  until  exfoliation  has  been  completed.  The  constant  application 
of  one  of  the  commercial,  10  to  25  per  cent,  salicylic  acid  plasters, 
will  also  usually  bring  peeling  of  the  skin  and  often  lessening  of  the 
blemish.  The  application  should  be  constant  and  continuous.  These 
severe  measures  should  not,  of  course,  be  employed  in  those  eczema- 
tously  inclined. 

Elastic  Skin  (Synonym:  Cutis  hyperelastica  (Unna)).  —  This  pecu- 
liar condition,  to  which  Crocker  and  a  few  others  believe  the  term  der- 
matolysis  is  more  appropriately  applied,  has  only  comparatively  recently 
received  attention.  It  is  that  in  which  the  integument  is  simply  loosely 
attached  to  the  underlying  tissues,  and  having  the  property  of  great 
elasticity  and  distensibility;  closely  similar,  in  fact,  to  that  which  ob- 
tains normally  in  the  cat  and  many  other  animals.  There  are  macro- 
scopically  no  perceptible  textural  changes,  the  skin  being  to  all  appear- 
ances perfectly  normal,  although  usually  with  quite  a  sense  of  softness 
to  the  touch.  The  amount  of  stretching  permissible  in  these  rare  case 
is  almost  beyond  belief  —  the  skin  of  the  breast  can  be  brought  up  over 
the  lower  part  of  the  face,  and  that  of  the  chin  can  be  stretched  out  like 
a  long  beard,  and  as  soon  as  let  go,  returns  quickly  to  its  place.  The 
subjects  of  this  anomaly  are  known  as  "elastic-skin  men,"  "India-rubber 
men,"  several  remarkable  examples  having  been  referred  to  or  reported 
by  Turner,1  Duhring,2  Kopp,3  and  Seifert.4  Such  cases  are  occasionally 


(Meekrin's  case,  a  Spaniard,  Georgius  Albes),  Diseases  of  the  Skin,  fifth 
edit.,  1736,  introduction,  p.  x;  this  case  is  also  referred  to  by  Wilson  (loc.  cit.,  p.  162), 
and  of  which  an  illustration  is  given  in  John  Bell's  Surgery,  1808,  vol.  iv,  op.  p.  36. 

2  Duhring,  Medical  News,  1883,  vol.  xliii,  p.  705  (clinical  demonstration,  reported 
by  Henry  Wile). 

3  Kopp,  Munch,  med.  Wochenschr.,  1888,  p.  259  (2  cases  —  father  and  son). 

4  Seifert,  Centralb.fur  klin.  Afed.,i8go,  p.  49. 


DERMA  TOL  YSIS  607 

to  be  seen  on  exhibition  around  the  country.  The  one  referred  to  by 
Duhring  was  also  under  my  notice,  the  elasticity  and  distensibility  being 
really  phenomenal.  In  this  case,  as  Dr.  Duhring  stated,  the  skin  was 
more  elastic  in  some  directions  than  others — more  when  drawn  trans- 
versely to  the  natural  lines  than  when  drawn  in  a  parallel  direction. 
When  the  stretched  fold  of  skin  was  held  up  to  the  light,  the  cutaneous 
circulation  was  beautifully  seen.  The  elasticity  may  be  general  or  only 
in  certain  regions;  in  the  case  cited  by  Turner  the  skin  of  the  left  side  of 
the  body  was  free,  or  relatively  free,  from  this  peculiarity. 

Sections  of  the  skin  from  Seifert's  patient,  which  Du  Mesnil1  also 
subsequently  described,  were  made  by  the  latter  and  histologically 
studied  by  him  and  also  by  Williams  and  Unna,  with  some  slight  diversity 
us  to  the  findings.  Kopp  was  of  the  opinion  that  the  elastic  fibers  were 
increased,  but  Du  Mesnil  did  not  find  this  to  be  the  fact,  but  that  the 
fibers  were  merely  wavy.  The  derma  consisted  of  a  more  or  less  homo- 
geneous mass,  inclosing  fusiform  cells,  and  with  absence  of  the  normal 
connecting  tissue  fibers;  the  latter  Williams,  in  his  examinations,  found 
present,  but  modified.  This  myxomatous  condition  would  seem  to 
represent  an  arrest  of  development.  In  addition  the  nerves  and  vessels 
showed  elongation  and  were  more  or  less  winding,  and,  according  to 
Williams  and  Unna,  the  muscle-fibers  were  increased— to  this  last  they 
are  inclined  to  attribute  the  elasticity  of  the  skin  in  returning  rapidly  to 
its  normal  position,  flying  back  quickly.  These  several  investigators 
place  most  stress  upon  the  abnormally  winding  course  of  the  vessels  and 
nerves  permitting  of  considerable  lengthening,  and  also  believe,  more- 
over, that  there  is  a  special  yielding  property  in  the  skin  tissue  itself. 
These  several  facts,  together  with  the  comparative  absence  or  modifica- 
tion in  the  connecting  fibrous  tissue  which  normally  binds  the  skin  closely 
to  the  underlying  structure,  would  serve  to  explain  the  stretching  o 
which  the  integument  in  the  cases  is  capable. 

iDu  Mesnil  Verhandl.  der.  physic,  med.  Gesellsch.  in  Wurzburg  1891,  vol.  xxiv 
(samepato  as  dlscX  by  SiefJ,  but  a  fuller  amount  with  case  UlustraUon  and  7 
nistologic  cuts);  Williams,  Unna— Unna's  Histopathology,  p.  9»4- 

m 


22      "M 

hi 


CLASS  V— ATROPHIES 
ALBINISMUS 

Synonyms. — Albinism;  Congenital  leukoderma;  Congenital  leukopathia;  Congeni- 
tal leukasmus;  Congenital  achroma:  Fr.,  Albinisme. 

Definition. — A  congenital  absence,  either  partial  or  complete, 
of  the  pigment  normally  present  in  the  skin,  hair,  and  eyes. 

Symptoms. — Partial  albinismus,  sometimes  termed  leukoderma, 
which,  as  a  rule,  involves  the  skin  pigment  alone  or  that  of  skin  and  hair, 
is  identical  in  its  features  to  vitiligo,  except  it  is  congenital,  and  lacks 
the  increased  pigmentation  of  the  bordering  skin  observed  in  the  latter 
affection.  One,  several,  or  many  areas,  and  of  various  size,  may  be 
present,  and  they  may  be  rounded  or  irregular  in  shape.  The  skin  of 
the  areas  is  milky- white  in  color,  sometimes  with  a  pinkish  tinge;  the 
hairs  are  generally  likewise  colorless.  The  patches  are  irregularly  dis- 
tributed, although,  exceptionally,  they  show  cutaneous  nerve  distribu- 
tion, of  which  Lesser1  cites  an  example.  In  rare  instances  the  albinismus 
is  limited  to  one  or  two  patches  of  hair,  and  in  some  of  these  latter  cases 
the  white  lock  or  locks  are  noted  to  be  situated  about  alike  through  several 
generations  (see  Canities).  Partial  albinismus,  as  to  the  integument, 
is  most  frequently  seen  in  negroes  (called  "pied"  or  "piebald"  negroes). 
As  a  rule,  the  patches  remain  the  same  throughout  life,  but  in  occasional 
instances  the  areas  extend,  and  exceptionally,  as  in  2  cases — negroes — 
noted  by  Simon,2  a  tendency  to  pigmentation  is  shown. 

In  complete  albinismus  the  skin  of  the  entire  body  is  milky-white, 
with  usually,  however,  a  pinkish  tinge,  due  to  the  .integumental  blood; 
the  hair  is  very  fine,  soft,  and  white  or  whitish-yellow  in  color,  although 
in  an  exceptional  instance  noted  by  Folker3  it  was  bright  red.  The 
irides  are  colorless,  pinkish,  or  light  blue,  and  the  pupils,  owing  to  ab- 
sence of  pigment  in  the  choroid,  are  red  or  reddish-pink.  This  absence 
of  pigment  in  the  eyes  gives  rise  to  photophobia  and  nystagmus,  noticed 
in  these  individuals,  and  which  also  leads  them  to  keep  the  lids  partly 
closed  during  the  lightest  part  of  the  day,  and  to  avoid  brilliant  light 
exposure.  The  subjects  of  this  complete  form  are  known  as  albinos 
(Ger.,  Kakerlaken),  and  they  are  noted,  as  a  rule,  to  be  of  rather  feeble 
constitution,  and  many  exhibit  imperfect  mental  development,  although 
to  this  are  many  exceptions.  There  are  no  structural  alterations  in 
the  skin,  there  being  no  departure  from  the  normal  other  than  complete 
absence  of  pigment;  and  its  functions  are  performed  in  a  perfectly 
natural  manner.  The  condition  is  permanent,  although  Ascherson, 

1  Lesser,  Ziemssen's  Handbook  of  Skin  Diseases,  p.  447  (with  illustration). 

2  Simon,  "Ueber  Albinismus  partialis  bei  Farbigen  und  Europaern,"   Deutsche 
Klinik,  1861,  pp.  399  and  406.     Almost  all  the  numerous  cases  described  in  this  paper 
are,  however,  examples  of  acquired  leukoderma — vitiligo. 

3  Folker,  lancet,  1879,  vol.  i,  p.  795. 

608 


ALBINISMUS  609 

Phoebus,  and  Mayer,  quoted  by  Seligsohn,1  have  noted  exceptional 
instances  in  which  it  partly  disappeared;  in  Mayer's  case  the  red  color  of 
the  iris  disappeared  from  year  to  year. 

Beyond  the  influences  of  heredity  no  cause  is  known,  and  a  history  of 
this  etiologic  factor  is  not  always  obtainable.  It  is  rarely  direct,  from 
one  generation  to  another,  the  parents  usually  being  free.  It  is  seen  in 
both  blacks  and  whites.  It  is  quite  common  for  two  or  three  of  the  chil- 
dren to  be  similarly  affected;  in  fact,  a  single  case  in  the  family  is  rather 
exceptional.  In  the  celebrated  Cape  May  (New  Jersey)  cases  reported 
by  Marcy2  the  father  and  mother  were  full-fledged  negroes,  and  so  far  as 
could  be  ascertained  there  had  been  no  similar  instance  in  the  family. 
The  first  two  children,  males,  were  black,  then  came  two  females,  both 
albinos,  one  after  the  other,  then  another  black  female  child,  and  the 
last  and  sixth  child,  a  male,  another  albino;  they  had  all  the  attributes  of 
albinism — cream-colored  and  silky,  though  woolly,  hair,  the  pink  eyes, 
and  milky  skin.  In  Folker's  cases  (Caucasians),  in  addition  to  the  albino 
girl  with  red  hair,  two  other  children  had  the  white  hair  and  pink  eyes 
of  the  pure  albino;  the  others,  five  in  number,  showed  no  evidence  of  the 
condition;  the  father  and  mother  were  free  from  the  deformity.  In  the 
family  observed  by  Sym,3  in  which  the  complexion  was  dark  in  the  father, 
mother,  and  relatives,  and  without  previous  history  of  the  condition, 
of  seven  children  four — the  first,  third,  fifth,  and  seventh — were  albinos, 
the  others  resembling  their  parents  in  color.  In  three  cases  the  irides 
were  bluish.  Lesser  (loc.  tit.}  refers  to  a  family  of  seven  children,  of 
whom  six  were  albinotic,  and  Pickel4  an  instance  of  a  family  of  thirteen, 
of  whom  seven  were  albinos;  and  Mayer,  where  the  second  and  fourth 
children  were  albinos,  the  first  and  third  normal.  It  would  seem,  by 
Boyle's5  observations,  that  the  condition  in  some  cases  may  fail  of  being 
absolutely  complete.  He  cites  an  example  seen  among  the  blacks  of 
Borneo,  whose  skin  was  of  a  dirty-white  color,  interspersed  with  large, 
freckle-like  spots;  the  "color  of  the  hair  could  hardly  be  described,"  the 
eyes  were  pale  blue,  and  he  was  unable  to  see  well  until  the  sun  was  low. 
The  parents  of  the  case  had  the  natural  complexion,  but  his  brothers 
and  sisters  were  albinos,  and  many  of  his  ancestors  were  said  to  have  had 
the  same  blemish.  According  to  Burton,  quoted  by  Beigel,  in  West 
Africa  there  is  occasionally  observed  a  condition  which  might  be  termed 
semi-albinismus,  in  which  the  skin,  in  color,  is  between  the  natural  hue 
of  blacks  and  whites,  and  he  refers  to  a  case  (of  which  he  subsequently 
saw  a  number),  of  a  black,  with  a  cafe-au-lait-colored  skin,  hair  dull  yellow, 
but  short  and  woolly,  and  the  eyes  a  "lively  brown." 

1  Seligsohn,   "Albinismus,"  in   Eulenburg's    Real- Encyclopaedic,   1880,  vol.  i,  p. 
160;  and  also  by  Behrend,  in  vol.  xiii,  1897,  p.  476. 

2  Marcy,  Amer.  Jour.  Med.  Sci.,  1839,  p.  517— also  a  short  preliminary  report  of 
the  first  children,  in  Amer.  Med.  Intelligencer,  1837-38,  vol.  i,  p.  225. 

3  Sym,    "Albinism— A   Curious   Family  History,"   Trans.  London  Ophthalmolog. 
Soc'y,  1891,  vol.  xi,  p.  218. 

4  Pickel,  Blumenbach's  Med.  Bibl.,  vol.  iii,  p.  167— quoted  by  Lesser,  Ziemssen  s 
Handbuch  der  Hautkrankheilen,  vol.  xiv,  p.  181. 

5  Boyle,  "Adventures  Among  the  Dyaks  of  Borneo,"  London,  1865,  p.  96— quoted 
by  Beigel  (albinismus  and  nigrismus),  Virchow's  Archiv,  1868,  vol.  xlm,  p.  529;  full 
translation  of  Beigel's  paper  in  Amer.  Jour.  Syphilog.  and  Dermatol.,  1870,  p.  136. 

39 


6  io  ATROPHIES 

In  addition  to  the  hereditary  factor  demonstrable  in  some  instances 
other  influences  have  been  suggested,  especially  fright  or  shock  during 
pregnancy.  This  does  not,  however,  seem  to  be  based  upon  a  rational 
foundation  or  upon  much  clinical  support,  although  the  mother  of 
Marcy's  cases  attributed  the  first  child  to  the  fright  produced,  while 
pregnant,  by  the  falling  down  of  an  old  white  mare  while  driving;  and 
in  a  case  reported  by  Jefferiss,1  in  an  only  child,  with  no  family  history 
of  the  malady,  the  mother  ascribed  it  to  the  strong  impression  made, 
in  the  first  months  of  pregnancy,  upon  her  mind  by  seeing  an  albino. 
Aube,  quoted  by  Seligsohn,  is  inclined  to  ascribe  the  condition  to  the 
marriage  of  blood  relations,  and  believes  the  facts  of  its  occurrence  in 
animals  are  suggestive  of  this.  Its  rather  rare  appearance,  however, 
would  seem  to  negative  such  an  opinion. 

As  may  readily  be  inferred,  albinismus  cannot  be  lessened  or  in- 
fluenced by  treatment — it  is,  in  fact,  without  remedy. 

VITILIGO 

Synonyms. — Leukoderma;  Leukopathia;  Acquired  leukasmus;  Acquired  leuko- 
pathia;  Acquired  achroma;  Acquired  piebald  skin. 

Definition. — A  disease  involving  the  pigment  of  the  skin  alone, 
characterized  by  the  development  of  several  or  more  round,  oval,  cir- 
cumscribed, smooth,  milky-white  patches,  tending  to  increase  in  size, 
and  exhibiting  at  their  margin  increased  pigmentation. 

Vitiligo  and  leukoderma  are  synonymous  and  interchangeable  terms, 
although  some  authors  use  the  former  for  the  acquired  disease  and  the 
latter  for  the  congenital  patchy  loss  of  pigment,  also  designated  partial 
albinismus. 

Symptoms. — In  this  affection  there  appear  one  or  more  small 
round  or  oval  white  spots,  most  frequently  primarily  on  the  backs  of 
the  hands,  trunk,  and  face,  these  being  favorite  localities.  In  their  earli- 
est beginning,  which,  as  a  rule,  is  insidious,  they  are  usually  unnoticed, 
and  often  they  escape  observation  until  they  are  the  size  of  a  pea  or 
larger.  It  is  not  improbable  that  close  inspection  would  show,  in  some 
cases  at  least,  that  the  first  change  was  a  hyperpigmentation  followed  by 
atrophy  of  pigment  and  the  development  of  the  characteristic  milky- 
white  spot.  They  tend  to  enlarge  slowly,  the  neighboring  skin  showing 
an  excess  of  pigment,  usually  sufficient  in  degree  to  give  it  a  much  darker 
color  than  obtains  in  the  normal  state.  Indeed,  in  those  of  white  skin 
the  darkened  border  is  often  considered  by  patients  as  the  pathologic 
condition,  and  the  inclosed  white  areas  looked  upon  merely  as  integument 
not  yet  affected.  In  those  of  darker  skin,  however,  and  in  negroes,  the 
change  to  the  milky-whiteness  is  naturally  the  more  conspicuous. 
The  spots  are  smooth  on  the  surface  and  are  not  elevated  above  the  level 
of  the  skin,  there  being  no  changes  other  than  pigment  diminution  with 
surrounding  increase  in  pigmentation.  They  vary  in  size  from  a  scarcely 
measurable  spot  to  that  of  the  palm  and  even  larger.  Their  shape  is 
usually  round  or  oval,  sometimes  irregular,  owing  to  the  spots  becoming 
1  Jefferiss,  Lancet,  1872,  vol.  ii,  p.  294. 


VITILIGO 


611 


confluent;  the  edges  are  always  convex,  those  of  the  pigmented  bordering 
skin  concave.     New  spots  may  form  from  time  to  time  and  coalesce  and 
may  cover  a  surface  of  greater  or  less  extent,  forming  large  white  areas 
with  irregularly  rounded  or  scalloped  borders.     When  such  ensues  the 
loss  of  pigment  is  much  less  noticeable  than  the  surrounding  hvperpig- 
mentation.     In  color  they  are  pinkish-white  or  dead  milky-white     Both 
to  the  touch  and  sight  no  difference  from  the  normal  skin  is  to  be  detected 
and  none  in  reality  exists,  except  that  of  the  pigment  changes.     Within 
the  whitened  areas  the  hairs  may  retain  their  normal  color,  but  generally 
they  also  share  in  the  pig- 
mentary loss.     The  activity 
of  the  sebaceous  and  sudori- 
ferous glands  is  not  inter- 
fered with,  and  subjective 
symptoms  are  not  present. 
The    malady    may    be 
extremely    slight,    only     a 
few    spots    presenting,    or 
they  may  be  numerous,  and 
exceptionally   may    gradu- 
ally invade  the  entire  sur- 
face,  as    in    instances    ob- 
served by  Levi,  Hall,  Hard- 
away,  Simon,  and  myself.1 
While  the   affection  shows 
a  predilection  for  the  dor- 
sum  of  the  hand,  the  face, 
neck,  and  trunk,  and  also 
the  genital  and  perineal  re- 
gion, it  may  begin  or  occur 
upon  any  hairy  or  non-hairy 
part2  of  the  body.     Occa- 
sionally there  will  be  a  few 
spots  on  the  face  and  hands 


Fig.  144. — Vitiligo;  patient  a  dark  brunette 
aged  thirty;  considerable  increase  in  pigmenta- 
tion beyond  the  white  vitiligo  areas. 


and  one  or  several  in  the  scalp,  the  latter  making  themselves  known 
by  the  whitening  of  hair  growing  thereon.  Not  an  infrequent  site 
is  around  the  eyes,  surrounding  them  by  a  white  band,  which  in  the 
negro  produces  striking  disfigurement.  The  disease  is  characterized 
by  its  slow  course  and  by  its  chronicity,  months  and  sometimes  years 
elapsing  before  it  reaches  conspicuous  development.  It  may,  after  a 

1  Levi,  "Recherches  stir  le  Vitiligo,"  Receuil  de  Mem.  dc  Med.  de  Chir.  et  de  Phartn. 
mil.,  1865,  p.  193  (3  cases);  Hall,  Louisville  Med.  News,  1880,  vol.  x.,  p.  148,  records 
the  case  of  a  dark  mulatto  who,  with  the  exception  of  a  part  of  the  chin  and  a  few  small 
patches  on  the  hands,  became  completely  white;  Hardaway,  Manual  of  Skin  Diseases, 
second  edit.,  p.  280  (2  cases,  i  a  white  man  and  i  a  negro,  with  illustration  of  the  negro, 
p.  278);  Simon  (loc.  cit.)  noted  a  few  instances  of  practically  general  involvement; 
Stelwagon,  Amer.  Jour.  Med.  Sci.,  July,  1885  (white  man);  and  Trans.  College  of 
Physicians,  Philada.,  1894  (negro). 

2  In  31  instances  noted  by  LeVi  it  began  on  the  scalp  in  6  cases,  epigastric  region  in 
4,  forearm  in  3,  scrotum  in  3,  breast  in  3,  ends  of  the  fingers  in  2,  hands  in  2,  face  in  2, 
back  in  i,  arm  in  i,  penis  in  i,  and  at  the  site  of  scars  in  2  (region  not  stated). 


6l2 


ATROPHIES 


time,  remain  stationary,  and  in  rare  instances  retrogresses,  but,  as  a  rule, 
however,  it  is  progressive,  although  its  increase  is  often  so  slow  that  it  is 
scarcely  perceptible.  With  some  exceptions  it  can  be  stated  that  when 
the  normal  pigment  has  once  been  lost,  it  does  not  return.  When  a  larger 
area  has  been  deprived  of  its  pigment  by  the  coalescence  of  several  or 
more  patches,  and  the  coalescing  hyperpigmented  borders  may  not  have 
completely  disappeared,  the  brownish  islets  remaining  are  taken  for  the 
diseased  condition  and  may  lead  to  errors  in  diagnosis.  Season  of  the 
year  has  no  material  influence,  if  any,  upon  the  morbid  process,  but 
during  the  summer  months  the  discoloration  is  more  noticeable  and 


Fig-  145- — Vitiligo;  showing  also  the  surrounding  hyperpigmentation.     A  common  site 

for  the  patches. 

disfiguring,  owing  to  the  increase  in  depth  of  coloring  of  the  bordering 
pigmentation,  which  is  due  to  the  greater  action  of  the  actinic  rays  and 
to  the  direct  exposure  to  the  sun,  the  whitened  areas  being  but  slightly, 
and  usually  not  at  all,  influenced.  As  a  result  the  white  looks  relatively 
more  pronounced,  the  surrounding  pigmentation  is  increased,  and  the 
blemish,  in  consequence,  more  noticeable.  In  women  of  naturally  very 
light  skin  the  patches  give  rise  to  but  little  annoyance  except  during  the 
sunny  season,  when,  for  the  reasons  stated,  they  become  quite  conspicu- 
ous. Not  infrequently,  however,  considerable  disfigurement  results 
when  such  regions  as  the  face,  neck,  and  hands  are  involved,  even  in  the 


VITILIGO  613 

winter  time,  and  proves  a  source  of  much  mental  worriment.  The  mal- 
ady in  the  negro  is,  of  course,  a  striking  one,  and  extensive  milky-white 
surface  often  results,  examples  of  the  disease  in  this  race  giving  rise  to 
the  occasional  newspaper  notices  of  a  "negro  turning  white";  in  a  few 
instances  already  referred  to  the  change  was  in  reality  complete.  At 
no  time  during  its  course  is  the  general  health  impaired,  the  malady 
having  no  damaging  influence,  but,  on  the  other  hand,  ill  health  from  any 
cause  is  apt  to  lead  to  further  increase  in  the  patches. 

Etiology  and  Pathology.— The  cause  of  vitiligo  is  unknown. 
Although  not  common,  it  is  not  infrequent.  A  relationship  to  disease 
of  the  suprarenal  capsules  has  been  suggested  (McCall  Anderson).  It 
occurs  in  males  as  well  as  females,  and  with,  usually,  about  like  fre- 
quency, although  of  Levi's  37  cases  28  were  men.  It  rarely  begins  before 
the  tenth,  nor  after  the  thirtieth,  year.  According  to  statistics,  it  is 
more  frequent  in  tropical  countries  (India)  and  in  the  dark  races.  Forel1 
states  that  it  is  very  common  in  certain  districts  of  Columbia,  where 
the  natives  are  mostly  of  mixed  negro,  Spanish,  and  Indian  blood.  It  is 
not  frequent,  but  still  not  at  all  rare,  in  our  own  country.  Some  observ- 
ers are  of  the  opinion  that  extremes  of  heat  and  cold  both  seem  of  pos- 
sible etiologic  import.  At  times  it  is  hereditary.  It  is  undoubtedly  to  be 
looked  upon  as  a  neurosis,  and  of  more  frequent  occurrence  in  neurotic 
individuals.  Often  however,  absolutely  no  history  of  systemic  disturbance 
can  be  obtained.  In  some  instances  severe  illness,  such  as  ague,  scarlatina, 
and  typhoid  fever,  would  appear  to  exert  an  influence.  There  scarcely 
seems  a  doubt  that  the  nervous  system  plays  an  important  part,  as  shown 
by  the  observations  of  Fevre,  Wyss,  Fournier,  Schwimmer,  Bulkley,  and 
others.2  Extensive  cases  resulting  after  fractures  and  injuries  to  nerves 
have  been  reported.  It  is  not  infrequently  associated  with  alopecia 
areata,  and  occasionally  with  morphea.  Its  occurrence  in  Graves' 
disease  has  also  been  noted  (Trousseau,  Raynaud,  Rolland,  Bramwell, 
Dore,  and  others).3  The  malady  has  been  occasionally  observed  to 
begin  at  the  site  of  an  injury,  from  pressure,  ulcerations,  condylomata 
lata,  and  burns.  Shepherd  has  noted  the  disease  in  one  instance  to 
start  from  the  pressure  of  a  collar-stud  and  another  from  the  spots 
left  after  burning  warts.  Hebra  believed  that  not  infrequently  the 
first  area  arose  in  close  proximity  to  a  previously  existing  pigmented 
mole.  The  so-called  pigmentary  syphilid  (?.».)  is  thought  by  some 
observers  to  be  a  vitiligo  (vitiligo  syphilitica)  starting  at  the  sites  of 
former  macules.4 

The  very  earliest  pathologic  change  to  be  noted  in  vitiligo  is.  I 

1  Forel.  Munch,  med.  Wochenschr.,  1897,  p.  1009. 

2  Quoted  by  Leloir,  Twentieth  Century  Practice,  vol.  v,  p.  848;  Lebrun,  Ihese  d 
Lille,  1886,  was  also  of  the  opinion  that  other  nervous  disturbances  were  usually  t< 

3  Dore,  "Cutaneous  Affections  Occurring  in  the  Course  of  Graves'  Disease,"  Brit. 

"^'•Itet  sypSSfc  has,5however,  any  etiologic  relationship  to  true  vitiligo,  as  Marie 
and  some  others  suggested,  seems,  in  my  judgment,  without  the  slightest  tangib 
foundation.     Thibierge  (Annales,  Feb.,  1905,  p.  128)   and  others  SteMfa 
evidence,  as  for  example  the  existence  of  vitiligo  m  those  whose  syphilis 
subsequently. 


614  ATROPHIES 

believe,  an  increase  of  pigment,  —  a  hypertrophy  instead  of  an  atrophy, 
—followed  by  diminution  or  atrophy,  and  in  the  further  spread  of  the 
lesions  the  same  pathologic  steps  are  gone  through.  Anatomically,  as 
to  be  inferred,  the  whitish  spots  are  seen  to  be  wholly  devoid  of  coloring- 
matter,  whereas  the  surrounding  brown  discoloration  shows  hyperpig- 
mentation.  The  atrophy  of  the  terminal  nerves  noted  by  Leloir1  and 
Chabrier  has  not,  up  to  the  present,  been  confirmed. 

Diagnosis.  —  The  diagnosis  is  usually  not  difficult.  In  extensive 
cases,  where  the  pigmented  portions  are  the  more  striking,  it  might  be 
confused  with  chloasma,  but  it  may  be  differentiated  from  the  latter  by 
the  fact  that  the  white  areas  have  convex  borders,  and  the  pigmented 
part  would  naturally  show  the  reverse,  —  concave,  —  while  in  chloasma 
these  would  be  reversed,  the  chloasma  pigmentation  being  irregularly 
round  or  diffused.  Moreover,  chloasma,  as  generally  encountered,  is 
upon  the  forehead  and  sometimes  on  other  parts  of  the  face  as  well, 
but  it  is  rare  elsewhere.  Under  the  same  circumstances  it  could  possibly 
be  confounded  with  tinea  versicolor,  but  the  same  points  as  regards  the 
borders  would  obtain  here  also,  and  when  it  is  borne  in  mind  that  in 
tinea  versicolor  the  patches  are  usually  furfuraceous,  of  a  yellow  or  fawn 
color,  and  the  intervening  skin  is  normal  in  appearance,  no  error  should 
arise;  furthermore,  the  microscope  will  reveal  the  presence  of  the  micro- 
sporon  furfur,  the  causative  agent  in  the  latter  malady.  Another  dis- 
ease which,  upon  casual  inspection,  it  resembles  to  some  extent  is  mor- 
phea.  The  latter,  however,  is  associated  with  structural  changes  in  the 
skin,  while  in  vitiligo  there  exists  only  an  absence  of  pigment  in  circum- 
scribed patches,  and  which  are  on  a  level  with  the  skin,  whereas  in  mor- 
phea  the  patches  may  be  somewhat  elevated  above  it,  or  sometimes 
slightly  depressed,  and  the  seat,  as  disclosed  to  the  touch,  of  other 
distinct  changes.  Occurring  in  tropical  climates,  it  is  at  times  con- 
founded with  the  white  patches  of  true  leprosy.  Indeed,  according  to 
Minch,  vitiligo  is  somewhat  widely  distributed  in  Turkestan,  and  is 
considered  contagious  by  the  Sarts;  affected  persons  are  segregated  and 
kept  with  the  lepers  within  special  inclosures  (Ziegler)  —  a  most  extra- 
ordinary procedure  unless,  as  is  possible,  they  are  held  as  simple  sus- 
pects temporarily.  In  this  type  of  leprosy,  however,  the  whitish  patches 
are  anesthetic  and  there  are  structural  changes  in  the  skin  and  constitu- 
tional symptoms  present,  which  is  not  the  case  in  vitiligo.  Partial 
albinism,  which,  as  already  remarked,  is  often  termed  leukoderma,  is, 
reality,  similar  to  this  malady  except  that  the  normal  pigment  is  absent 
from  birth;  it  is,  therefore,  a  congenital  condition,  whereas  vitiligo  de- 
velops during  life. 

Prognosis  and  Treatment.—  The  outlook  for  recovery  from 
the  malady  is  not  very  encouraging.  The  spots  tend,  as  a  rule,  to  in- 
crease quite  slowly  in  size  for  a  number  of  years,  and  the  skin  over  parts 
of  the  body  may  become  entirely  deprived  of  pigment.  In  such  instances 


"Contribution  a  1'Etude  des  affections  cutanees  d'origine  trophique," 
Arch,  de  Pkysiol.,  1881,  p.  397;  see  also  interesting  clinical  and  histologic  paper  by 
.  arc',,  p?t*age  zur  Pathogenese  der  Vitiligo  und  zur  Histogenese  der  Hautpigmen- 
tirung    (with  review  and  references),  Virchow's  Archiv,  vol.  cxxxvi,  p.  21. 


VITILIGO  615 

the  last  remnants  are  a  few  islets  of  pigmentation,  the  remains  of  por- 
tions of  the  pigmented  borders,  which  also  gradually  fade  away.  Gen- 
eral involvement  is,  however,  extremely  rare.  Not  infrequently,  after 
progressing  for  some  years,  it  comes  to  a  standstill,  and  exceptionally  it 
retrogresses  and  disappears.  Fortunately,  the  disease  gives  rise  to  no 
symptoms  other  than  the  disfigurement. 

It  is  questionable  how  far  treatment  influences  its  course.  The  con- 
tinued administration  of  arsenic,  along  with  tonic  remedies,  if  indicated, 
has  in  some  instances,  it  is  believed,  influenced  it  favorably.  Duhring 
considers  this  the  most  valuable  remedy,  and  in  some  cases  under  my 
care  the  progress  of  the  malady  seemed  to  be  stayed.  Pilocarpin  has 
likewise  been  suggested,  and  also  thyroid;  recently  good  effects  from 
suprarenal  gland  have  been  claimed.  In  young  patients  cure  has  been 
stated  to  follow  the  use  of  potassium  bromid  internally,  along  with  alka- 
line baths  (Besnier  and  Doyon).  General  galvanization  and  the  use  of 
the  battery  with  the  positive  electrode  to  the  back  of  the  neck  and  the 
other  over  the  patches  has  been  credited  with  favorable  influence.  The 
general  condition  of  the  patient  should  receive  attention,  and  measures 
directed  toward  bringing  the  health  up  to  the  normal  state  adopted.  In 
recent  years  I  have  prescribed  most  frequently  both  arsenic  and  supra- 
renal gland  in  this  disease,  and  exceptionally  with  seeming  benefit. 

Externally  the  white  patches  can  be  rendered  less  conspicuous,  and 
the  disfigurement  lessened,  by  reducing  the  pigmentation  of  the  border 
by  the  means  used  in  the  treatment  of  chloasma.  Recently  Savill1 
successfully  employed  for  this  purpose  pure  phenol,  painting  it  over; 
the  outer  epidermis  subsequently  exfoliating,  with  a  disappearance  of 
the  discoloration.  In  cases  of  sensitive  skin  it  would  be  advisable  to 
apply  it  at  first  weakened  with  alcohol,  and  to  limit  the  application  to  a 
small  area.  In  addition  to  endeavoring  to  lessen  the  bordering  pig- 
mentation, stimulating  applications  to  the  white  patches,  with  a  view  to 
producing  hyperemia  and  consequent  pigment  deposit,  can,  if  thought 
advisable,  be  practised.  One  of  the  best  for  this  purpose  is  the  negative 
electrode  of  a  galvanic  battery,  with  a  current  of  2  to  5  milliamperes. 
It  should  not  be  held  on  the  same  spot  for  more  than  one  to  several 
minutes,  so  as  to  produce  redness,  but  to  avoid  too  great  effect,  otherwise 
some  damage  might  be  done.  The  application  of  the  tinsel  or  metallic 
brush,  either  with  the  faradic  or  galvanic  battery,  and  the  high  frequency 
electrode  will  likewise  produce  redness.  The  actinic  rays,  as  well  as 
heat  rays,  of  the  various  lamps  will  also  tend  to  produce  pigmentation. 
Mustard,  in  the  form  of  a  plaster,  cantharides,  burning  glass,  and  similar 
measures  are  also  resorted  to.  The  white  patches  may  be  masked  by 
coloring,  from  time  to  time,  with  walnut  juice  or  similar  stain,  or  wit] 
an  extremely  weak  tincture  of  iodin  or  like  substance. 
1  Savill,  Brit.  Jour.  Derm.,  1898,  p.  99- 


6l6  ATROPHIES 

GLOSSY  SKIN 

Synonyms.— Atrophoderma  neuriticum;  Fr.,  Peau  lisse. 

Symptoms.— It  is  to  Paget,1  Weir  Mitchell,  Morehouse,  and 
Keen2  that  we  owe  our  chief  knowledge  of  this  affection,  although, 
according  to  Leloir,3  it  was  first  described  by  Alexander  Denmark  in 
case  of  a  wound  of  the  radial  nerve.  Its  most  common  and  usual  site 
is  some  part  of  the  hand,  and  in  almost  all  instances  the  fingers,  rarely  all 
of  them.  The  affected  skin  is  at  first  noted  to  be  a  deep  red  or  mottled  or 
red  and  pale  in  patches,  and  smooth  and  shining,  giving  it  a  glossy  ap- 
pearance, and  hence  the  term  commonly  used  to  describe  it— glossy  skin. 
It  is  dry,  thinned,  and  with  a  pseudocicatricial  aspect.  The  fingers, 
from  the  varying,  usually  slight,  associated  atrophy  of  the  skin  and  sub- 
cutaneous tissue  of  the  distal  portion,  are  often  tapering,  with,  as  a  rule, 
the  almost  entire  disappearance  of  the  wrinkles,  the  skin  appearing  as  if 
tightly  drawn  over  the  subjacent  tissues.  The  general  effect,  as  Mitchell 
expresses  it,  is:  the  surface  of  the  affected  part  is  glossy  and  shining,  as 
though  it  had  been  skilfully  varnished,  or  in  some  instances  presents  the 
characters  of  large,  thin,  and  highly  polished  scars.  Not  infrequently, 
especially  in  the  beginning,  as  Paget  states,  its  resemblance  to  chilblains 
is  often  striking.  The  hair  growth  of  the  part  usually  wholly  or  partially 
disappears.  In  places  there  may  be  a  tendency  to  partial  loss  of  the 
overlying  epithelium,  the  cutis  being  exposed,  and  cracking  or  fissuring 
of  the  thinned  skin  is  sometimes  observed.  The  nails  at  the  free  border 
are  usually  curved  over  both  at  the  end  and  sides.  Occasionally  slight 
retraction  of  the  skin  from  the  matrix  occurs,  and  when  about  the  toes, 
painful  fissures  or  ulcerations  sometimes  result.  The  atrophic  condition 
is  also  observed  on  the  palm,  and  here  the  glossy  thin  area  or  spots  are 
noted  to  be  slightly  depressed.  The  malady  is  generally  preceded  and 
accompanied  by  neuralgic  or  burning  pain,  of  variable  degree,  but  usually 
severe;  while  commonly  more  or  less  limited  to  the  affected  region,  it 
may  involve  the  whole  limb.  In  Watson's4  case  the  neuralgia  was  ex- 
treme, acute  in  character,  lasting  about  a  day,  and  shifted  from  one  hand 
to  the  other.  While  the  skin  is,  as  a  rule,  unnaturally  dry,  in  some  in- 
stances increased  sweat  secretion  has  been  observed. 

Etiology  and  Pathology.— The  malady  is  a  trophoneurotic 
one,  and  is  due  to  any  cause  which  brings  about  disease  or  injury  of 
the  supplying  nerves.  A  neuritis  or  injury  from  a  gunshot  or  other 
wound  is  the  most  common  exciting  factor.  In  nerve  lesion  the  con- 
dition, according  to  Mitchell,  never  appears  before  the  second  week, 
usually  coinciding  with  the  beginning  of  the  healing  process.  As  a  com- 
plication it  has  also  been  observed  in  some  general  disorders,  such  as 
chronic  myelitis,  leprosy,  gout,  and  rheumatism.  Watson's  case  was 
apparently  independent  of  any  recognizable  cause. 

1  Paget  (Some  Forms  of  Local  Paralysis),  Med.  Times  and  Gazette,  1864,  vol.  i,  p. 
333- 

2  Mitchell,  Morehouse,  and  Keen,  Gunshot  Wounds  and  Other  Injuries  of  the  Nerves, 
Philadelphia,  1864,  p.  77;  Mitchell,  Injuries  of  Nerves  and  their  Consequences,  Phil- 
adelphia, 1872. 

8  Leloir,  Twentieth  Century  Practice,  vol.  v  (Diseases  of  the  Skin),  p.  834. 
4  Watson,  Lancet,  1890,  vol.  i,  p.  647. 


ATROPHIA   SENILIS  6  1/ 

Prognosis  and  Treatment.—  The  duration  is  variable,  from 
weeks  to  years,  although,  according  to  Mitchell's  observations,  there 
is  final  spontaneous  disappearance.  Treatment  consists  in  removing 
or  modifying  the  cause,  restoring  the  nerve  tone  of  the  part,  and  the  use 
of  local  protective  measures  of  a  soothing  and  oily  character,  and  the 
avoidance  of  exposure  to  cold. 

ATROPHIA  SENILIS 

Synonyms.  —  Atrophia  cutis  senilis;  Atrophoderma  senile;  Senile  atrophy;  Old 
age  of  the  skin. 

Old  age  changes  in  the  skin  are  commonly  observed  after  the  six- 
tieth year  is  passed,  and  sometimes  earlier,  although  rarely  before  the 
age  of  forty-five  or  fifty.1  The  skin  is  noted  to  be  of  a  dull  yellowish 
hue,  with  sometimes  a  greenish  tinge;  it  is  dry,  inelastic,  with  often 
positive  thinning,  sometimes  slight  scaliness,  usually  of  a  branny  char- 
acter; somewhat  wrinkled,  with  here  and  there  pigmented  areas  of 
freckle-like  nature,  and  pea-  to  bean-sized  yellowish  or  brownish  spots, 
covered  with  a  variable  amount  of  grayish  or  brownish  sebaceous  scali- 
ness or  crusting,  which,  if  removed,  often  discloses  a  red,  sometimes 
granular-looking,  surface  and  atrophic  thinning  (degenerative  seborrhea). 
Sometimes,  instead  of  being  so  covered,  the  coating  is  found  to  be  hard, 
somewhat  horny,  and  firmly  adherent,  or  there  may  be  small,  thickened, 
corneous,  pea-  to  bean-sized,  slightly  scaly  or  crusted  areas,  which  may 
also  undergo  surface  degeneration  —  keratosis  senilis.  These  senile 
keratoses,  as  well  as  the  degenerative  seborrheic  patches,  which  may  often 
begin  as  slightly  horny,  scurfy  spots,  are  not  infrequently  the  seat  of 
epithelial  changes,  which  may  develop  into  epithelioma,  although  they 
frequently  persist  for  years  without  displaying  any  destructive  tend- 
ency. In  some  instances  slight  white  or  grayish  atrophic  points  or  spots 
are  also  noted,  and  dilated  capillaries,  isolated  or  in  tufts,  are  quite  fre- 
quently seen.  A  pigmented  pea-  to  finger-nail-sized  slightly  elevated 
wart,  covered  with  a  greasy  brownish  coating  (seborrheic  wart,  verruca 
senilis),  and  sometimes  present  in  considerable  number,  is  also  not  an 
uncommon  lesion  ;  at  times  the  surface  is  slightly  uneven  or  papillomatous. 
Small,  solid  fibromata  which  may  have  existed,  more  commonly  on  the 
neck  and  back,  undergo  central  absorption  or  atrophy,  and  remain  as 
shriveled,  pendulous  sacs.  The  face  and  dorsal  surface  of  the  hands 
are  the  sites  where  the  changes  are  usually  most  conspicuous,  although 
the  shoulders  and  upper  part  of  the  back,  and  also  the  lower  part  of  the 
legs  frequently  show  one  or  several  of  the  described  lesions.  The  upper 
part  of  the  back  and  less  frequently  the  dorsum  of  the  hand  are  favorite 
regions  for  the  sebaceous  warts,  where  several  to  ten,  fifteen,  o 

sometimes  develop.  , 

These  various  lesions   are  not,  however,  necessarily  present 


i  Rossbach  (Ein  merkwiirdiger  Fall  von  greisenhafter  Veranderun,  ;  der  ^gemeinen 
Korperdecke  bei  einem  achtzehnjahrigen  Jung  mg),  Deutsch.  ^^^^f  's°°f,e 
8<  vol   xxxvi  D   jo?  reports  with  4  illustrations,  an  extraordinary  instance  o 
wrinkHng  and  oVefchanges  in  the  Idn  in  a  youth  of  eighteen,  giving  him  the  appear- 


ance  of  a  man  of  advanced  years. 


6i8 


ATROPHIES 


same  individual:  in  some  a  dry,  inelastic,  slightly  harsh,  possibly 
somewhat  branny,  condition  of  the  skin  is  noted,  with  an  accentuation 
of  the  natural  folds  or  wrinkles,  whereas  in  others  the  skin  is  somewhat 
similarly  affected,  with  a  general  dingy  hue  and  writh  many  pigmentary 
or  freckle-like  spots,  with,  possibly,  one  or  two  small  crusted  seborrheic 
patches.  These  latter  are  more  common  about  the  nose  and  sides  of 
the  forehead.  As  a  rule,  there  are  no  subjective  symptoms  associated 
with  these  various  conditions,  although  in  those  instances  in  wrhich  the 
dryness  and  harshness,  with  a  tendency  to  branniness,  are  especially 
pronounced,  there  may  be,  particularly  upon  the  extremities,  a  variable 
amount  of  itching. 


Fig.  146.— Old  age  changes— atrophic,  pigmentary  and  keratotic,  with  shriveling  or 

wrinkling. 

The  histologic  changes  have  been  studied  by  Neumann,  who  found,  in 
the  quantitative  or  simple  atrophy,  thinning  of  the  epidermis  and  corium, 
with  its  connective-tissue  corpuscles  usually  smaller  and  less  numerous. 
Partial  or  complete  disappearance  of  the  papillae  is  noted.  Pigment 
is  found  between  the  connective-tissue  bundles  and  also  here  and  there 
in  the  vessels.  The  sebaceous  glands  and  hair-follicles  also  generally 
show  some  alteration,  the  former  being  sometimes  observed  with  dilated 
acini  filled  with  epidermic  scales  and  debris,  and  in  other  cases  seem 
made  up  of  a  yellowish-brown  mass.  The  sweat-glands  rarely  show 
change.  In  degenerative  atrophy  a  granular  or  vitreous  degeneration 


STRIPS  ET  MACULA  ATROPHIC&  619 

of  the  cutaneous  elements,  especially  of  the  connective  tissue,  takes 
place,  considered  by  some  as  amyloid  or  fatty  degeneration.  Unna1  is 
inclined  to  believe  that  simple  atrophy  is  not  observed  as  a  senile  change, 
but  that  it  is  always  degenerative  in  nature,  and  that  the  different  con- 
stituents do  not  share  in  it  equally.  He  calls  attention  especially  to  the 
fact  of  the  relative  youth  and  proliferative  power  of  epithelium  in  the 
aged,  compared  to  the  connective  tissue,  as  demonstrated  by  the  tend- 
ency to  epithelial  growths  at  such  age. 

Treatment.  —  While  nothing  can  ordinarily  stay  the  ravages  of 
time,  the  maintenance  of  a  condition  of  good  health,  hygienic  living, 
and  cleanliness,  with  frequent  bathing,  will  do  something  toward  dimin- 
ishing its  effects.  Scurfiness  and  dryness  can  be  counteracted  by  an 
occasional  oily  application,  such  as  almond  oil,  vaselin,  or  cold  cream. 
The  tendency  to  degeneration,  as  displayed  by  the  seborrheic  spots  and 
the  corneous  accumulations,  can  best  be  stopped  by  ointments  contain- 
ing sulphur  and  salicylic  acid,  5  to  30  or  more  grains  (0.335-2.)  of  the 
former,  3  to  20  (0.2-1.335)  of  the  latter,  to  a  half-ounce  (16.)  of  cold 
cream  or  vaselin:  to  be  rubbed  in  nightly,  the  strength  of  application 
depending  upon  irritability  of  the  skin,  stopping  just  short  of  irritation. 
The  timely  use  of  such  applications  has,  in  my  hands,  often  stayed  the 
tendency  to  epitheliomatous  change,  a  fact  to  which  Montgomery2  and 
others  have  also  attested.  (See  also  Keratosis  senilis.) 

STRIAE  ET  MACULAE  ATROPHICAE 

Synonyms.  —  A  trophic  lines  and  spots;  Atrophoderma  striatum  et  macula  turn; 
Atrophia  maculosa  et  striata;  False  cicatrices;  Fr.,  Vergetures;  Stries  atrophiques. 

Symptoms.  —  The  atrophic  striae  (atrophia  cutis  linearis;  striae 
atrophicae;  linear  atrophy)  are  usually  one  or  two  lines  in  width,  of 
variable  length,  somewhat  depressed,  and  commonly  closely  set  and  ar- 
ranged in  parallels;  or  they  may  be  irregular  and  undulating,  and  with 
a  scarcely  perceptible  depression.  In  color  they  are  a  pinkish-white, 
grayish,  or  white,  with  usually  a  glistening,  scar-like  appearance.  Occa- 
sionally with  the  lines  are  noted  pin-head  to  bean-sized  or  larger  spots 
(maculae  atrophies),  of  closely  similar  appearances,  and  slightly  depressed; 
these  latter  may  rarely  be  the  sole  manifestation.  There  are,  with  rare 
exceptions,  no  subjective  symptoms  and  no  change  in  sensibility.  The 
hairs  on  the  involved  areas  or  lines  usually  show  atrophic  tendency,  and 
sometimes  completely  disappear.  In  origin  these  atrophic  lines  and 
spots  may  be  idiopathic  or  symptomatic,  although  there  is  a  predominant 
belief  that  they,  or  most  cases  at  least,  belong  in  the  latter  class,  and  due 
essentially  to  mechanical  overstretching.  The  most  familiar  example 
is  that  of  linese  albicantes,  observed  on  the  abdomen  of  pregnant  women 
(lines  gravidarum)  and  others  in  whom  abdominal  stretching  has  re- 
sulted from  tumors  or,  and  on  other  parts  as  well,  from  rapid  develop- 
ment of  fat.  They  are  mostly  closely  set,  in  parallels,  and  running  trans- 
versely to  the  direction  of  greatest  distention,  although  in  some  n 


Snwa:  "*  -  2o  '^-  See  Keratosis  senilis 


for  other  suggestions  as  to  treatment 


620  ATROPHIES 

in  which  the  stretching  is  fairly  uniform  in  all  directions  they  may  be 
concentrically  arranged  (Langer).  Independent  of  pregnancy,  however, 
probably  from  the  other  cause  mentioned — from  fat  development— 
these  atrophic  lines  are  quite  common;  Schultze,  quoted  by  Jar- 
isch,1  found  in  36  per  cent,  of  unmarried  adult  women  parallel  atrophic 
lines  running  perpendicularly  on  the  front  of  the  upper  thighs,  and  the 
same,  but  of  less  regular  direction,  in  6  per  cent,  of  men  examined;  he 
believed  that  the  preponderance  is  explained  by  the  fact  that  at  puberty 
there  is  pronounced  broadening  of  this  region  in  women,  whereas  in  men, 
in  whom  the  streaks  were  just  as  frequently  transverse,  the  rapid  growth 
is  in  the  length. 

While  such  instances  are  probably  to  be  designated  as  symptomatic, 
others  have  been  observed  which  cannot  be  so  readily  placed  in  this 
class,  but  are  more  properly  to  be  considered  idiopathic,  as,  for  example, 
those  in  which  the  condition  has  followed  typhoid  fever,  of  which  Shep- 
herd2 has  reported  a  remarkable  example.  In  his  patient,  a  boy  of  fifteen, 
the  stripes  were  situated  above  both  knees  and  over  both  patellae,  de- 
pressed, thin,  and  dry,  purplish  in  color,  elliptic  in  shape,  and  tapering 
to  a  fine  point  at  each  end,  the  largest  being  \  inch  wide  and  6  inches 
long.  There  was  a  distinct  tendency  to  parallelism,  transversely  to 
the  limb,  and  a  few  atrophic  macules  were  also  to  be  seen.  The  new 
lesions  which  appeared  while  the  patient  was  under  observation  wrere, 
for  the  most  part,  in  spots  which  united  to  form  a  stripe.  The  first 
step  was  the  appearance  of  a  shiny,  depressed,  cicatricial-looking  spot, 
and  no  antecedent  hypertrophy,  as  described  by  Liveing,  Duhring,  and 
others.  Bradshaw,  quoted  by  Shepherd,  had  almost  a  precisely  similar 
case  as  to  location  and  characters  in  a  girl  aged  thirteen.  Plagge3 
has  observed  the  striae  on  the  abdomen  in  typhoid  fever,  in  which  there 
had  been  no  abdominal  distention,  but,  on  the  contrary,  extreme  emacia- 
tion. Barrs4  had  a  case  under  observation  in  which  there  were  striae  paral- 
lel with  the  ribs  in  the  dorsolumbar  region,  four  on  left  side  and  eight  on 
right,  the  widest  \  inch  wide,  and  the  longest,  4  inches,  having 
the  ordinary  appearances,  and  which  had  followed  an  attack  of  pneu- 
monia a  year  previously,  and  appearing  without  preliminary  edema 
or  inflammation  or  distention.  The  patient,  a  nervous  woman,  had 
experienced,  at  the  time,  intense  pain  over  the  streaks.  There  was  no 
anesthesia.  Wilks,5  quoted  by  Shepherd,  also  noted  2  instances  of 
linear  atrophy,  about  the  knees  in  a  youth  aged  nineteen,  and  a  girl  of 
eighteen,  with  striae  all  over  the  body,  but  especially  the  legs;  in  the  latter 
the  marks  were  tender  and  sensitive,  at  first  faint  red,  subsequently 

1  Jarisch,  Hautkrankheiten,  1900  p.  918. 

2  Shepherd,  Jour.  Cutan.  Dis.,  1891,  p.  59  (with  illustration  and  some  valuable  liter- 
ature and  references,  to  which  I  am  indebted.     Several  recent  interesting  cases  of  these 
striae  about  the  knees  (stride  patdlares)  have  been  reported  by  Northrup  (i   case), 
Fischer  (i  case),  Kobner  (2  cases),  and  by  Bunch  (2  cases),  Brit.  Jour.  Derm.,  Jan.,  1905, 
who  reviews  the  subject  with  reference  to  the  above  cases  and  others.     The  condition 
in  these  6  cases  was  observed  in  growing  children,  and,  with  the  exception  of  i  case, 
developed  during  or  after  typhoid  fever. 

1  Plagge.  Zeitschrift  f .  die  Staatsarzneikunde,  1861,  p.  369. 
4  Barrs,  Brit.  Jour.  Derm.,  1891,  p.  152. 
6  Wilks,  Guy's  Hasp.  Reps.,  1861,  p.  297. 


ET  MACULA.   ATROPHICJE  621 

purple,  and  then  dead  white.  In  these  two  there  was  no  apparent  cause, 
although  the  boy  had  a  tuberculous  knee-joint.  A  case  was  under  my 
own  care  in  a  male  adult  in  whom,  on  the  lumbar  region,  right  side, 
there  were  numerous  parallel  atrophic  lines,  with  a  few  cross  striae, 
of  unknown  origin,  the  patient  being  in  good  health,  In  some  instances, 
as  in  i  of  2  cases  of  the  striated  type  observed  by  Fere  and  Quermonne,1 
principally  in  the  lumbar  region,  the  lines  present  bordering  pigmenta- 
tion ;  in  their  other  case,  involving  the  throat,  breast,  lumbar  and  gluteal 
regions,  the  malady  began  as  brownish  striae,  subsequently  growing  white. 
Other  examples  by  Troisier,  Manouvrier,  and  Bouchard,  of  apparently 
idiopathic  origin,  are  also  referred  to  by  Shepherd  (loc.  cit.).  It  is 
probable,  therefore,  that  all  cases  of  atrophic  lines  cannot  be  placed  to 
the  score  of  being  mechanically  produced  by  overdistention,  although 
Bouchard  suggests  that  the  rapid  increase  of  tissue  after  fevers  might 
be  the  factor,  but  this  does  not  seem  to  be  supported  by  a  study  of  the 
cases.  Even  with  the  acceptance  of  this  there  must  be  some  underlying 
inherent  condition  of  the  cutaneous  tissues.  According  to  the  observa- 
tions2 of  Auboger,  Bouchard,  and  Manouvrier  linear  atrophy  developing 
in  typhoid  is  a  symptom  of  grave  import,  as  the  fever  in  such  instances 
generally  assumes  an  ataxo-adynamic  form. 

Idiopathic  atrophic  macules  usually  present  the  same  characters 
as  the  lines  as  commonly  met  with.  In  the  cases  observed  by  Wilson,3 
Liveing,4  and  Duhring5  there  was  an  antecedent  erythematous  tinge; 
also  in  Taylor's6  case.  In  Jadassohn's7  patient,  a  woman  aged  twenty- 
three,  there  were  numerous  lentil-  to  dime-sized,  bright  red,  depressed, 
and  thin  areas,  covered  with  wrinkled  epidermis,  on  the  extensor  surface 
of  both  arms,  from  the  wrist  to  the  shoulder;  shilling-sized,  dark-red 
similar  spots  over  the  olecranon,  with  depressed  striae  branching  from 
them;  and  groups  of  red,  depressed  striae  blanching  upon  pressure;  some 
ordinary'  striae  on  thighs;  the  first  stage  of  the  macules  seemed  to  be  a 
small  red  papule.  Some  of  these  various  cases  referred  to  would,  I 
believe,  better  bear  the  interpretation  of  morphea  than  that  of  the 
malady  under  consideration;  the  relationship  is  doubtless  often  a  close 
one.8  Jadassohn's  case  of  so  general  and  almost  continuous  mvolve- 

1  Fe"re  and  Quermonne,  Le  Pr  ogres  Med.,  1881,  p.  839. 

2  Paris  letter,  Brit.  Med.  Jour.,  1887,  i,  p.  3°°-  .   . 

»  Wilson,  Diseases  of  the  Skin;  also  Jour.  Cutan.  Med.,  1868,  vol.  i,  p.  140. 

4  Liveing,  Brit.  Med.  Jour.,  Jan.  19,  1878. 

5  Duhring,  Diseases  of  the  Skin,  third  edit.,  p.  442. 


Sherwell  (J,u,.  Cu,y.  K,,  .903,  P. 


S±S,t»  b»  obse^d  by  Macleod  .<™>-S££g%f&  b  y  *d 
MSWN2&  lySKTW  and  concede 


622  ATROPHIES 

ment  seems  midway  between  "atrophic  lines  and  spots"  and  idiopathic 
general  atrophy. 

Symptomatic  or  consecutive  patch  atrophy,  sometimes  presenting 
a  clinical  analogy  to  idiopathic  atrophic  macules,  is  observed  in  certain 
skin  diseases,  such  as  leprosy,  lupus  vulgaris,  lupus  erythematosus, 
syphilis,  lichen  planus,  etc.,  but  this  is  considered  in  connection  with 
the  disease  with  which  they  are  associated. 

Pathology. — Exclusive  of  the  cases  in  which  overstretching  is 
the  factor  it  is  probable  the  condition  is,  as  Schwimmer  and  some  others 
believe,  of  trophoneurotic  origin,  and,  as  Shepherd  states,  that  in  those 
instances  following  fevers  the  latter  were  severe  and  prolonged.  The 
symmetry  of  the  lesions  and  the  neurotic  character  of  most  patients  also 
lend  weight  to  this  view. 

The  pathologic  histology  of  the  atrophic  lines  has  been  studied  by 
Kaposi,  Langer,1  and  a  few  others,  who  found  an  atrophic  condition  of 
the  epidermis,  the  papillae  obliterated,  diminution  of  the  blood-vessels, 
and  disappearance  of  the  fat-cells,  separation  of  the  connective-tissue 
fibers,  and  the  glandular  structures  atrophied.  Langer's  investigations 
led  him  to  believe  that  the  striae  are  produced  by  violent  stretching, 
due  to  disarrangement  or  separation  of  the  connective-tissue  fibers, 
and  not  to  rupture.  Jadassohn  noted  in  his  case  thinning  of  the  epider- 
mis, but  with  no  structural  alteration,  and  more  or  less  complete  dis- 
appearance of  elastic  fibers  of  the  cutis;  there  were  no  signs  of  an  in- 
flammatory process,  although  some  blood-vessels  were  surrounded  by 
slight  round-cell  infiltration;  the  papules  referred  to  indicated,  however, 
Jadassohn  believes,  that  inflammation  is  the  initial  factor. 

When  once  the  atrophic  lines  and  spots  are  established,  the  condi- 
tion is  a  permanent  one,  and  not  removable  or  influenced  by  treatment. 

DIFFUSE  IDIOPATHIC  ATROPHY  OF  SKIN2 

Synonyms. — Atrophia  maculosa  cutis;  Acrodermatitis  chronica  atrophicans; 
anetodermia. 

A  more  or  less  diffuse  atrophy  of  the  skin  (also  called  general  idio- 
pathic atrophy,  progressive  idiopathic  atrophy,  atrophia  cutis  uni- 

that  it  should  be  considered  as  an  unusual  type  of  morphea  or  localized  scleroderma 
("morphcea  guttata");  Juliusberg's  case,  Dermatolog.  Zeitschr.,  1909,  vol.  xv,  p.  12 
(with  clinical  and  histologic  illustrations),  seems  to  strengthen  this  view;  Riecke, 
Archiv,  1909,  vol.  xcix,  p.  181  (with  colored  case  and  histologic  illustration).  It  is 
possible  that  an  occasional  case  might  be  explained  upon  the  basis  of  a  previous  lichen 
planus  of  the  atrophic  type  (lichen  planus  atrophicus). 

1  Langer,  Med.  Jahrbucher,  1880,  p.  49  (with  6  histologic  cuts). 

2  Literature:  E.  Wilson,  Lectures  on  Dermatology,  London,  1878,  p.  393;  Schwimmer, 
Die  Neuropalischen^  Dermatonosen,  p.  189;  Atkinson,  Richmond  and  Louisville  Med. 
Jour.,  1877,  vol.  xxiv,  p.  564;  Glax,  Allg.  Wiener  med.  Zeitung,  No.  35,  1874;  full  abs. 
in  Archiv,  1875,  p.  114;  Buchwald,  Archiv,  1883,  p.  553  (with  illustration);  Behrend, 
abs.  in  Archiv,  1885,  p.   346   (original  in  Berlin,   klin.   Wochenschr.,  No.   6,   1885); 
Teuton,  Deutsch.  med.  Wochenschr.,  1886,  p.  6;  Pospelow  (2  cases),  Annales,  1886, 
p.  505  (with  illustration  and  references);  Groen,  Norsk  Magazine,  abs.-ref.  in  Lancet, 
1891,  vol.  ii,  p.  1238;  Beer,  Archiv,  1892,  p.  835;  Williams,  Brit.  Jour.  Derm.,  1894, 
p.  342  (case  demonstration);  Bronson,  Jour.  Cutan.  Dis.,  1895,  p.  i  (with  colored  plates 
and  other  illustrations  and  references);  Elliot,  ibid.,  1895,  P-  *52;  Fordyce,  ibid.,  1897, 
p.  230  (case  demonstration);  Kaposi,  Archiv,  1897,  vol.  xxxix,  p.  413  (case  demonstra- 


DIFFUSE  IDIOPATHIC  ATROPHY  OF  THE  SKIN  623 

versalis)  has  been  reported  from  time  to  time.  The  chief  features  are: 
atrophic  thinning,  dryness,  and  a  variable  degree  of  branniness,  or  ill- 
defined,  thin,  flaky  scaliness,  with  usually  loss  of  the  hairs  and  absence, 
relative  or  complete,  of  the  sweat  secretion;  and  sometimes  a  white, 
streaky,  or  patchy  appearance,  frequently  with  interspersing  of  brownish 
discoloration;  with,  in  typical  examples,  a  variable  amount  of  looseness 
and  wrinkling  of  the  skin,  and  in  some  cases  a  conspicuousness  of  the 
surface  veins.  In  some  instances  there  is  an  underlying  dusky-red  hue, 
with  sometimes  intermingling  of  purplish  or  brownish.  In  some  places, 
varying  considerably  in  different  cases,  there  is  also  noted  a  waxy, 
glistening,  parchment-like  surface,  as  in  macular  atrophy.  Indeed,  not 
infrequently  the  atrophic  changes  are  more  marked  here  and  there, 
producing  spot-like  or  small,  white,  thin,  scar-like  areas,  somewhat 
depressed.  On  parts  covering  prominent  bony  projections,  as  at  the 


Fig.  147.—  Atrophy  of  the  skin;  old  woman;  chiefly  involving  the  legs,  especially  the 
knee  and  lower  thigh  regions. 

ankles,  ulcers  are  apt  to  form.  In  Fordyce's  patient  a  number  of  out- 
breaks of  bullse  about  the  ankles  occurred.  As  a  rule,  there  are  no  dis- 
tinctive subjective  symptoms,  although  occasionally  shooting  pains, 

tion);  Neumann,  ibid.,  1898,  vol.  xliv,  p.  3  (with  references  and  3  colored  histologic 
cuts  Colombini,  Monatshefte,  1898,  vol.  nviii,  p.  65;  Holder,  Jour  Cutan.  ZJs  1899, 
p.  37  (case  demonstration);  Kingsbury,  "A  Case  of  Acrodermatitis  Chron  ca  Atro- 
pVcans  with  Co-existing  Scleroderma,"  ibid.,  1907,  P,  4MJ  Mahnowsk  i  '  Atrophie 
idiopathique  de  la  peau,"  Annales,  1908,  p.  5  6  2,  reports  5  cases,  **^^gV"£ 
bibliography;  Kanoky  and  Sutton,  "A  Comparative  Study  of  ^e™^c^™™? 
Atrophicans  and  Diffuse  Scleroderma,  with  'Associated  Morphcea  Atroph.ca  /jr. 
Cutan  Dis  Dec  1909  (illustrated,  with  bibliography);  Beck,  Beiti  ig  zui 
vci  LTd&athLSLtatrophieUr,^ 

subiect  described  under  idiopathic  atrophy,  acrodermatitis  chromca  atroph 
SytSSKSm;  with  clinical  and  histologic  study  of  o  cases);  the  writer  thinks 


Nos.  2  and  3. 


624  ATROPHIES 

as  in  Bronson's  case,  involving  both  extremities,  and  rarely  a  sensitive- 
ness to  touch  or  pressure.  The  -amount  of  surface  involved  varies  from 
a  part  of  one  or  two  limbs,  as  in  Elliot's  patient,  to  that  of  practically 
the  entire  surface,  as  in  Neumann's  and  Colombini's  cases,  and  in  the 
congenital  cases  of  Behrend  and  Williams.  The  lower  extremities  are 
most  commonly  involved,  and  the  region  of  the  knees  is  a  not  infrequent 
starting-point;  in  some  both  upper  and  lower  extremities  are  affected 
(Touton,  Pospelow,  Groen,  Bronson,  Fordyce,  Holder).  In  several 
instances  the  first  evidence  was  upon  the  dorsal  surface  of  the  hand. 

Some  of  the  cases,  more  especially  those  first  reported,  could,  I 
believe,  be  better  placed  as  examples,  probably  anomalous,  of  other 
maladies.  There  is,  as  Crocker  suggests,  a  strong  suggestion  of  sclero- 
derma,  with  marked  atrophic  tendency  in  several, — especially  in  those 
of  Wilson,  Schwimmer,  Atkinson,  and  Glax,— although  Atkinson's 
case,  which  was  unilateral,  lacked  the  ordinary  features  of  scleroderma, 
and  had  much  in  common  with  cutaneous  atrophy.  Some  cases  were 
of  more  or  less  limited  character  and  chiefly  patchy,  as  in  Beer's  patient; 
in  this  there  was  preceding  edema,  and  it  was  somewhat  suggestive  of  a 
circumscribed  scleroderma.  Both  Schwimmer  and  Glax,  at  the  time, 
thought  their  cases  probably,  but  incorrectly,  belonged  under  xeroderma 
pigmentosum.  Those  described  by  Buchwald,  Pospelow,  Bronson,  and 
Colombini  have  much  in  common,  especially  as  to  laxity  of  the  skin; 
this,  in  •  one  of  Pospelow's  cases,  was,  however,  somewhat  extreme, 
resembling  dermatolysis.  In  Neumann's  patient,  practically  universal, 
there  was  diffuse  redness,  with  thinning,  wrinkling,  and  furfuraceous 
and  lamellar  desquamation.  The  wrinkling  observed  in  most  of  these 
patients,  as  in  Bronson's  patient,  follows  the  cleavage  lines  of  the  skin; 
in  most  instances  it  is  not  especially  noticeable,  resembling,  at  a  dis- 
tance, minute  striae,  giving  the  thinned  skin  a  cigarette-paper  appear- 
ance, but  in  others  it  is  of  the  nature  of  distinct  folds.  In  Bronson's 
case,  as  hi  some  others,  there  is  remarkable  symmetry  in  the  distribution. 
In  some  patients  the  neighboring  lymphatic  glands  were  enlarged. 

The  causes  of  the  disease  are  not  known;  in  rare  instances  it  is  con- 
genital, in  others,  and  probably  in  almost  all,  appearing  at  mature  or 
advancing  adult  age.  In  10  cases  it  began  in  i  (Pospelow — female,  aged 
fifty)  at  the  age  of  sixteen,  i  (Buchwald — male,  aged  thirty-six)  at 
twenty,  3  (Bronson,  Elliot,  Neumann — males,  aged  forty-five,  forty-five, 
and  thirty-two)  at  about  thirty,  i  (Touton— male,  aged  fifty-seven)  at 
thirty-five,  i  (Fordyce — female,  aged  forty)  at  thirty-eight,  i  (Holder — 
female,  aged  fifty-four)  at  the  age  of  forty-six,  i  (Pospelow — female, 
aged  fifty)  at  forty-eight,  and  i  (Colombini — female,  aged  fifty-five) 
at  fifty-four  and  a  half.  In  12  cases  the  sexes  were  evenly  divided. 
The  health  of  most  patients  seemed  fair,  although  in  several  instances  the 
malady  followed  "taking  cold"  or  a  chill;  in  the  cases  of  Fordyce  and 
Holder  there  were  associated  symptoms  of  headache,  dizziness,  and  ex- 
treme nervousness.  The  primary  pathologic  condition  in  some  in- 
stances— in  all,  according  to  Finger — appears  to  be  a  scarcely  per- 
ceptible inflammatory  process,  which  seems  borne  out  by  the  histologic 
examination  (Colombini).  In  Elliot's  case  a  purplish-red  zone  bounded 


KRAUROSIS    lULVsE  625 

the  advancing  area  of  atrophy,  and  this  Elliot  believed  was  the  primary 
step  in  the  process,  and  the  atrophy  only  a  consequence.  The  process 
in  this  case  and  in  some  others  bears  in  this  respect,  in  my  judgment  a 
close  analogy  to  that  of  morphea.  The  changes  found  are  those  of  well- 
marked  atrophy,  involving  the  entire  integument  and  glandular  struc- 
tures, similar,  in  fact,  to  those  observed  in  striae  et  maculae  atrophicae. 
Fordyce  found  marked  changes  in  the  vessels,  the  lumen  of  some  being 
completely  obliterated. 

The  prognosis  for  the  malady  is  not  favorable  for  recovery, 
although  beyond  variable  discomfort,  however,  the  general  health  did 
not  seriously  suffer,  except  in  the  generalized  cases.  There  seems  prac- 
tically no  tendency  to  extensive  involutionary  changes,  the  malady 
usually  progressing  up  to  a  certain  point,  and  then  remaining,  relatively 
at  least,  stationary.  In  most  instances  several  years  elapse  before  reach- 
ing its  greatest  extension,  although  in  Kaposi's  and  Colombini's  cases 
in  five  or  six  months  almost  the  entire  surface  was  involved.  The  gen- 
eral treatment  indicated  would  be  arsenic,  cod-liver  oil,  and  tonics, 
with  mild  oily  applications  to  reduce  the  dryness  and  harshness. 

KRAUROSIS  VULVAE 

Breisky,1  Heitzmann,2  Janovski,3  Ohmann-Dumesnil,4  Baldy  and 
Williams,5  Ewald,6  Thibierge,7  and  others  have  called  attention  to  the 
rather  rare,  peculiar  affection  of  the  genitalia  in  women,  characterized 
by  atrophic  changes,  shriveling,  and  contraction,  with,  as  a  rule,  a  more 
or  less  intense  pruritus.  The  parts  usually  involved  are  vestibulum, 
labia  minora,  with  the  fourchet  and  praeputium  clitoridis,  the  inner 
surface  of  the  labia  majora,  extending  to  the  posterior  commissure,  and 
the  immediately  adjacent  perineum.  The  folds  are  partly  or  completely 
obliterated,  and  later  the  labia  minora  almost  entirely  disappear,  their 
site  being  indicated  by  a  slight  sulcus  or  furrow.  The  atrophic  change 
may  involve  the  praeputium  clitoridis  to  such  a  degree  as  to  leave  no 
recognizable  trace.  The  posterior  portion  of  the  vulva  also  suffers  to  a 
great  extent,  and  here  and  in  the  other  parts  there  is  noted  a  tightening 
or  spanning  of  the  tissues,  with  a  tendency  to  some  hardening.  There 
is  generally  some  patchy  thickening,  which  may  be  somewhat  similar 
to  the  plaques  of  leukoplakia  buccalis.  The  contiguous  and  covering 
integument  is  usually  grayish  or  whitish,  dry  and  often  glossy,  and 

1  Breisky,  Zeitschr.fur  Heilkunde,  1885,  p.  69  (12  cases;  histologic  cuts). 

2  C.  Heitzmann,  abs.  Trans.  Amer.  Derm.  Assoc.for  1888  (4  cases);  never  published 
in  full — abs.  of  the  cases  in  Ohmann-Dumesnil's  paper. 

3  Janovski,  Monatshefie,  1888,  vol.  vii,  p.  951  (6  cases). 

4  Ohmann-Dumesnil,  ibid.,  1890,  vol.  x,  p.  294  (4  cases,  with  r6sum6  ql  all  other 
published  cases  and  others  (unpublished)  communicated  to  the  author— in  all  a  tabula- 
tion of  35  cases). 

B  Baldy  and  Williams,  Amer.  Jour.  Med.  Sri.,  1899,  vol.  cxxvm,  p.  528  (i  case, 
with  a  review  of  literature). 

8  Ewald,  New  Yorker  med.  Monatsschrift,  1901,  p.  209. 

The  case  described  by  R.  F.  Weir,  New  York  Med.  /wr.,  Mar.,  1875,  as  Icn- 
thyosis  of  the  Vulva,"  seems  also  to  be  an  example  of  this  affection. 

7  Thibierge,  Annales,  1908,  p.  i  (report  of  cases  and  review),  also  refers  to  Jayle  s 
important  paper,  "Le  kraurosis  vulvae,"  Revue  de  gynecol.  el  de  chirurg.  abdom.,  1906,  p. 
633- 

40 


626  ATROPHIES 

sometimes  thickened.  Breisky  stated  that  there  was  no  preceding  or 
accompanying  inflammation  or  erythema,  but  in  some  instances  pruritus. 
Heitzmann's  cases  showed  features  of  chronic  eczema  of  patchy  character, 
these  patches  being  slightly  milky  and  psoriatic  looking,  and  with  con- 
siderable tormenting  itching.  Baldy  and  Williams  recognize  the  etio- 
logic  bearing  of  pruritus,  which,  in  consequence  of  the  scratching,  leads 
to  inflammation,  with  the  subsequent  cicatricial  tissue  formation  in  the 
corium  and  hypoderm,  although  admitting  that  there  is  still  an  unknown 
factor  to  which  the  unusual  changes  are  due. 

In  short,  nothing  definite  can  be  said  as  to  etiologic  factors,  except 
that  vaginal  discharge  and  pruritus  are  the  most  common  recognizable 
antecedent  and  accompanying  symptoms.  It  appears  to  bear  no  rela- 
tion to  coitus  or  pregnancy,  as  it  is  observed  among  both  the  unmarried 
and  married,  the  chaste  and  the  prostitute.  Both  Jayle  and  Thibierge 
incline  to  the  belief  that  the  malady  is  chiefly  met  with  in  women  whose 
ovaries  have  been  removed  and  in  those  whose  ovaries  have  physiologic- 
ally atrophied.  Thibierge  considers  it  is  to  be  looked  upon  as  a  locali- 
zation of  the  atrophic  process  which  characterizes  the  senile  involutions 
of  the  skin  in  general.  The  histologic  examination,  according  to  Breisky 
(quoted  by  Janovski),  shows  atrophic  changes  in  the  upper  part  of  the 
corium,  especially  the  papillary  layer,  which  is  found  sclerosed,  dull, 
vitreous  looking,  and  lightly  streaked.  The  glandular  structures  are 
almost  completely  gone  and  there  is  a  small-celled  infiltration  at  the 
bottom  of  the  papillae. 

Unfortunately,  the  malady  is  persistent,  and  in  spite  of  treat- 
ment usually  continuous.  The  possibility  of  epitheliomatous  devel- 
opment, as  in  Weir's  case,  must  be  kept  in  mind.  The  vaginal  dis- 
charge, if  present,  should  receive  attention,  as  it  serves  to  aggravate, 
even  if  its  removal  does  not  cure.  Heitzmann  was  the  only  hopeful 
observer  as  regards  the  result  of  treatment;  he  states  that  he  succeeded 
in  curing  his  patients  by  removing  the  thickened  patches  present  in  his 
cases  by  the  curet,  and  followed  by  continuous  applications  of  from  0.5 
to  2  per  cent,  of  salicylic  acid  solution,  alternating  with  pyrogallol 
solution  of  the  same  strength.  Owing  to  the  tendency  to  recur,  however, 
the  treatment  must  be  repeated  in  some  cases.  Baldy  and  Williams 
advise  the  total  removal  of  the  affected  parts  as  a  curative  measure. 

AINHUM 

Synonym. — Dactylolysis  spontanea. 

Definition. — A  disease  characterized  by  a  slow  but  gradual 
linear  strangulation  of  one  or  more  of  the  toes,  especially  the  smallest, 
and  resulting  eventually  in  spontaneous  amputation.  This  affection, 
an  account  of  which  was  first  presented  by  Clark,1  and  since  by  Da 
Silva  Lima2  and  others,  is  seen  most  frequently  in  the  negro  and  Hindu 

1  Clark,  Trans.  Epidemiolog.  Soc'y,  1860,  vol.  i,  p.  105  (brief  notice). 

2  Da  Silva  Lima,  Arch.  Derm.,  1880,  p.  367.     Accounts  are  also  to  be  found  in 
Hirsch's  Geograph.  and  Histor.  Pathology,  New  Syd.  Soc'y's  Translation,  1886,  vol.  liii, 
p.  728  (with  bibliography),  and  Fox  and  Farquhar's  Endemic  Skin  Diseases  of  India, 
etc.,  app.  vii,  p.  114,  London,  1876;  De  Brun,  "L'ainhum  des  auteurs,  constitue-t-il  une 


AINHUM 

races,  although  cases  have  occurred  in  Arabs,  Mussulmans,  and  Chinese. 
But  few  cases  have  been  recorded  in  white  individuals.  It  is  met  with 
not  infrequently  on  the  west  coast  of  Africa,  Egypt,  Trinidad,  India, 
in  Bahia,  Rio  de  Janeiro,  Buenos  Ayres,  and  some  other  parts  of  the 
world.  It  is  also  rarely  seen  in  parts  of  the  United  States,  as  Virginia,1 
North  Carolina,  and  Illinois.2 

Symptoms. — The  affection  begins  with  a  furrow  on  the  plantar 
aspect,  usually  of  the  little  toe,  at  the  interphalangeal  articulation. 
This  furrow  extends  quite  slowly  around  the  toe,  and  becomes  gradually 
deeper,  until  the  constriction  completely  surrounds  that  member.  The 


Fig.  148.— Ainhum;  small  toe  of  left  foot  already  gone,  beginning  ligation  of 
the  third  toe,  and  similar  tendency  in  some  toes  of  the  other  foot  and  on  the  small 
finger  of  the  left  hand;  in  fact,  this  constricting  tendency  is  noted  on  almost  all 
fingers  and  toes.  Patient  is  a  male  adult,  aged  about  twenty-eight  a  farmer,  native 
born  ,wUh  a  generalized  condition  of  the  skin  suggestive  of  a  pitynasis  rubra  pilans, 
and  existing  since  childhood  (case  referred  to  m  the  text). 

end  of  the  toe  enlarges  to  twice  its  normal  size.  After  several  years, 
varying  from  four  to  ten,  the  phalanx  is  absorbed,  the  blood-vessels 
become  obliterated,  and  the  toe  drops  off.  The  process,  as  a  rule,  is 


°gr^uhring,  "A  Case  of  Ainhum,  with  Microscopic  Examination  by  H.  Wile,"  Anter. 

Jour.  Med.  Set.,  1884,  vol.  Ixxxvn,  p.  150.      .  illustrations);  Shepherd 

'Herrick,  Phila.  Med.  Jour.,  1898,  vol.  i,  p.  246  (with  £'ustra™;,    ^ 
(Montreal,  Canada)  also  reports  a  czse-Amer.  Jour.  Med.  Set.,  H»7, 


137;  both  of  these  cases  were  male  negroes. 


628  ATROPHIES 

not  accompanied  by  subjective  symptoms,  although  later  it  is  some- 
times painful,  and  toward  the  end  there  may  be  inflammation  or  ulcera- 
tion.  Sometimes  a  small  ulcer  forms  in  or  near  the  digitoplantar  fold, 
and  in  such  instances  the  pain  is  usually  very  severe.  At  times  other 
toes  on  the  same  or  on  the  other  foot  may  be  involved,  and  even  a  finger 
may  become  affected.  Involvement  other  than  the  small  toe  is,  how- 
ever, exceptional.  It  would  seem  that  it  may  be  associated  with  other 
maladies  in  which  epidermic  thickening  and  keratosis  are  noted.  Hyde 
and  Montgomery1  noted  a  similar,  gradually  constricting  band  in  three 
white  subjects,  associated  with  symmetric  palmar  and  plantar  keratosis; 
and  in  a  patient  under  my  care  presenting  features  suggestive  of  a  general 
pityriasis  rubra  pilaris  there  had  been  gradual  amputation  and  loss  of 
one  small  toe,  and  the  little  finger  and  others  of  the  digits  and  toes  were 
showing  beginning  evidences  of  such  constriction.  The  diseased  parts 
usually  retain  their  normal  sensibility,  and  the  nail  is  rarely  affected. 

Etiology  and  Pathology. — The  disease  usually  attacks  adults, 
although  a  few  cases  have  been  reported  in  children.  It  is  quite  rare 
in  the  white  race.  More  cases  occur  in  males  than  females.  Da  Silva 
Lima,  Duhring,  and  a  few  others  believe  that  it  may  occasionally  be 
hereditary.  In  Duhring's  case  the  father  of  the  patient  (negro,  aged 
forty)  had  lost  both  his  small  toes  in  the  same  manner,  and  the  mother, 
at  the  time  of  observation  of  the  patient,  had  the  same  malady.  We 
are  in  the  dark,  however,  as  to  its  true  causation.  It  is  thought  by  some 
to  be  of  parasitic  origin.  By  others  it  has  been  attributed  to  traumatism, 
owing  to  the  habit  of  negroes  of  going  barefooted,  and  also  to  the  wearing 
of  a  ligature  applied  intentionally,  but  such  hypotheses  are  not  borne  out 
by  the  facts.  Nor  does  the  view  advanced  by  Zambaco  Pacha2  that  it 
is  an  attenuated  form  of  leprosy  have  any  substantial  support.  It  is 
probably  a  trophoneurosis.  Microscopic  examination  shows  the  epider- 
mis and  papillary  layer,  especially  the  former,  to  be  hyper trophied,  the 
interpapillary  downgrowth  being  quite  marked.  The  blood-vessels 
are  the  seat  of  the  following  changes:  in  the  walls  of  the  larger  arteries 
the  adventitia  is  greatly  increased  and  the  intima  much  thickened,  thus 
interfering  with  the  caliber  of  the  vessel.  The  constriction  is  usually 
about  the  shaft  of  the  proximal  phalanx,  although  it  also  has  occurred 
(Crombie)  at  the  interphalangeal  articulation;  absorption  of  the  osseous 
tissue  occurs  as  constricting  fibrous  tissue  takes  its  place  (Eyles).3 
Pyle,  from  his  review  of  the  subject,  largely  guided  by  Eyles'  histologic 
study,  states  that  the  findings  show  it  to  be  a  direct  ingrowth  of  the 
epithelium,  with  a  corresponding  depression  of  the  surface,  due  to  rapid 
hyperplasia  that  pushes  down  and  strangles  the  papillae,  thus  cutting 
off  the  blood-supply  from  the  epithelial  cells,  causing  them  to  undergo  a 
horny  change.  It  would  seem  that  the  malady  might  be  pathologically 
analogous  to  congenital  amputation,  as  Proust4  has  suggested,  a  view, 
however,  which  does  not  find  general  acceptance. 

1  Hyde  and  Montgomery,  Diseases  of  the  Skin,  seventh  edit.,  1900,  p.  609. 

2  Zambaco  Pacha,  Bull.de  I'acad.  de  med.,  July  28,  1896;  see  De  Brun's  paper  (loc. 
til.). 

1  Eyles,  "The  Histology  of  Ainhum,"  Lancet,  1886,  ii,  p.  576. 
4  Proust,  Gazelle  des  hopilaux,  1889,  p.  369. 


PERFORATING    ULCER    OF  THE  FOOT  629 

Treatment  -It  fa  stated  by  Da  Silva  Lima,  Murray,  and  others, 
that  if,  in  the  earlier  stage  of  the  disease,  the  constricting  band  is  trans- 
versely incised  freely,  the  affection  may  be  brought  to  a  stand  When 
however,  the  disorder  is  of  long  duration,  amputation  of  the  toe  is  the 
only  recourse. 

PERFORATING  ULCER  OF  THE  FOOT 

orans  pedis;  Fr-'  Mal  Perf°rant  du  pied;£er.,  Perforirendes 


Definition.—  Perforating  ulcer  of  the  foot  is  a  trophoneurotic 
disease  beginning  primarily  as  a  degenerative,  circumscribed,  more 
or  less  calloused  formation,  and  developing  into  an  indolent,  and  usually 
painless,  sinus,  leading  down  through  the  deeper  tissues  to  the  bone. 

This  malady  is  rare,  and  comes  more  frequently  under  the  notice  of 
the  surgeon,  although  occasionally  also  under  dermatologic  observation. 
It  has  long  been  known,  especially  among  the  French  surgeons.  The 
most  elaborate  study  of  the  disease,  both  from  a  clinical  and  pathologic 
standpoint,  was  that  by  Savory  and  Butlin,1  although  others,  both 
before  and  since,  among  whom  Michaud,2  Duplay,3  Lagrange,4  Schwim- 
mer,5  Gasquel,6  have  also  described  and  discussed  the  malady,  that  of 
the  last  named  being  especially  complete. 

Symptoms.  —  It  begins  with  the  formation  of  a  localized  callosity 
or  epidermic  thickening,  sometimes  essentially  the  nature  of  a  corn, 
on  the  plantar  surface,  and  most  usually  situated  over  the  articulation 
of  the  metatarsal  bone  with  the  phalanx  of  the  first  or  last  toe,  the 
regions  which  are  subjected  to  more  or  less  pressure.  Exceptionally, 
however,  it  has  also  been  observed  on  the  palm  of  the  hand,  as  in  Ter- 
rillon's  case,7  over  the  metacarpophalangeal  articulation  of  the  ring- 
finger.  Beneath  this  callous  plate  suppuration  and  necrosis  take  place, 
and  the  overlying  horny  covering,  or  the  central  part  of  it,  is  generally 
soon  cast  off,  disclosing  a  shallow  ulcer  or  sinus,  which  gradually  ex- 
tends more  and  more  deeply,  and  finally  exposes  the  bone,  which  soon, 
as  a  rule,  also  shares,  to  a  variable  degree,  in  the  necrotic  process.  The 
orifice  is  sometimes  surrounded  by  granulations,  beyond  which  the  adja- 
cent epidermis  is  usually  much  thickened.  This  latter  is  often  a  con- 
spicuous feature,  the  sinus  apparently  having  its  opening  through  a 
callous  mass  or  large,  flattened-out,  clavus-like  formation.  The  external 
opening  is  generally  of  less  diameter  than  the  deeper  part  of  the  sinus. 
There  is  very  little  discharge.  The  formation  is  extremely  indolent  and 
usually  painless,  and,  moreover,  shows  but  little,  if  any,  tenderness  on 

1  Savory  and  Butlin,  London  Medico-Chirurg.  Soc'y  Trans.,  1879,  vol.  Ixii.,  p.  373 
(with  colored  plate,  histologic  cuts,  and  bibliography). 

2  Michaud,  "Sur  1'etat  des  nerfs  dans  I'ulce're  perforant,"  Lyon  Medicale,  1876,  p.  5. 

3  Duplay,  Arch.  gen.  de  med.,  1876,  vol.  xxvii,  p.  346  (hospital  service  reported  by 
Marot),  and  Jour,  de  med.  et  chirurg.  prat.,  1875,  vol.  xlvi,  p.  13. 

4  Lagrange,  "De  1'etiologie   multiple  des   mal  perforant  plantaire,     La  bemaine 
Med.,  1886,  vol.  vi,  p.  485. 

6  Schwimmer,  Ziemssen's  Handbuch  der  spec.  Pathol.,  1883-84,  vol.  xiv.,  p.  80. 
*  Gasquel,  These  de  Paris,  July,  1890. 

1  Terrillon,  Bull,  de  la  soc.  de  chirurg.,  de  Paris,  1885,  vol.  u,  p.  155  (case  demon 
stration). 


630  ATROPHIES 

pressure,  although  walking  itself  is  sometimes  painful.  The  affected 
part  is,  especially  in  places,  commonly  more  or  less  anesthetic  and  of 
subnormal  temperature,  although  occasionally  hyperesthesia  has  been 
noted.  The  foot  frequently,  sooner  or  later,  becomes  the  seat  of  other 
symptoms  or  changes  pointing  toward  nerve  impairment,  such  as  in- 
creased hair-growth,  hyperidrosis,  usually  of  a  fetid  character  (bromi- 
drosis),  pigmentation,  and  alterations  in  the  nails.  The  plantar  surface 
may  also  exhibit  more  or  less  diffused  epidermic  thickening  or  several 
or  more  scattered  callosities  or  clavus-like  lesions.  The  ulcer  is  usually 
single,  but  in  some  cases  several  have  been  present;  in  the  latter  event 
they  may  be  on  the  sole  of  one  foot,  or  both  feet  may  be  the  seat  of  the 
disease.  As  already  stated,  exceptionally  a  similar  formation  has  been 
observed  on  the  palm. 

The  course  of  the  malady  is  slow.  Sometimes,  but  more  especially 
when  the  patient  is  kept  at  rest,  the  sinus  heals  up,  to  break  down  again 
usually  as  soon  as  the  patient  becomes  active.  The  destructive  process 
may  bring  about  complete  disorganization  of  the  involved  joint. 

Btiology  and  Pathology. — The  malady  occurs  principally  in 
association  with  those  diseases  in  wrhich  there  are  nerve  involvement 
and  loss  of  tissue  resisting  power,  such  as  locomotor  ataxia,  anesthetic 
leprosy,  syphilis,  peripheral  neuritis,  diabetes,1  etc.  It  is,  in  fact,  ac- 
cepted that  the  malady  is  a  trophoneurosis,  and  dependent  upon  impair- 
ment or  degeneration  of  the  central,  truncal,  or  peripheral  nerves.  This 
is  shown  in  Gasquel's  analytic  study  of  91  cases:  69  had  central,  and  8 
peripheral,  nerve-lesion.  Of  the  number,  32  were  subjects  of  locomotor 
ataxia,  and  17  of  general  paralysis,  while  8  were  alcoholics  and  14  dia- 
betics, and  1 2  had  varied  diseases  or  lesions  of  the  cord,  of  which  4  were  of 
traumatic  origin.  While,  therefore,  there  is  underlying  nerve  degenera- 
tion, there  is  but  little  doubt,  too,  that  local  pressure  and  traumatism 
are  also  important  factors.  As  regards  sex  and  age  liability,  of  Gasquel's 
91  cases  84  were  males  and  53  occurred  between  the  ages  of  thirty  and 
fifty,  19  over  fifty,  and  7  under  thirty,  3  of  which  were  under  twenty. 

According  to  Savory  and  Butlin,  there  is  degeneration  of  the  sen- 
sory and  nutrient  fibrillae  of  the  affected  nerves,  resulting  from  pressure 
upon  them  by  the  thickened  endoneurium;  the  motor  fibrils,  owing  to 
their  thicker  medullary  sheath  and  larger  size,  escape  damage.  In  some 
cases  there  is  arterial  disease,  the  coats  of  the  vessels  being  found  under- 
going calcareous  or  other  degeneration,  and  this  has  led  to  the  view  that 
there  is  a  causal  relation  between  such  and  the  perforating  ulcer;  but 
this  is  contradicted  by  the  fact  that  in  other  instances  the  vessels  have 
been  in  normal  condition. 

Diagnosis. — When  the  associated  general  nervous  disease  and 
phenomena  are  taken  into  consideration  with  the  local  development 
and  behavior  of  the  lesions,  a  mistake  could  rarely  occur.  There  may 
be  possible  confusion  in  the  beginning  with  a  circumscribed  callosity; 
later  with  a  simple  suppurating  corn,  and  still  later  with  a  tuberculous 
or  syphilitic  ulcer. 

1  Wessinger,  Jour.  Cutan.  Dis.,  1889,  p.  178,  reports  a  case  occurring  in  a  diabetic, 
a  woman  of  advancing  years,  first  developing  in  one  foot  and  then  in  the  other. 


MORGAN'S  DISEASE  631 

Prognosis  and  Treatment.—  Treatment  is,  as  a  rule,  unsatis- 
factory, the  affection  being  persistent  and  exceedingly  rebellious,  and 
permanent  betterment  or  cure  scarcely  possible.  Nor  have  the  results 
in  those  cases  which  have  been  operated  upon,  either  by  thorough  cur- 
etting, excision,  or  partial  or  complete  amputation,  been,  except  in  some 
instances,  under  favoring  circumstances,  permanent,  as  the  malady  is 
apt  to  recur,  even  sometimes  in  the  stump  of  the  amputated  limb.  If 
curetting  is  employed,  the  surrounding  hardened  horny  plate  should 
first  be  softened  and  removed  by  a  25  per  cent,  salicylic  acid  plaster. 
Treves1  accomplishes  this  by  continuous  poulticing  with  linseed  meal, 
shaving  away  the  softened  part  from  day  to  day;  finally,  after  its  removal 
has  been  attained,  requiring  ten  to  fourteen  days,  the  poultices  are  dis- 
continued, and  a  paste  composed  of  salicylic  acid  and  glycerin,  of  the 
consistence  of  thick  cream,  with  the  addition  of  10  grains  (0.65)  of 
carbolic  acid  to  the  ounce  (32.),  is  applied  to  the  sore.  Under  this  plan 
complete  healing  often  takes  place,  especially  if  the  bone  is  not  diseased. 
Success  is  only  temporary,  however,  unless  the  pressure  can  be  kept  from 
the  part,  and  for  this  purpose  Savory  and  Butlin  advise  an  artificial  leg 
applied  to  the  bent  knee.  For  pure  surgical  methods,  excision,  ampu- 
tation, etc.,  the  reader  is  referred  to  works  on  surgery,  to  the  domain  of 
which  the  management  of  the  malady  properly  belongs. 

MORVAN'S  DISEASE 

Synonyms—  Syringomyelia;  Myelosyringosis;  Analgesic  paralysis  with  whitlow; 
Fr.,  Panaris  analgesique;  Maladie  de  Morvan;  Ger.,  Morvansche  Krankheit. 

Definition.—  An  affection  of  the  spinal  cord,  with  peripheral 
symptoms,  chiefly  of  the  upper  extremities,  and  characterized  by  mus- 
cular atrophy  and  trophic  disturbances,  partial  anesthesia,  and  the  oc- 
currence of  whitlows,  cutaneous  ulceration,  and  necrosis. 

This  disease  was  first  described  by  Morvan,2  in  the  year  1883,  undei 
the  title  "De  la  paresie  analgesique  a  panaris  des  extremites  supeneures 
ou  pareso-analgesie  des  extremites  superieures,"  and  regarded  by  him  a: 
being  a  special  disease,  independent  of  syringomyeha.     The  present 
acceptance,  on  the  whole,  however,  is  to  regard  this  condition  as  a  type 
of  the  latter,  a  view  adopted  by  Charcot,  and  also  previously  by  Roth 
and  the  correctness  of  which  is  confirmed  by  the  histologic  findings 
Toffroy  and  Achard4  and  others.  .    . 

Svmtrtoms.-The  disease  usually  begins  insidiously,  with  pain  11 
an  arm,  Accompanied  by  loss  of  muscular  power,  which  is  succeeded 
by  analgesia  and  the  occurrence  of  recurrent  whitlows,  in  son 
stances  occurring  in  one  or  several  crops.    In  some  cases  analges, 

i  Treves,  "Treatment  of  Perforating  Ulcer  of  the  Foot  »  Lancet,  1884,  H,  P-  949- 


ins. 


(regarding  identity  and  histologic  findings). 


ATROPHIES 

the  first  symptom  which  attracts  the  patient's  attention.  One  or  several 
whitlows  may  present  at  the  one  time,  and  in  the  course  of  the  disease 
as  many  as  nine  have  been  known  to  occur  (Morvan).  They  may  suc- 
ceed one  another  rapidly,  or  several  years  may  intervene  between  their 
appearance  They  usually  are  seen  on  the  fingers  only,  but  occasionally 
the  same  condition  has  been  noted  on  the  toes.  The  phalanges  become 
necrosed  and  drop  off,  the  hand  generally  becomes  claw-like,  great  de- 
formity resulting.  Trophic  and  vasomotor  cutaneous  disturbances, 
blueness  of  the  skin,  fissures,  vesicles,  bullse,  ulceration  involving  the 
sheath  of  the  tendons,  changes  in  the  nail  substance,  pigmentary  changes, 
and  glossy  skin  are  quite  frequently  also  observed.  Other  symptoms 
are  hyperidrosis,  more  or  less  loss  of  tendon-reflexes,  impaired  vision, 
scolio'sis,  and  arthropathies.  Atrophy  of  the  muscles  of  the  hand  and 
flexor  muscles  of  the  wrist  and  paresis  result;  the  sensations  of  heat,  cold, 
and  pain  are  lost,  although  the  sense  of  touch  remains. 

Ordinarily  the  upper  extremities  are  alone  involved,  and  it  may  be 
confined  to  one,  but  usually  first  one  and  then  the  other  becomes  affected. 
In  other  rare  instances  one  leg  and  foot  show  the  changes,  or  it  may  be 
in  both  lower  extremities,  and  exceptionally  it  has  involved  both  arms 
and  legs.  A  rare  instance  is  also  reported  by  Jacquet,1  in  which  trophic 
ulcerations  were  on  the  neck,  head,  and  shoulders.  The  malady  is  not 
only  insidious,  but  often  extremely  slow  in  its  progress,  in  some  instances, 
as  in  Prouff's2  cases,  lasting  many  years,  sometimes  with  more  or  less 
prolonged  remissions. 

Etiology  and  Pathology. — This  rare  affection  occurs  more 
frequently  in  males,  and  with  occasional  exception  between  the  ages 
of  twenty  and  fifty.  Some  of  the  cases  are  seemingly  attributable  to 
traumatism,  malaria,  syphilis,  rheumatism,  and  other  constitutional 
diseases,  but  it  is  to  be  said  that  these  are  simply  possible  factors,  and 
that  the  underlying  cause,  in  the  great  majority  of  instances,  is  wholly 
obscure,  and  certainly  cannot  be  demonstrated.  Its  resemblance  to 
anesthetic  leprosy  has  been  remarked  upon,  and  Zambaco3  believes  it 
to  be  a  slight  or  modified  form  of  that  disease.  Dyer4  states  that,  except 
the  absence  of  bacillus,  it  has  no  distinguishing  features  from  some  of  the 
mild  types  of  lepra,  and  reports  a  few  cases  in  point. 

Pathologically,  the  malady  is  apparently  of  central  spinal  origin. 
According  to  Gombault,  Joffroy,  Church,  Marinesco,  Dercum  and 
Spiller,  and  Starr,  cavities  surrounded  by  dense  neuroglia  are  found 
behind  the  central  canal,  and  are  believed  to  be  due  to  absorption  of 
gliomata.  Sclerosis  of  the  posterior  horns  and  columns  of  the  cord  has 

1  Jacquet,  part  vi,  plate  xviii,  International  Atlas,  1891. 

2  Prouff,  Gaz.  hebdom.,  1887,  p.  249  (lasted  over  forty  years). 

3  Zambaco,  Trans,  of  First  Internal.  Leprosy  Conference,  Berlin,  1898;  see  also  his 
paper,  "Lepra  anesthetique  et  syringomyelie,"  Gaz.  hebdom.,  1891,  vol.  xxviii,  p.  196. 

4  Dyer,  "Syringomyelia  and  Lepra  nervorum,"  New  Orleans  Med.  and  Surg.  Jour., 
1893-94,  vol.  xxi,  p.  81;   see  also  Cagney,  "Syringomyelia  and  Leprosy,"  Brit.  Jour. 
Derm.,  1894,  p.  375;  and  Jeanselme's  paper,  "La  Lepre,"  La  Presse  med.,  1897,  Nos. 
84  and  85  (containing  suggestive  cases,  with  illustrations);  also  von  During,  "Die 
Schwierigheiten  in  der  Diagnose  nervosen  Lepraformen,  insbesondere  in  Beziehungauf 
die   Syringomyelie,"   Archiv.  1898,  vol.  xliii,  p.  137;  Pick's  Fetschrift,  part  i  (with  3 
plates    and    references). 


MORGAN'S  DISEASE 


633 


also  been  noted.  Gombault  and  Joffroy*  examined  the  peripheral 
nerves  and  found  sclerosis  and  neuritis.  Sachs  and  Armstrong2  suggest 
that  the  earliest  pathologic  process  may  be  seated  in  the  peripheral 
nerves,  and  that  the  central  changes  are  secondary.  This  would  be  in 
consonance  with  the  belief  that  some  cases  seem  to  follow  a  local 
peripheral  traumatism.  Both  the  pathologic  findings  and  clinical 
symptoms  are  in  accord  with  the  view  that  the  malady  is  identical  with 
syringomyelia. 

Diagnosis.— As  already  remarked,  the  clinical  features  of  the 
disease  at  times  bear  a  close  resemblance  to  some  cases  of  leprosy  of 
the  anesthetic  type;  but  the  absence  of  the  bacillus,  as  well  as  other 
differences,  are  usually  sufficient  to  distinguish.  There  is  occasionally 
a  slight  similarity  in  some  of  the  hand  symptoms  in  certain  cases  of  sclero- 
derma,  but  that  is  the  whole  extent  of  the  resemblance,  so  that  a  mistake 
is  scarcely  possible  if  the  usual  and  more  extensive  symptoms  of  sclero- 
derma  are  kept  in  view.3 

Prognosis  and  Treatment.— The  outlook  for  a  cessation  or 
cure  of  the  malady  is  not  promising.  Its  progress,  as  already  stated, 
is  slow,  ten,  fifteen,  sometimes  more  years  elapsing  before  serious  con- 
sequences, as  regards  life,  ensue.  The  resulting  deformity  and  mutila- 
tion are  gradual.  Treatment  is  essentially  symptomatic.  The  parts 
are  to  be  protected  against  injury,  and  the  whitlows  and  ulcerations 
treated  upon  ordinary  antiseptic  surgical  principles.  The  patient's 
general  health  should  receive  attention.  Arsenic,  strychnin,  silver 
nitrate,  and  other  remedies  have  been  tried,  but  no  estimation  as  to 
their  possible  value  can  be  definitely  stated.  Application  of  the  galvanic 
current  up  and  down  the  spine,  and  also  along  the  main  peripheral  trunks 
and  branches,  has  been  suggested  as  of  benefit.4 

1  Gombault,  in  Monod  and  Reboul's  paper,  Arch.  gen.  de  med.,  1888,  ii,  p.  28; 
Prouff  and  Gombault,  "Un  cas  de  mal.  de  Morvan  suivi  d'autopsie,"  Gaz.  hebdom., 
1889,  pp.  308  and  318;  Joffroy  and  Achard,  "Un  cas  de  mal.  de  Morvan  aved  autopsie," 
Arch,  de  med.  exper.,  1890  (with  7  histologic  cuts). 

2  Sachs  and  Armstrong,  "Morvan's  Disease,"  New  York  Med.  Jour.,  1892,  vol.  Iv, 
p.  482  (with  bibliography). 

3  Pospelow,  in  a  recent  valuable  exhaustive  paper,  "Trpphische  Storungen  der 
Haut  bei  spinaler  Gliomatose  oder  Syringomyelie,"  Archiv  (Pick's  Festschrift,  part  ii), 
1898,  vol.  xliv,  p.  91,  believes,  from  his  study  of  the  subject,  that  scleroderma  is  occa- 
sionally associated  with  the  malady. 

4  Other  valuable  contributions  on  the  disease  are:  Bruhl,  Contribution  a  V etude  de 
la  syringomyelie,  Paris,  1890  (an  exhaustive  monograph  with  bibliography);  Thibie'rge, 
"Les  alterations  cutanees  de  la  syringomyelie,"  Annales,  1890,  p.  799;  Schlesinger, 
Die  Syringomyelie,  Liepzig  and  Vienna,  1895  (a  complete  exposition  with  bibliography). 


CLASS  VI-NEW  GROWTHS 
dCATRIX 

Synonyms.— Scar;  Scar-tissue;  Fr.,  Cicatrice ;Ger.,  Narbe. 

Definition. — Scar,  is  briefly  defined,  a  connective-tissue,  soft  or 
firm,  reddish  or  whitish,  new  formation  replacing  loss  of  substance. 

The  appearances  of  ordinary  scars  are  well  known,  and  have,  to  some 
extent,  been  already  described  in  the  preliminary  chapter  on  lesions  of 
the  skin.  According  to  the  causes  which  have  led  to  its  formation  a 
scar  may  be  linear  or  irregular,  slight  or  pronounced.  At  first  the  color 
is  usually  a  pinkish  or  reddish,  frequently  with  variable  pigmentation, 
later  becoming,  as  a  rule,  white  and  glistening.  The  normal  scar  is  flat, 
on  a  level  with  the  skin  or  somewhat  sunken,  or  simply  replacing  tissue 
loss.  In  others — atrophic  scars — there  is  considerable  depression,  the 
scar-formation  developing  only  sufficiently  to  cover  or  skin  over  the 
preceding  depressed  wound  or  ulcer.  This  is  particularly  noted  in  the 
scars  replacing  substance  loss  in  some  diseases,  as  small-pox,  acne  vario- 
liformis,  etc.  On  the  other  hand,  the  scar-tissue  formation,  instead  of 
ceasing  at  the  point  of  compensatory  replacement,  continues,  and  the 
result  is  a  hypertrophic  scar,  sometimes  projecting  but  slightly,  at  other 
times  becoming  of  considerable  proportions;  it  never  extends  laterally 
beyond  the  original  substance  loss  which  it  replaces — does  not,  in  fact, 
invade  the  surrounding  healthy  tissue,  in  this  respect  differing  essentially 
from  keloid,  to  which  it  bears  resemblance.  Indeed,  ordinarily,  from 
a  contraction  of  the  constituent  tissue  of  the  scar,  the  surrounding  healthy 
parts  are  usually  drawn  upon  somewhat  and  stretched,  so  that  finally  the 
scar  area  is  much  smaller  than  the  area  of  substance  loss  which  it  replaces. 
The  scar  is  thin  or  thick,  depending  chiefly  upon  the  depth  of  the  tissue 
loss.  Damage  to  the  integument  must  involve  at  least  the  upper  part 
of  the  corium;  destruction,  which  extends  only  to  the  corium,  although 
removing  the  whole  epidermis,  including  the  rete,  does  not  leave  a  scar, 
being  replaced;  hence  in  eczema  and  similar  diseases  the  disease  disap- 
pears without  trace.  Destruction  of  the  superficial  part  of  the  papillary 
layer  is  doubtless  often  possible  with  scarcely  perceptible,  certainly 
rarely  permanent,  scarring.  Even  with  destruction  of  the  whole  depth 
of  the  papillary  layer  there  is  usually  but  shallow  scarring,  and  this 
generally  eventually  practically  disappears. 

The  division  of  cicatrices  into  traumatic  scars  and  pathologic  scars 
is  of  scarcely  any  import — the  former,  as  readily  inferred,  due  to  injury, 
the  latter  the  consequence  of  some  morbid  process.  In  the  latter  class 
the  shape  often  gives  a  clue  to  the  causative  malady,  as  in  the  circinate 
or  segmental  scar  grouping  of  the  late  syphilodermata.  The  syphilitic 
scar  is,  moreover,  usually  quite  soft;  on  the  other  hand,  the  cicatricial 

634 


CICATR1X  635 

formation  in  lupus  vulgaris  is  often  thick,  tough,  and  stringy.  It  is 
true  scars  even  from  the  same  disease  will  sometimes  vary  considerably, 
being  soft  and  smooth,  or  hard,  irregular,  or  keloidal  in  appearance.  As 
a  rule,  there  are  no  subjective  symptoms,  but  occasionally  there  may  be 
attacks  of  a  "burning  sensation"  or  of  pain,  probably  from  an  entrapped 
and  compressed  nerve-fiber;  when  about  the  joints,  mobility  may  be 
more  or  less  impaired,  due  to  the  tough  and  unyielding  character  of  the 
formation  and  to  the  resulting  contractions;  these  latter  are  sometimes 
sufficient  to  produce  considerable  distortion. 

Pathology. — As  is  to  be  supposed,  the  principal  and  practically 
entire  constituent  histologically  of  a  scar  is  connective  tissue,  and  this 
is  found  to  consist  of  coarse  interlacing  bundles,  with  absence  of  glandular 
structures,  hair-follicles  and  hairs,  and  furrows.  In  its  earliest  stage 
the  formation  resulting  from  the  granulation  tissue  is  primarily  of 
myxomatous  nature,  rich  in  vascular  supply;  gradually  this  myx- 
omatous  and  myxofibrous  granulation  tissue  becomes  changed  into  a 
purely  fibrous  cicatricial  tissue  (Heitzmann),1  and  the  blood-vessels  be- 
come lessened  in  size  and  may  be  obliterated.  According  to  Heitzmann, 
"the  old  view  that  papillae  are  absent  is  erroneous,  for  these  are  found 
in  almost  every  scar,  though,  as  a  general  rule,  they  are  shallow  and  irreg- 
ular. Even  in  cases  where  the  surface  appears  smooth  to  the  naked 
eye  shallow  papillary  formations  are  found  to  exist."  This  is  contrary 
to  the  opinion  of  Kaposi  and  some  others,  who  state  that  they  are  always 
absent.  The  epithelial  layers  do  not  differ  from  those  of  normal  thin 
portions  of  skin  (Heitzmann). 

Treatment. — Scars  are  permanent  formations,  except  those 
following  extremely  superficial  substance  loss,  which  usually,  after 
some  years,  partly  or  completely  disappear.  There  is,  in  fact,  in  almost 
all  scars  of  small  and  not  too  deep  a  character,  a  tendency  to  become 
slightly  less  conspicuous  as  the  years  go  on.  Exceptionally,  however, 
there  is  an  increased  upward  growth,  which  may  reach  a  marked  char- 
acter, as  in  the  so-called  hypertrophic  scar. 

Treatment  of  these  formations  is  usually  without  much  effect. 
When  small,  numerous,  and  close  together,  massage  and  slightly  or 
moderately  stimulating  applications,  such  as  are  sometimes  of  some 
influence  in  lessening  senile  looseness  of  the  skin,  or  wrinkled  skin,  may, 
if  persevered  in,  bring  about  some  improvement.  Ordinarily,  however, 
unless  the  scar  is  unnecessarily  large  and  unsightly,  nothing  is  to  be 
done;  but  in  the  latter  cases,  when  practicable,  an  operation— excision 
of  the  cicatrix— and  slight  undermining  of  the  skin  of  the  flaps,  permit- 
ting greater  stretching  and  a  closer  adaptation,  will  sometimes  result  in 
replacing  an  unsightly  scar  by  a  linear  or  narrow  cicatricial  band;  or 
the  plan  of  plastic  operation  and  transplantation  can  be  adopted, 
pertrophic  scars  can  also  be  thus  treated,  sometimes,  however,  showing 
a  recurring  tendency,  as  is  exhibited  in  their  closely  analogous  formation 
— keloid.  Vidal  advised  thoroughly  hashing  the  part  with  paralle 
and  cross  incisions.  In  fact,  the  various  plans  for  the  treatment  of  hyper- 
trophic  scars  are  the  same  as  in  keloid  (q.  i.).  This  may  also  be  said 
1  Heitzmann,  Morrow's  System,  vol.  iii  (Dermatology),  p.  47 1- 


636 


NEW  GROWTHS 


the  plans  for  the  treatment  of  painful  scars.  Rontgen-ray  treatment,1 
pushed  to  the  point  of  moderate  reaction,  has  proved  of  some  service  in 
occasional  instances,  more  especially  in  small-pox  and  acne  scars. 

KELOID 

Synonyms. — Cheloid;  Alibert's  keloid;  Kelis;  Kelos;  Fr.,  Cheloide;  Kelolde. 

Definition. — Keloid  is  a  fibrocellular  new  growth  of  the  corium 
appearing  as  one  or  several  variously  sized,  irregularly  shaped,  elevated, 
smooth,  firm,  pinkish,  or  pale-reddish  cicatriform  lesions. 

Symptoms. — The  growth  begins  as  a  small,  hard,  elevated, 
occasionally  somewhat  deeply  imbedded,  pinkish  or  reddish  tubercle 
or  nodule,  increasing  gradually  in  size.  Usually  months  or  years  elapse 
before  the  tumor  reaches  conspicuous  dimensions.  In  fact,  not  infre- 
quently, and  more  especially  in  multiple  cases,  the  growth  increases 
but  slowly,  and,  after  attaining  small  proportions,  sometimes  scarcely 


Fig.  149. — Keloid;  over  sternum. 

greater  than  a  large  pea  or  bean,  remains  stationary  more  or  less  in- 
definitely or  permanently.  These  small  growths  are  of  a  pinkish- 
white  or  reddish  color,  firmly  seated  in  the  corium,  distinctly  elevated, 
and  usually  smooth  and  glossy,  with  a  rounded  or  somewhat  flattened 
top,  and  with  almost  perpendicular  or  slightly  sloping  sides.  It  is  hard, 
and  the  surface  may  show,  on  close  inspection,  one  or  two  capillaries. 
Ordinarily,  however,  and  particularly  in  the  single  growth,  it  gradually 
increases  in  size,  spreading  laterally  by  an  invasion  of  the  surrounding 
skin,  and  frequently  extending  upward  as  well,  sometimes  finally  reach- 
ing considerable  elevation.  Very  commonly  the  border  extends  out- 
ward in  the  shape  of  several  or  more  claw-like  projections;  to  this  feature 
is  owing  the  name  keloid.  The  process  may  go  on  slowly  or  somewhat 
rapidly,  and  in  extreme  cases  a  large  area  may  be  involved  and  enormous 
proportions  reached. 

In  average  cases,  when  developed,  the  growth  is  observed  to  be  one, 
1  Varney,  Internal.  Jour.  Surg.,  Oct.,  1903,  p.  309. 


KELOID 

several,  or  more  inches  in  diameter,  is  sharply  denned,  elevated,  hard, 
rounded  or  oval,  fungoid  or  crab-shaped,  and  firmly  implanted  in  the 
skin,  and  having  a  scar-like  aspect.  It  is  of  a  pinkish,  pearl  white,  or 
reddish  color,  commonly  devoid  of  hair,  with  no  tendency  to  scaliness, 
and  with  usually  several  vessels  coursing  over  it.  In  some  instances 
it  is  elongated  and  ovalish.  The  surface,  which  is  generally  shiny  and 
glistening,  with  the  epidermis  having  a  stretched  and  tense  appearance, 
is  flattened  or  irregularly  rounded,  or  with  slight  nodular  projections; 
often  the  central  part  is  slightly  lower  than  the  main  and  peripheral 
portions.  Sometimes,  instead  of  the  colors  just  named,  it  is  of  slight  or 
distinctly  purplish  hue;  and  occasionally,  in  place  of  the  rounded,  ovalish, 
lozenge-  or  crab-shaped  growth,  the  formation  is  exceedingly  irregular, 
with  prolongations  which  may  extend  to  a  considerable  distance,  and 
from  which  also  may  go  claw-shaped  extensions;  exceptionally  it  is 
streak-  or  band-like.  In  general  the  height  is  about  \  to  \  inch,  although 
in  the  enormous  keloids  it  may  reach  several  inches  or  more,  the  whole 
growth  assuming  large,  tumor-like  proportions. 

While  in  many  instances  there  are  no  subjective  symptoms, — which, 
in  fact,  may  be  said  to  be  the  rule, — in  others  itching  or  tenderness  is 
complained  of,  and  occasionally  it  is  spontaneously  painful.  The  most 
frequent  situation  for  keloid  is  over  the  sternum,  although  other  parts 
of  the  upper  trunk  are  often  the  site  of  the  growth;  it  may  also  appear 
on  the  face,  ears,  neck,  and  extremities.  Commonly  but  one  or  two 
lesions  are  present,  but  there  may  be  several  or  more  up  to  a  considerable 
number,  as  in  the  instances  observed  by  Wilson,1  Schwimmer,2  De 
Amicis,3  Goodhart,4  Smith,5  Hardaway,6  and  others.  In  those  cases 
following  small-pox  the  lesions  are  usually  numerous,  though,  as  a  rule, 
small.  In  some  of  the  instances  of  multiple  keloid  the  growths  are  more 
or  less  symmetrically  arranged,  as  in  the  cases  of  De  Amicis  and  Smith 
just  referred  to,  and  also  in  an  instance  observed  by  Vidal.7 

Etiology.— The  cause  of  keloid  is  not  known.  It  has  been  the 
custom  to  divide  these  growth  into  two  varieties — those  that  arise 
at  the  site  of  burns,  cuts,  acne,  syphilis  scars,  etc.,  designated  scar  keloid, 
cicatricial  keloid,  false  keloid,  spurious  keloid,  secondary  keloid,  and  those 
that  are  believed  to  originate  in  normal  and  uninjured  skin,  as  idiopathic 
keloid,  primary  keloid,  spontaneous  keloid,  true  keloid.  In  later  years 
there  has,  however,  been  less  and  less  tendency  to  make  these  two 

1  E.  Wilson,  Diseases  of  the  Skin,  1867,  p.  381  (39  growths— 30  on  the  breast,  9  on 
back),  cited  by  Schwimmer. 

2  Schwimmer,  "Die  multiple  Keloid,"  Arckiv,  1880,  p.  225  (105  growths  more  or 
less  general,  with  review  of  the  subject  and  principal  references  to  date;  hi 
report  of  this  case  by  Babesiu,  p.  237). 

3  De  Amicis,  "Cheloide  spontan6e  multiple,"   Trans.  Internal.  Dermatolog.  Long., 
Paris,  1889,  p.  93  (318  growths,  symmetrically  on  the  scapulohumeral  regions  anc 

3  C°^G^£rf' London  Clin.  Soc'y  Trans.,  1880,  vol.  xiii,  p.  51  (development  from 
small-pox  scars— numerous  and  quite  pronounced,  with  colored  plate  ot  tace;. 

5  W  G  Smith,  Brit.  Jour.  Derm.,  1889,  p.  157  (numerous,  but  number  not  stated, 
more  or  less  general,  and,  upon  the  whole,  a  decided  tendency  to  symmetry}. 

•  Hardaway,  Manual  of  Skin  Diseases,  second  edit.,  case  illustration  op.  p.  287 
(negro — with  numerous  lesions  on  trunk  and  arms). 

*  Vidal,  Trans.  Internal.  Dermatolog.  Cong.,  Pans,  1889,  p.  103  (12  growths,  sym- 
metric over  shoulders  and  nape  of  the  neck). 


638  NEW  GROWTHS 

divisions,  and  the  doubt  of  a  keloid  arising  without  a  slight  traumatism 
is  pretty  generally  entertained.  When  we  consider  that  the  injury  which 
often  seems  to  start  the  pathologic  process  may  be  extremely  slight, 
such  as  scratching,  insect-bites,  slight  pricks,  and  the  like,  it  can  readily 
be  seen  how  such  could  be  easily  overlooked  or  actually  be  so  insignificant 
as  to  go  unrecognized,  and  thus  give  rise  to  the  assumption  that  the 
keloid  was  spontaneous.  Even  the  more  or  less  general  cases,  such  as 
those  of  De  Amicis,  Schwimmer,  and  others,  which  are  apparently  spon- 
taneous, and  which  are  usually  quoted  as  convincing  examples  of  this 
variety,  could  be  readily  explained  upon  the  assumption  of  such  trifling 
abrasions  or  injuries  as  just  noted.  There  is,  therefore,  in  my  judgment, 
considerable  ground  for  Unna's1  opinion  that  the  most  frequent  site  for 
the  so-called  spontaneous  keloid  growth,  over  the  sternum  and  about 
the  breast,  is  due  to  the  irritation  and  scratching  invoked  by  dermatitis 
seborrhoica,  so  common  in  this  region.  Crocker  suggests  that  possibly 
the  frequency  in  this  region  "may  be  accounted  for,  in  women,  by  the 
pressure  and  friction  of  the  stays,  and,  in  men,  by  the  fact  that  this  part 
is  exposed  to  similar  influences,  as  leaning  against  a  desk,  etc." 

It  would  seem,  in  fact,  that  the  evidence  against  the  possibility, 
certainly  probability,  of  a  keloid  arising  without  some  break  in  the  con- 
tinuity of  the  cutaneous  tissues,  be  it  ever  so  slight  and  superficial,  is 
extremely  remote.2  The  arising  of  the^  growth  in  trifling  or  severe  de- 
structive injuries  and  burns,  usually  after  apparently  normal  scarring 
has  taken  place,  is  common  enough;  and  sometimes  the  increased  growth 
does  not  extend  beyond  the  original  scar,  constituting  the  already  de- 
scribed hypertrophic  scar,  and  which,  for  this  reason,  is  considered  distinct 
from  keloid;  more  commonly,  however,  the  process  extends  and  invades 
the  surrounding  tissue,  representing  the  keloid  growth  proper.  It  is  to 
be  noted,  however,  that  relatively  few  persons  are  susceptible  to  this 
development,  as  it  is  rather  uncommon,  so  that  a  predisposition  of  the 
tissues  is  to  be  accepted.  This  predisposition  is  especially  observed  in 
negroes,  in  some  of  whom,  as  well  as  much  less  frequently  in  the  white 
race,  traumatism,3  even  of  the  slightest  character,  or  scarring  cutaneous 
lesion,  leads  to  keloidal  development.  They  may  arise  from  unsuspected 
causes,  as  in  those  noted  by  Block4  and  Crocker.5  According  to  Taylor 

1  Unna,  Histopathology,  p.  839. 

_2  See  interesting  and  exhaustive  report  on  Goodhart's  case  and  keloid  in  general, 
in  its  various  aspects,  by  committee  (Duckworth,  Liveing,  Crocker,  Hutchinson,  and 
Goodhart),  in  London  Clin.  Soc'y  Trans.,  1880,  vol.  xiii,  p.  54. 

3  Taylor,  Jour.  Cutan.  Dis.,  1893,  p.  114  (Soc'y  Trans.),  exhibited  a  rather  remark- 
able and  extreme  instance  of  a  colored  woman,  aged  twenty-three,  who,  from  the  con- 
stant carrying  of  heavy  loads  of  brush  and  stone,  which  knocked  against  and  lacerated 
the  skin  through  her  thin  clothing,  developed  large  masses  of  keloidal  tissue,  encircling 
the  waist,  and  very  closely  resembling  masses  of  intestines;  for  the  same  reason  large 
keloidal  growths  appeared  on  the  arms,  shoulders,  and  breasts,  and  there  was  also  a 
large  lesion  on  the  ear,  following  ear-piercing. 

4  Block,  Jour.  Cutan.  Dis.,  1895,  p.  107  (with  2  illustrations),  records  an  instance  of 
rather  extensive  typical  keloidal  growths  following  some  months  after  a  burn  pro- 
duced by  a  stroke  of  lightning,  the  burn  having  been  superficial  and  leaving  no  scar. 

6  Crocker,  Diseases  of  the  Skin,  third  edit.,  p.  938,  states  one  of  the  most  extensive 
cases  of  keloid  recorded  followed  a  prolonged  attack  of  prickly  heat  in  a  soldier  in 
India — see  Longmore's  report  of  this  case  (with  2  illustrations),  Trans.  London  Med. 
Chirurg.  Soc'y,  1863,  vol.  xlvi,  p.  105. 


KELOID 


639 


(toe.  «/.),*  Pf  i  per  cent,  of  syphilitic  cicatrices  become  the  seat  of  keloid 
It  is  possible  that  the  nature  or  the  intensity  of  the  irritant  or  character 
of  the  irritation  may  be  a  factor  in  some  instances,  as  suggested  by  Wei- 
ander  S*  case,  in  which,  in  the  same  tattooed  figure,  keloid  developed  only 
where  the  part  was  tattooed  with  red,  and  not  where  it  was  tattooed  with 
blue. 

Sex  and  age  have  but  little  if  any  influence;  for  obvious  reasons 
the  male  sex,  being  more  exposed  to  the  usual  exciting  factor  of  trau- 
matism,  probably  presents  the  greater  number  of  cases,  although  the 
contrary  has  been  stated  by  some  authors.  While  observed  at  any  age 
it  is  most  common  between  the  ages  of  twenty-five  and  fifty.  In  occa- 
sional instances  a  family  and  hereditary  vulnerability  has  been  noted 
(Hebra,  Wilson,  Hutchinson)  .2 

Pathology.— The  formation  is  a  connective-tissue  new  growth, 
as  demonstrated  by  the  histologic  studies  of  Langhans,3  Warren,  Crocker' 
Neumann,  Leloir  and  Vidal,4  Unna,5  Joseph,6  and  others,  although 
beyond  the  fact  of  traumatism  or  cutaneous  lesions  being  usually  the 
initial  factor,  but  little  is  known  of  its  pathology.  The  growth  takes 
its  start  in  the  corium,  and,  as  Warren  and  others  have  shown,  about  the 
vessels,  and  consists  of  dense  bundles  of  fibrous  connective  tissue  run- 
ning parallel  to  the  surface  and  usually  in  the  direction  of  the  long 
axis;  here  and  there,  however,  they  run  vertically.  The  whole  cutis  is 
occupied  by  this  new  formation,  a  layer  of  loose  connective  tissue  which 
is  more  or  less  highly  vascular,  separating  it  from  the  epidermis,  and,  in 
fact,  incompletely  encapsulating  the  growth;  the  tumor  itself  centrally 
is  not,  however,  rich  in  blood-vessels.  Nuclei  and  spindle-shaped  nu- 
cleated bodies  are  noted  in  some  abundance  along  the  vessels  in  the  periph- 
eral part,  although  scanty  in  the  body  of  the  growth.  According  to 
Warren,  the  vessels  are  affected  far  beyond  the  keloid  mass,  an  observa- 
tion confirmed  by  Crocker's  investigations,  and  this  probably  explains  its 
recurrence  after  what  would  appear  to  be  complete  removal  of  the  tumor. 
Kaposi  makes  three  divisions  histologically  of  keloidal  growths — spon- 
taneous keloid,  keloid  originating  in  a  scar,  or  false  keloid,  so  called,  and 
hypertrophic  scar.  In  the  first,  he  states,  the  epidermis,  together  with 
the  papillae,  is  normal;  in  the  third — hypertrophic  scar — the  papillae 
are  gone,  destroyed  by  the  disease  or  traumatism  which  gave  rise  to  the 
scars;  in  the  false  keloid  the  conditions  of  the  other  two  are  usually  com- 
bined. The  absence  of  papillae  (Babesiu)  in  Schwimmer's  case,  pre- 
sumably a  typical  example  of  spontaneous  keloid,  and  the  finding  of 
shallow  papillae  in  hypertrophic  scar  (Heitzmann),  show  that  these  divi- 

1  Welander,  Nordiskt.  med.  Arkiv,  1893,  No.  3 — quoted  by  Unna  (loc.  cit.). 

2  Hutchinson,  Edinburgh  Med.  Jour.,  1897,  vol.  xliii,  p.  5. 

3  Langhans,  Virchow's  Archiv,  1867,  vol.  xl,  p.  330  (case  illustration,  6  histologic 
cuts,  review  of  previous  investigations  and  references). 

4  Leloir  and  Vidal,  Traite  descriptif,  1889-93,  p.  in  (with  re'sume'  of  previous  ob- 
servations and  references). 

5  Unna,  Histo pathology,  p.  839  (with  principal  references). 

6  Joseph,    Archiv,    1899,   vol.   xlix,   p.  277  (with  histologic  cuts— 4  photomicro- 
graphs showing  gross  features,  and  10  colored  cuts  showing  finer  structure;  based  upon 
study  of  hypertrophic  scar,  true  keloid,  and  false  keloid,  with  a  complete  re'sume'  and 
references  of  the  investigations  of  others). 


640  NEW  GROWTHS 

sions  are  to  a  great  extent  purely  arbitrary,  although  Leloir  also  upheld 
Kaposi's  differentiation  between  the  "true"  and  "false"  keloidal  growths. 
Joseph  likewise,  in  his  admirable  paper,  remarks  that  his  own  investiga- 
tions teach  that  there  are  histologic  differences  in  these  several  keloidal 
formations.  According  to  the  aggregate  investigations,  however,  as 
Heidingsfeld's1  recent  findings  also  indicate,  the  histologic  conditions 
in  keloids  originating  apparently  spontaneously,  and  those  starting 
at  the  site  of  a  traumatism  or  a  scar,  except  for  the  difference  naturally 
to  be  found  at  the  seat  of  the  latter,  and  those  naturally  to  be  found  in 
the  early  and  later  stages,  show  no  material  divergence.  The  glandular 
structures,  hair-follicles,  and  muscular  fibers  are  not  found  within  the 
growth,  but  are  pushed  aside,  where  they  are,  according  to  Crocker, 
noted  to  be  copiously  infiltrated  with  round  cells,  obscuring  or  even 
breaking  up  their  structure. 

Diagnosis. — This  is  usually  a  matter  of  no  difficulty.  It  resem- 
bles hypertrophic  scar,  but  this  latter,  which,  although  essentially  keloidal 
in  appearance  and  in  its  upward  growth,  does  not  extend  beyond  the 
limit  of  the  original  scar  or  line  of  injury.  In  many  cases  the  claw-like 
prolongations,  often  present  even  in  the  early  stages,  disclose  the  keloidal 
nature.  As  spontaneous  keloid  and  keloid  originating  in  a  traumatism 
or  scar  are  essentially,  and  probably  wholly,  identical  histologically, 
and  certainly  clinically,  there  is  no  need  of  undertaking  the  impossible 
task  of  differentiating  the  one  from  the  other. 

Prognosis. — With  but  few  exceptions  the  growth  is  persistent, 
and  usually  irresponsive  to  treatment.  In  many  instances,  however, 
after  attaining  an  indefinite  development,  often  quite  small,  it  remains 
stationary.  Hutchinson2  takes  rather  a  favorable  view,  stating  that 
(he  includes  hypertrophic  scars  in  this  generalization) :  "In  a  very  large 
majority  of  cases  keloid  shows  a  tendency,  after  some  years'  duration, 
to  spontaneous  disappearance,"  and  "the  common  cases  in  which,  in 
children,  the  scars  of  burns  are  attacked,  almost  invariably  get  well,  and 
their  duration  is  in  many  instances  only  short."  This  favorable  opinion 
is,  however,  not  generally  shared,  but  from  my  own  observations  I  should 
say  that  in  a  moderate  proportion  of  the  aggregate  cases  gradual  lessening 
of  the  growth  finally  takes  place,  and  in  some  instances  almost  complete 
disappearance.  Those  developing  at  the  site  of  small-pox  scars  seem 
less  hopeless  than  in  other  instances,  as  illustrated  by  Goodhard's  case 
(loc.  cit.),  in  which  involution  was  rapid.  Taylor  (loc.  cit.)  states,  as  to 
keloid  found  in  connection  with  syphilitic  scars,  that  two  forms  are 
found — the  acute  and  succulent  variety,  which  causes  a  good  deal  of 
pain  and  pruritus,  and  which,  after  a  few  months  or  a  year,  undergoes 
involution;  and,  second,  the  chronic  variety,  which  gives  rise  to  little, 
if  any,  discomfort,  but  is  permanent. 

Fortunately,  keloids  are  benign  in  character  and  remain  throughout 
as  such,  although,  like  any  projecting  abnormal  growth,  constant  and 
repeated  irritation  might,  especially  in  those  advancing  in  years,  set  up 

1  Heidingsfeld,  "Keloid:  A  Comparative  Histologic  Study,"  Jour.  Amer.  Med. 
Assoc.,  1909,  vol.  liii,  p.  1277  (with  histologic  cuts,  review,  and  references). 

2  Hutchinson,  Med.  Times  and  Gazette,  1885,  i,  p.  671. 


KELOID  641 

malignant  change.1     Such  an  outcome  is,  however,  to  be  looked  upon  as  . 
exceptional  and  probably  as  purely  accidental. 

Treatment.— The  treatment  of  keloid,  it  must  be  admitted,  is 
rarely  wholly  satisfactory.  In  average  examples  of  keloid,  unless  in  a 
conspicuous  situation,  treatment  is  rarely  sought,  and,  upon  the  whole, 
except  beyond  the  trial  of  mild  applications,  are  just  as  well  let  alone. 
There  is  nothing  to  be  expected  ordinarily  from  any  constitutional  reme- 
dies, although  in  one  instance  J.  William  White2  noted  a  diminution  in  a 
growth  in  a  patient  to  whom  thyroid  extract  was  being  given  in  moderate 
dosage.  Led  by  White's  observation,  I  have  tried  this  remedy  in  several 
cases,  and  in  one,  a  keloid  developing  from  a  large  scar,  there  has  been 
some  material  diminution,  although  whether  the  result  of  such  treatment 
or  a  spontaneous  subsidence  I  am  not  prepared  to  say.  In  addition  to 
this  preparation,  in  multiple  cases  especially,  a  possible  influence  from  the 
continued  and  increasing  administration  of  arsenic  should  be  considered. 

The  palliative  measures  which  have  seemed  to  me,  in  some  instances, 
of  service  in  retarding  the  growing  tendency  and  lessening  the  pain  and 
itching  sometimes  complained  of,  and  occasionally  in  reducing  the  size 
of  the  growth,  consist  of  frictions  with  a  10  to  25  per  cent,  ichthyol  oint- 
ment, the  continuous  application  of  a  plaster-like  ointment  made  up  of 
salicylic  scid,  10-20  grains  (0.65-1.35),  lead  plaster  and  soap  plaster, 
each,  3  drams  (12.),  and  petrolatum  to  make  the  ounce  (32.);  or  this 
same  ointment,  with  the  still  further  addition  of  i  or  2  drams  (4-8.) 
of  ichthyol.  Mercurial  plaster  continuously  applied  is  also  beneficial 
in  some  instances.  The  usefulness  of  these  applications  is  in  accord  with 
Professor  Duhring's3  experience,  who  considers  that  iodin  and  lead  and 
mercurial  plasters  are  the  best  remedies  to  be  used  with  the  view  of  pro- 
moting absorption.  Occasionally,  in  the  painful  growths,  belladonna, 
cocain,  and  menthol  applications  are  necessary,  and  very  exceptionally 
morphin  injections.  Recently  Balzer  and  Mousseaux,4  and  subse- 
quently Pere,5  reported  a  favorable  effect  with  a  plan  of  treatment  pre- 
viously suggested  by  Marie,6  consisting  of  injections  into  the  tumor,  at 
many  points,  of  a  solution  of  creasote  in  olive  oil  of  20  per  cent,  strength, 
until  the  tumor  becomes  pale;  inflammation,  tumefaction,  and  sloughing 
of  a  portion  usually  result,  and,  when  healed  over,  injections  are  again 
made.  Tousey,7  and  subsequently  Newton8  and  Crocker  and  Fernet,9 
have  noted  somewhat  favorable  influence  from  injections  of  thiosinamin, 
Tousey  recording  a  cure,  although  Jackson,10  in  a  number  of  cases,  failed 

1  Anderson,  Lancet,  i,  1888,  p.  1025,  records  an  instance  in  which  malignancy  de- 
veloped in  a  growth  in  the  abdominal  region,  which  was  looked  upon  as  primarily  ol 
keloidal  nature.  . ,  „  .      .  „   jr- 

2  J.  William  White,  "Memorandum  as  to  a  New  Use  of  Thyroid  Extract, 
•oersityMed.  Mag.,  Aug.,  1895  (scar  keloid;  with  illustrations). 

3  Duhring,  Diseases  of  the  Skin,  third  edit.,  p.  461. 

4  Balzer  and  Mousseaux,  Annales,  1898,  p.  1147. 

5  Pere,  Jour.  mal.  cutan.,  1899,  p.  454- 

•  Marie,  Bull,  et  mem.  soc.  med.  des  hop,  1893,  vol.  x,  p.  167 
'Tousey,  "Thiosinamine:  A  Treatment  for  Inoperable  Tumors  and 
Contractures,"  New  York  Med.  Jour.,  1896,  vol.  Ixin,  p.  579- 

:  gSS'£fc£:  SWSrfjftl,  .*».  P.  43-  (case  dea.onsU.Uon). 

10  G.  T.  Jackson,  Diseases  of  the  Skin. 
41 


642  NEW  GROWTHS 

to  get  any  result.  It  is  administered  as  a  10  to  15  per  cent,  solution  in 
equal  parts  of  glycerin  and  water,  or  in  alcohol,  10  to  20  minims  (0.65- 
1.35)  at  an  injection;  or  it  may  be  given,  in  the  dose  of  3  grains  (0.2) 
daily,  by  the  mouth. 

Should  treatment  be  demanded  and  the  milder  measures  fail,  if 
thought  advisable  operative  measures  may  be  cautiously  tried.  Of 
these,  the  safest  and  least  likely  to  be  attended  by  a  possible  result  of 
increased  growth  is  electrolysis;  next  in  order  may  be  mentioned  punc- 
tate scarification,  linear  scarification,  and  last,  excision.  The  method 
by  electrolysis  was  suggested  by  Hardaway,1  although  admitting  that 
it  was  only  occasionally  beneficial;  it  has  also  been  favorably  spoken  of 
by  Brocq2  and  Crocker.3  It  is  seldom  curative,  but,  as  I  can  myself 
confirm,  it  quite  frequently  stays  the  growth  or  reduces  its  size,  and 
lessens  or  abolishes  the  pain  and  itching  sometimes  present.  A  current 
of  about  5  milliamperes  is  used,  the  needle  being  thrust  from  the  edge 
slantingly  toward  the  center,  and  moderately  deeply,  and  at  various 
places,  close  together.  It  may,  especially  in  the  larger  growths,  also  be 
inserted  at  different  points  in  the  top  of  the  tumor.  Crocker  advises 
it  to  be  thrust  from  the  side  of  the  base,  at  close  intervals,  so  as  to  cut  off 
the  blood-supply.  It  is  somewhat  painful,  and,  as  a  rule,  but  a  limited 
amount  can  be  treated  at  the  one  time,  and  usually  several  repetitions 
may  be  necessary  in  the  same  portion.  It  may  be  stated  to  be,  as  also 
Leviseur4  and  Joseph5  found  it,  a  moderately  successful  plan  in  some 
cases,  and  generally  those  where  the  growth  is  small. 

The  next  plan  in  point  of  value,  in  my  experience,  is  that  of  linear 
scarification,  as  originally  suggested,  I  believe,  by  Leloir  and  Vidal,6 
the  parts  being  thoroughly  cross-tracked,  as  in  lupus  vulgaris  (q.  v.}. 
Immediately  afterward  a  mild  antiseptic  dressing  is  applied,  such  as  a 
wet  or  dry  boric  acid  dressing,  followed  the  next  day  and  subsequently 
by  the  continuous  application  of  one  of  the  plaster-like  applications 
already  named,  and  compression  made  by  a  pad  and  bandage.  Lawrence7 
was  successful  in  a  case  with  this  plan,  combined  with  persistent,  moder- 
ate pressure  secured  by  placing  over  the  minced  growth  large  rubber 
tubing  and  binding  firmly  down  by  adhesive  strips. 

Excision  is  the  most  common  surgical  method,  but  it  is  rarely  per- 
manently successful,  recurrences  usually  taking  place.  It  is  probable 
that  if  the  line  of  excision  were  extended  far  beyond  the  apparent 
borders  of  the  tumor,  results  would  be  more  satisfactory,  as  in  this 
way  the  blood-vessels  in  the  immediately  adjacent  seemingly  healthy 
tissue,  which,  as  remarked,  Warren  and  Crocker  have  shown  to  be  in- 
volved, would  be  removed,  and  no  focus  for  new  development  left. 

1  Hardaway,  Jour.  Cutan.  Dis.,  1889,  p.  112. 

2  Brocq,  Traitement  des  maladies  de  la  peau,  second  edit.,  p.  373. 

3  Crocker,  Brit.  Jour.  Derm.,  1899,  pp.  297  and  431  (case  demonstration). 

4  Leviseur,  "Cutaneous  Electrolysis,"  New   York  Med.  Record,  1899,  vol.  Ivi,  p. 
262. 

5  Joseph,  loc.  cit. 

6  Leloir  and  Vidal,  "De  la  ch61olde,"  etc.,  Annales,  1890,  p.  193  (an  exhaustive 
exposition  of  the  subject  of  keloidal  growths,  with  treatment  by  Vidal;  with  numeruos 
references) . 

7  Lawrence,  Brit.  Med.  Jour.,  1898,  ii,  p.  151. 


DERMATITIS  PAPILLARIS  CAPILLITII  643 

While  these  various  operative  methods  prove  useful  in  some  instances 
A  is  to  be  borne  m  mind  that  not  infrequently  renewed  activity  in  the 
progress  of  the  growth  is  noted  to  follow,  although  I  have  not  ob served 
this  in  the  cases  in  which  electrolysis  was  employed.  This  latter  method 

seTed  to  me  th^  'f  ^  *•  "*  COmpOUnd  ^  ^^ 
-emed  to  me  the  most  conservative  plan,  although  onlv  occasionally 

more  than  moderately  successful.     Recently  favorable  influence  has  fot 
lowed  the  use  of  the  *-rays. 

DERMATITIS  PAPILLARIS  CAPILLITH1 

Synonyms.— Acne  keloid  or  acne  cheloidienne  (Bazin);  Sycosis  framboesiformis 
(Hebra);  Dermatitis  papillomatosa  capillitii;  Folliculitis  nuch*  sclerotisans^EhrmZ)! 

Definition.— A  frambesiform  disease  of  the  nucha,  and  usually 
extending  upward  toward  the  occiput,  presenting  mixed  sycosifonn 
nodular,  and  keloidal  aspects. 

Symptoms.— The  disease  begins  at  the  lower  occipital  region,  or 
just  at  the  border  of  the  hair,  with  the  appearance  of  a  number  of  isolated 
cutaneous  tubercles  or  sycosiform  or  acne-like  lesions,  pin-head  to  small 
pea  in  size,  but  which  grow  larger,  and,  with  the  accession  of  new  lesions, 
soon  become  closely  grouped  or  bunched.  They  are  then  frequently 
pea-  to  small  cherry-sized,  red,  pale  red,  or  whitish  in  color,  and  some- 
times contain  pus;  or  pus  may  form  beneath  the  mass  here  and  there, 
and  tend  to  undermine;  the  nodule,  upon  incision,  emits  a  creaking  sound. 
In  some  instances  the  surface  becomes  raw,  and  then  may  later  present 
a  papillomatous  granulation  tissue  growth,  the  whole  being  occasionally 
covered  with  crusts,  and  secreting  a  gummy  or  seropurulent  fluid,  and 
emitting  an  offensive  odor. 

There  is  more  or  less  scar-tissue  with  hair  loss,  and  here  and  there  are 
seen  small  projecting  tufts  of  hair;  some  of  the  hairs  are  atrophied  and 
crooked.  In  some  or  many  of  the  lesions,  or  at  many  points  in  the  dis- 
ease mass,  keloidal  changes  are  noted;  and  in  the  milder  cases  the  erup- 

1  Literature:  Kaposi,  Pathologic  und  Therapie  der  Hautkrankheiten,  Wien,  1880, 
and  subsequent  editions;  Morrant  Baker,  Trans.  London  Path.  Soc'y,  1882,  vol.  xxxiii, 
p.  367  (with  colored  plate);  Williams,  ibid.,  1884,  vol.  xxxv,  p.  397  (with  histologic 
plate);  Hyde  (2  cases),  Jour.  Cutan.  Dis.,  1883,  pp.  33  and  78;  Marcacci,  Giorn.  ital., 
1887,  p.  295;  Eve,  Illus.  M'ed.  News,  London,  June  8,  1889  (with  colored  plate) ;  Du- 
breuilh  (histology),  Annales  de  la  Polidinique  de  Bordeaux,  1889,  p.  107;  Heitzmann, 
Jour.  Cutan.  Dis.,  1889,  p.  450;  Crocker,  Diseases  of  Skin,  second  edit.,  p.  624;  Leloir 
et  Vidal,  Traite  Descriptif;  Melle,  Giorn.  ital.,  1891,  p.  181;  Mibelli,  ibid.,  1893,  p.  469; 
Ullmann,  Archiv,  1893,  vol.  xxv,  p.  727;  Ehrmann,  ibid.,  1895,  vol.  xxxii,  p.  323; 
Forges  (with  4  colored  histologic  cuts  and  bibliography  as  to  histology),  ibid.,  1899, 
vol.  Hi,  p.  323;  Stelwagon  (brief  report  of  case  with  photo.),  Jour.  Cutan.  Dis.,  1893, 
p.  230;  Secchi,  Monatshefte,  1896,  vol.  xxiii,  Nov.  15;  Ledermann  (histology),  Ver- 
handlungen  der  Duetschen  Gesellschaft,  V.  Cong.,  1896,  p.  443;  Van  Harlingen,  Trans. 
College  of  Physicians,  Phila.,  1897,  p.  208;  Dyer,  Amer.  Jour.  Derm,  and  Gen.-Urin. 
Dis.,  July,  1899;  Tryb,  "Ueber  Nachenkeloid  or  Dermatitis  nuchae  sclerotisans," 
Dermatolog.  Wochenschr.,  Dec.  7,  1912,  Iv,  p.  1491  (5  cases,  review  and  col'd  histolog. 
cuts;  believes  it  to  be  a  folliculitis  followed  with  an  associated  perifolliculitis  and  keloi- 
dal tissue  formation);  Vorner,  Archiv,  1912,  cxi,  No.  3,  reports  a  case  with  histology 
(reviews  the  literature  of  the  subject;  he  regards  the  process  as  a  local  injury  leading 
to  "hemorrhagic  abscess"  in  the  cutis;  that  there  is  no  genuine  keloid  or  fibroma  but 
rather  a  simple  cicatricial  hypertrophy  of  an  inflammatory  nature;  he  found  in  many 
of  the  giant-cells  in  the  tissue  acid-fast  rods  resembling  tubercle  bacilli,  but  in  smears, 
however,  he  was  only  able  to  demonstrate  cocci). 


644 


NEW  GROWTHS 


tion  presents  a  decidedly  keloidal  and  tubercular,  acne-like  appearance. 
It  is  this  keloidal  tendency  which  distinguishes  it  from  an  ordinary  syco- 
siform  inflammation.  The  disease  develops  slowly,  and  in  some  cases, 
after  several  months  or  years,  halts,  and  remains  apparently  stationary. 
Rarely  retrogressive  changes  are  observed  in  some  parts.  On  the  other 
hand,  the  malady  may  progress  and  reach  considerable  dimensions,  both 
in  area,  extending  up  to  the  vertex,  and  forming  somewhat  massive  pro- 
jections. The  cases  coming  under  my  observation  were  moderately 
developed,  constituting  the  average  case  met  with. 

Etiology  and  Pathology.— The  cause  of  the  disease  is  not 
known.  It  is  infrequent.  It  may  occur  in  either  sex,  but  is  much 
more  common  in  males,  and  is  most  frequently  seen  during  early  adult 
and  middle  age. 

There  is  some  difference  of  opinion  among  investigators  as  to  whether 
the  process  begins  about  the  follicles  (Leloir  and  Vidal,  Dubreuilh, 

Unna,  Ehrmann)  or  as 
an  inflammatory  proc- 
ess in  the  cutis  (Kaposi, 
Ledermann) .  Clinically 
its  origin  seems  certainly 
connected  with  the  fol- 
licles, and  it  appears  as 
if  due  to  some  infection. 
Besnier  and  Doyon  con- 
sider it  a  papillomatous 
growth  developing  from 


acne  lesions,  etc.,  and 
traumatism.  The  forma- 
tions in  the  earlier  stages 
are  of  .  the  nature  of 
highly  vascular  papillary 
growths,  with  structure 
somewhat  similar  to 
granulation  tissue;  later 
they  undergo  sclerosis, 
with  atrophy  of  the 
hair-follicles.  Round- 
cell  infiltration  is  noted 
in  the  corium;  hyper- 
trophy of  the  epidermis  and  enlargement  of  the  papilla:  and  blood-vessels 
are  also  observed.  Hyalin  corpuscles  are  seen  (Mantegazza,  Secchi), 
which  the  latter  observer  considers  to  be  blastomyces.  Ehrmann  found 
staphylococci.  Vorner  found  in  the  tissues  acid-fast  rods  resembling 
tubercle  bacilli.  In  my  cases  the  sclerotic  or  keloidal  element  was 
quite  a  marked  feature;  all  were  men— the  majority  being  negroes; 
2  of  the  negroes  were  brothers. 

Diagnosis.— Its  features  are  so  peculiar  that  it  can  scarcely  be 
confounded  with  any  other  disease.  In  its  beginning  sycosis  and  acne 
nodules  are  suggested. 


Fig.  150. — Dermatitis  papillaris  capillitii;  man  aged 
thirty-nine,  of  five  years' duration;  some  slight  under- 
mining, keloidal  aspect  predominant. 


MOLLUSCUM  CONTAGIOSUM  645 

Prognosis  and  Treatment.— No  tendency  to  spontaneous  cure 
is  noted,  but  in  some  instances,  as  already  remarked,  the  process  halts 
after  a  variable  time;  it  may,  however,  be  progressive.  The  general 
health  is  not  influenced  by  it.  It  is  extremely  rebellious  to  treatment, 
commonly  resisting  all  measures;  moderate  improvement  is,  however, 
not  unusual. 

The  treatment  used  is  similar  to  that  employed  in  sycosis.  The 
hairs  are  to  be  extracted,  the  parts  frequently  cleansed,  and  any  pustules 
or  pus-accumulation  evacuated.  A  sulphur  and  ichthyol  ointment  is 
the  most  valuable:  i  to  2  drams  (4--8.)  of  the  latter  to  an  ounce  (32.) 
of  sulphur  ointment  full  strength  or  weakened,  according  to  inflammatory 
conditions.  The  object  is  not  irritation,  but  mild  antiseptic  stimulation. 
Resorcin  and  boric  acid  lotions  are  also  at  times  of  some  service.  Of  the 
operative  methods  commended  as  of  some  benefit  may  be  mentioned 
electrolysis  (Ehrmann),  linear  scarification  (Hallopeau  and  Leredde), 
and  excision  (Ledermann).  Van  Harlingen  states  that  he  has  cured 
several  cases  in  the  incipient  stage  by  thorough  destruction  by  the  electro- 
cautery;  in  one  case  in  which  complete  excision  had  been  made  by  a 
surgeon  there  was  a  return  of  the  growth.  Judging  from  its  favorable 
influence  in  sycosis,  the  #-ray  treatment  should  be  of  value  in  this  dis- 
ease. 

MOLLUSCUM  CONTAGIOSUM 

Synonyms. — Molluscum  epitheliale;  Molluscum  sebaceum;  Epithelioma  mollus- 
cum;  Epithelioma  contagiosum;  Acn6  varioliforme  (Bazin). 

Definition.— A  contagious  disease  of  the  skin  characterized  by 
pin-head-  to  pea-sized  or  larger,  rounded,  semiglobular  or  slightly  flat- 
tened, pearl-like  elevations,  of  whitish  or  pinkish  color,  and  with  minute 
central  depression. 

Symptoms.— The  lesions  begin  as  pin-head-sized,  waxy-looking, 
rounded  or  acuminated  elevations,  which  often,  in  the  very  beginning, 
bear  some  resemblance  to  minute  warts.  They  gradually  attain  the 
size  of  pin-heads  and  small  and  large  peas,  and  display,  sometimes 
quite  perceptibly,  in  others  visible  only  on  close  inspection,  a  depression 
or  umbilication,  in  the  center  of  which  is  noted  a  darkish  point  repre- 
senting the  mouth  of  the  follicle.  In  the  beginning  they  are  usually 
rounded  or  semiglobular;  as  they  increase  in  size  the  top  becomes  some- 
what flattened.  They  have  a  broad  base,  but  occasionally  in  some  cases 
in  a  few  lesions,  after  some  duration,  a  tendency  to  become  pedunculated 
is  noted.  They  may  be  either  whitish,  almost  skin  colored  or  pinkish, 
and  often  look  not  unlike  drops  of  wax  or  small  pearl  buttons.  Some- 
times they  have  a  slight  resemblance  to  the  prepustular  lesion  of  variola; 
hence  the  French  term,  acne  varioliforme  (Bazin).  While  firm  at  first 
and  sometimes  continuing  so,  they  usually,  as  they  increase  in  size,  tend 
to  soften  slightly,  and  if  squeezed  emit  from  the  central  orifice  a  semi- 
solid  cheesy-looking  substance.  Sometimes  this  latter,  slightly  « 
moderately  hardened,  projects  a  line  or  two  out  of  the  opening  Some 
lesions,  after  weeks  or  months,  having  attained  the  size  of  a  moderately 
large  pea  or  small  cherry,  redden,  become  inflamed,  tend  to  break  down 


646  HEW  GROWTHS 

and  suppurate,  and  then  heal  up  and  disappear,  usually  without  trace. 
As  a  rule,  however,  they  are  sluggish  in  character  and  unaccompanied  by 
any  active  signs  of  inflammation.  Not  infrequently,  indeed,  the  lesions 
disappear  slowly  by  absorption,  and  possibly  partly  by  desiccation, 
without  apparent  previous  softening.  The  course  of  a  single  lesion 
varies,  sometimes  disappearing  spontaneously  in  several  weeks  or  a  few 
months,  or  lasting  one  or  two  years.  As  a  rule,  while  the  older  ones 
are  gradually  disappearing  new  growths  may  present,  so  that,  if  at 
all  numerous,  all  sizes  and  various  stages  are  commonly  to  be  seen. 
Inmost  cases  10  or  12  lesions  are  present,  although  occasionally  they 
may  be  quite  numerous.1  They  are  usually  discrete,  but  exceptionally 
2  or  3  may  be  bunched  together,2  and  in  rare  instances  are  somewhat 
closely  packed,  forming  almost  a  solid  mass.3  Their  most  common 


Fig  151. — Molluscum  contagiosum. 

seat  is  the  face,  but  not  infrequently,  along  with  those  on  the  face  or 
independently,  the  growth  occurs  on  other  parts,4  more  especially  such 

1  Frick,  Jour.  Amer.  Med.  Assoc.,  1899,  i,  p.  536,  reported  a  case,  a  male  adult, 
with  over  400  lesions,  chiefly  about  face,  neck,  forehead,  and  scalp;  and  also  cites  other 
instances,  with  references.    In  a  recent  institution  (for  young  men)  epidemic  observed 
by  Hartzell,  not  only  were  the  lesions  numerous,  but  almost  all  small,  and  in  all  cases 
on  the  trunk  and  arms;  three  cases  from  the  same  epidemic  came  under  my  care,  each 
with  about  100  lesions,  also  all  small,  and  all  on  trunk. 

2  Crocker,  Diseases  of  the  Skin,  third  edit.,  p.  730,  describes  a  case  in  which  there 
were  compound  tumors  with  2  or  3  openings  or  plugs. 

3  Hallopeau,  Jour.  mal.  cutan.,  1899,  p.  405,  records  a  remarkable  case  in  a  woman 
presenting  numerous  and  variously  situated  lesions,  in  some  places  closely  crowded 
together  and  resembling  bunches  of  grapes. 

4  In  Fordyce's  case  (Jour.  Cutan.  Dis.,  1892,  pp.  367  and  372)  the  lesions  were  on 
inner  aspects  of  both  thighs,  just  above  the  knees;  Pringle's  (Brit.  Jour.  Derm.,  1898, 
p.  198),  on  the  scrotum,  perineum,  and  contiguous  parts,  and  in  another  (ibid.,  p.  418) 
on  the  scalp;  Abraham's  (ibid.,  1899,  p.  474,  in  addition  to  a  large  number  of  wide  dis- 
tribution on  the  cutaneous  surface,  the  mouth  was  also  the  seat  of  lesions,  closely 
crowded  together,  resembling  plaques  of  leukoplakia,  and  there  were  also  massed 
lesions  on  the  penis;  Allen's  (Jour.  Cutan.  Dis.,  1886,  p.  238),  some  lesions  on  the  ver- 
milion border  of  the  lips;   Sprecher  (Dermatol.  Centrdbl.,  Sept.,  1899,  p.  354),  on  the 
dorsum  of  one  foot. 


MOLLUSCUM  CONTAGIOSUM  647 

as  the  neck,  breast,  arms,  scalp,  and  genitalia.  In  the  last  region  they 
seem  more  common  on  the  Continent  of  Europe  than  in  England  or  in 
our  own  country.  In  rare  instances  the  eruption  has  been  more  or  less 
generalized,  sparsely  scattered,  or  numerous.  On  the  face,  the  most 
common  situation  is  about  or  on  the  eyelids,  and  even  on  the  border, 
in  this  latter  situation  sometimes  exciting  considerable  irritation,  and 
exceptionally  a  conjunctivitis  (Steffen,  Muetze).1  While  in  almost  all 
cases  the  size  of  the  lesion  may  vary  between  pin-point  and  an  average 
pea  in  size,  occasionally  they  are  somewhat  larger,  and  very  exceptionally 
they  may  attain  much  greater  dimensions,  rarely,  however,  the  extreme 
size  (molluscum  giganteum),  of  one  to  several  inches  in  diameter,  as 
in  cases  described  by  W.  Smith,2  Laache,3  Kaposi,4  and  a  few  others. 

There  are  no  subjective  symptoms,  the  lesions  appearing  and  con- 
tinuing throughout  their  course,  with  apparently  no  pain,  itching,  or 
burning.  Those  which  become  inflammatory  accidentally  or  spon- 
taneously by  tendency  to  break  down  may  be  slightly  sore  and  painful. 
There  are  no  constitutional  symptoms. 

Ktiology. — The  disease  is  contagious.  Since  the  time  of  Bate- 
man,  who  first  clearly  described  the  malady,  there  has  been  much  dis- 
pute on  this  point,  but  in  England,5  where  it  is  apparently  more  common 
than  elsewhere,  its  contagiousness  has  been  generally  recognized;  and 
this  is  supported  in  this  country  by  the  overwhelming  evidence  presented 
by  Fox,  Allen,  Mittendorf ,  Jackson,  Graham,  Knowles,  myself,  and  others.6 
Wigglesworth,  Allen,  and  Brocq  were  subjects  of  accidental  inoculation, 
Retzius,  Peterson,  Vidal,  Stanziale,  Pick,  Haab,  and  Nobel  succeeded 
in  experimentally  producing  the  disease;  there  are,  it  is  true,  many 

1  Steffen,   Klin.  Monatsblatter  f.  Augenheilkunde,  1895,  p.  457,  and  1896,  p.  66; 
Muetze,  "Ueber  Molluscum  Contagiosum  der  Lider,"  Archiv  f.  Augenheilkunde,  1896, 
vol.  xxxiii,  p.  302  (with  review  of  the  subject,  histology,  with  2  cuts  and  literature 
references). 

2  Walter  Smith,  Dublin  Jour.  Med.  Sci.,  Nov.,  1878  (numerous  and  general,  reach- 
ing the  extreme  of  three  inches  in  diameter). 

3  Laache  (Nicolaysen's  case),   Nordiskt  Medicinskt  Arkiv,  1882,  vol.  xiv,  p.  21 — 
abs.  in  Jour.  Cutan.  Dis.,  1885,  p.  64  (tumor  the  size  of  two  fists). 

4  Kaposi,  Wien.  klin.  Wochenschr.,  1896,  No.  26,  and  Archiv,  1897,  vol.  xxxviii, 
p.  144. 

5  Duckworth,  St.  Bartholomew's  Hasp.  Reports,  vols.  iv  and  vii,  reviews  literature 
to  1872. 

6Stelwagon,  "The  Question  of  Contagiousness  of  Molluscum  Contagiosum, 
Jour.  Cutan.  Dis.,  1895,  p.  50.  This  paper  reviews  the  literature,  with  references, 
bearing  upon  this  point  (numerous  examples  of  contagion  in  families,  schools,  asylums, 
of  accidental  inoculation  and  successful  experimental  inoculation),  citing,  among 
other  English  observers,  cases  observed  by  Liveing,  Morrant  Baker,  W.  Smith,  and 
Mackenzie;  and  among  other  foreign  observers,  Caillaut,  Havenith,  Ebert,  Tommasoh. 

Knowles,  "Report  of  an  Institutional  Epidemic  of  Fifty-nine  Cases,"  Jour.  Amer. 
Med.  Assoc.,  1909,  vol.  liii,  p.  671  (with  brief  review  to  date,  and  references);  "Mol- 
luscum Contagiosum:  Report  of  Ten  Family  Epidemics  and  Forty-one  Cases  in  Chil- 
dren," New  York  Med.  Jour.,  May,  14,  1910  (with  reference). 

Hartzell,  "An  Epidemic  of  Epithelioma  (Molluscum)  Contagiosum,  with  some 
New  Observations  Concerning  the  Molluscum  Bodies,"  New  York  Med.  Record,  June 
22,  1912  (with  histologic  illustrations;  epidemic  in  a  large  institution  for  young  men, 
about  5  per  cent,  having  the  disease;  the  growths  were  small,  but  numerous,  only  on 
the  trunk  and  arms).  . 

There  is  recorded  by  Paton  in  the  Westminster  Hospital  Reports,  1908-09,  vol.  xvi, 
p.  n,  London,  an  observation  of  7  cases  in  which  operation  wounds  were  infected  with 
molluscum  contagiosum;  three  small  lesions  were  found  on  the  right  hand  of  the  oper- 
ating surgeon. 


648 


NEW  GROWTHS 


recorded  failures  at  experimental  inoculation,  including  my  own,  but 
these  have  no  weight  in  the  face  of  successful  attempts,  even  though 
scanty  in  number.  The  incubation  period,  as  proved  in  the  above 
cases,  and  also  by  clinical  observation,  is  long— from  several  weeks  to  a 
few  months.  Hutchinson,  Crocker,  and  Malcolm  Morris1  have  noted 
that  Turkish  baths  are  a  source  of  contagion — the  first  stating  that  most 
of  his  male  patients  were  frequenters  of  these  baths;  in  such  instances, 
doubtless,  the  media  of  contagion  are  the  towels  and  gloves. 

The  disease  is  seen  in  both  sexes  and  at  all  ages,  but  it  is  by  far  most 
common  in  children  and  among  the  poor,  especially,  as  in  most  of  my 
own  cases,  in  asylums  and  institutions.  Several  observers  have  noted 


Fig.  152. — Molluscum  contagiosum;  section  through  a  small  lesion,  showing  its 
epithelial  lobular  formation,  with  the  connective-tissue  septa  separating  the  lower  part 
of  the  lobules;  the  plug  in  the  central  upper  part  consists  of  a  crowded  accumulation  of 
the  so-called  "molluscum  bodies"  (courtesy  of  Dr.  H.  G.  Piffard). 

the  occasional  coexistence  of  warts  and  molluscum  contagiosum,  but 
this  does  not  seem  to  me  unusual,  inasmuch  as  warts  are  quite  common 
among  the  poorer  children. 

Pathology. — The  growth  was  originally  considered,  by  several 
prominent  observers,  to  have  its  seat  in  the  sebaceous  gland  (Tilbury 
Fox,  Kaposi,  Leloir,  Vidal,  and  a  few  others),  and  the  hasty  examina- 
tion of  a  tumor  is  very  suggestive  of  a  pathologically  changed,  lobu- 
lated  glandular  structure;  but  later  and  repeated  studies,  led  by 
Virchow  and  confirmed  by  others  (among  whom  Boeck,  Simon,  Robin- 
son, Crocker,  Sangster,  Thin,  Neisser,  Piffard,  Fordyce,  Gilchrist, 

1  Malcolm  Morris,  Diseases  of  the  Skin.  Graham  Little,  Brit.  Jour.  Derm.,  1910, 
p.  181  (reports  2  cases  following  Turkish  baths;  discusses  the  question  of  frequency 
and  infrequency  in  the  cities  of  Great  Britain  and  Ireland). 


MOLLUSCUM  CONTAGIOSUM 


649 


Kuznitzky),  have  demonstrated  that  it  takes  its  origin  from  the  epithe- 
lium,— in  fact  that  it  is  in  reality  a  hyperplasia  of  the  rete  or  a  benign 
epithelioma, — and  with  no  connection  with  the  sebaceous  gland. 
Opinions  differ  somewhat  as  to  whether  it  takes  its  start  from  the  epi- 
thelial lining  of  the  hair-follicle  or  in  the  rete  layer  proper. 

A  vertical  section  through  a  molluscum  growth  shows  it  to  be  made 
up  of  several  lobules,  due  to  the  downgrowth  of  the  rete,  which  con- 
verge toward  the  apex  and  broaden  toward  the  base,  the  fine  connective- 
tissue  septa,  formed  by  the  compressed  papillae,  which  divide  them, 
appearing  continuous,  and  extending  about  half-way  up,  as  is  clearly 
shown  in  the  cut.  The  upper  central  part,  approaching  the  outlet, 


FIG  IK  —Molluscum  contagiosum;  transverse  section,  showing  the  lobules  the 
septa,  and  the  various  stages  of  the  cell  changes;  in  the  central  part  the  so-called 
'  molluscum  bodies  "  or  "  molluscum  corpuscles  "  (courtesy  of  Dr.  J.  A.  F« 

where  they  have  fused  or  converged  together,  is  composed  of  a  mass  of 
changed  epithelial  cells,  opaque  and  whitish  in  color,  rounded  or  ovoid, 
somewhat  sharply  defined,  fatty-looking  bodies,  constituting  the  so- 
called  molluscum  bodies  first  described  by  Patterson.     The  epithelial 
cells  in  the  lower  part  of  the  lobules  are  at  first  practically  unaltered, 
but  which,  as  they  are  crowded  up  by  the  underlying  proliferation 
undergo  degeneration  or  some  peculiar  change,  become  enlarged,  and 
result  in  the  peculiar  formation  referred  to;  others  again,  instead  of  the 
changes  briefly  referred  to,  harden  and  are  more  or  less  cornified 
whole  molluscum  lesion  is  inclosed  in  a  fibrous  capsule,  the  base  resting 
on  the  corium.     The  first  change  noted  in  the  transformation  of  the  ep 
thelial  cell  is  the  appearance  within  of  small,  clear,  or  hyaline  bod 


650 


NEW  GROWTHS 


as  a  rule  close  to  the  nucleus  of  the  cells,  usually  oval  in  shape,  with 
tapering  or  pointed  ends,  and  containing  a  nucleus— molluscum  bodies;1 
further  growth  ensues,  and  finally,  in  some,  a  granular-looking  mass 
results  with  a  waxy-looking  translucent  peripheral  zone;  or,  in  conse- 
quence' probably  of  further  growth,  degeneration  ensues  and  the  cell- 
wall  and  the  remaining  protoplasm  cornify  and  grow  opaque,  and  the 
contents  are  rendered  less  recognizable.  The  term  "molluscum  body" 
or  "molluscum  corpuscle"  has  been  applied  both  to  the  bodies  forming 
within  the  cell  and  to  the  completely  crowded  cell,  although  its  proper 
or  more  exact  application  should  be,  as  Macallum  suggests,  only  to  the 
former,  the  cell  containing  them  to  be  more  accurately  named  the  "mol- 
luscum cell." 

Although  admittedly  contagious,  what  starts  the  pathologic  process 
remains  yet  a  mystery.  The  readiest  and  most  natural  explanation, 
in  the  light  of  other  bacteriologic  studies,  is  to  be  found  in  the  assumption 
of  a  parasitic  element,  which,  I  believe,  persistent  search  will  yet  find. 
While  it  can  probably  be  said  that  the  psorosperm  theory,  so  promis- 
ingly lighted  by  the  writings  of  Darier,  Wickham,  and  others,  has  been 
for  some  tune  wholly  abandoned,  Neisser,2  who  has  contributed  much 
time  to  the  investigation  of  this  malady,  together  with  a  few  others 
(more  especially  Bellinger,  Mansiiroff ,  Touton,  Winogradow,  Lindstrom), 
was  reluctant  to  give  up  the  belief  in  the  parasitic  character  (coccidia) 
of  the  molluscum  corpuscles  or  bodies.  In  this  connection  it  is  inter- 
esting to  recall  that  Virchow  directed  attention  to  their  resemblance  to 
the  gregarinae  of  rabbits  some  years  ago.  The  parasitic  character  of  the 
molluscum  bodies  can  scarcely  be  accepted,  however,  in  view  of  the 
investigations  and  observations  of  Boeck,  Caspary,  Piffard,  Crocker, 
Torok  and  Tommasoli,  Kromayer,  Unna,  Audry,  Macallum,  Fordyce, 
Lubarsch,  and  others,  which,  for  the  most  part,  indicate  that  these  in- 
tracellular  masses  are  a  peculiar  form  of  cell  degeneration,  of  a  colloid, 
hyaline,  or  protoplasmic  character.  C.  J.  White,3  in  a  recent  valuable 
study,  concluded  that  nobody  has  demonstrated,  up  to  this  time,  any 
parasitic  body  in  the  growth,  and  that  the  change  is  not  a  colloid  or 
hyaline  degeneration,  but  rather  an  extraordinary  metamorphosis  of 
rete  cells  into  keratin. 

1  Hartzell,  (loc.  cit.),  in  addition  to  the  common  findings,  found  in  the  area  occupied 
by  the  molluscum  bodies  a  few  small  cells,  which  he  believes  has  not  been  described 
before;  consisting  of  a  perfectly  oval  body  with  distinct  double  wall,  entirely  filled  with 
a  mass  of  fine  fibrils  in  which  no  nucleus  could  be  discovered;  the  cells  of  this  variety 
were  so  deeply  stained  that  it  was  extremely  difficult  to  make  out  details. 

2  Neisser  (Ueber  das  Epithelioma  (sive  Molluscum)  Contagiosum) ,  Archiv,  1888,  p. 
553  (with  ii  cuts);  an  elaborate  and  exhaustive  paper;  the  writer  deals  with  the  dis- 
ease in  all  its  aspects,  and  gives  a  complete  bibliography;  also  (Ueber  Molluscum  Con- 
tagiosum), Verhandl.  der  IV  Deutsch.  dermatolog.  Cong,  (with  a  number  of  excellent 
cuts).     These  two  papers  give  a  review  of  the  contributions  and  work  of  others  to  date. 
Other  important  literature  of  recent  date  bearing  upon  pathology  and  histology: 
Torok,  Monatshefte,   1892,   vol.  xv,  p.   109   (with  references);    Lubarsch-Ostertag's 
Ergebnisse  der  allgemeinen  Pathologic,  1895,  abt.  ii,  p.  398  (with  references);  Macallum, 
Jour.  Cutan.  Dis.,  1892,  p.  93  (with  good  cuts);  Beck  (Ehrmann's  laboratory),  Archiv, 
1896,  Bd.  xxxvii,  p.  167. 

3  Chas.  J.  White  and  W.  H.  Robey,  Jr.,  "Molluscum  Contagiosum,"  Jour.  Med. 
Research,  April,  1902,  p.  255  (a  personal  study,  general  review,  and  resume,  with  histo- 
logic  cuts,  and  full  bibliography). 


MOLLUSC  'UM  CONTAGIOSUM  651 

As  bearing  upon  the  pathogenic  factor  'is  the  observation  by  Bol- 
linger1  and  others,  who  have  remarked  upon  the  resemblance  of  mollus- 
cum  tumors  to  the  growths  found  on  the  beaks  and  eyelids  of  fowls, 
especially  chickens  and  pigeons,  and  with  which  the  observations  of 
Salzer,2  Colcott  Fox,3  and  Shattock4  appear  to  prove  their  identity. 
Recently  Salzer  reported  a  suggestive,  but  not  unquestionable,  case 
in  which  the  patient  had  shown  the  disease  about  the  time  some  pet 
pigeons,  which  she  was  in  the  habit  of  feeding  out  of  her  hand,  had 
developed  growths  on  the  beak.  Colcott  Fox  met  with  the  growths 
on  the  legs,  feet,  and  head  of  a  white  Wyandotte  chicken,  and  micro- 
scopic examination  proved  them  typical  of  molluscum  contagiosum. 
Shattock  observed  similar  growths  in  two  mated  sparrows. 

Diagnosis.  —  There  should  be  no  difficulty,  as  a  rule,  in  the 
diagnosis,  as  the  size  of  the  lesions,  their  waxy  or  glistening  appearance, 
and  the  presence  of  the  central  depression  and  orifice  are  sufficiently 
characteristic.  The  disease  is  to  be  differentiated  from  fibroma,  milium, 
warts,  and  acne. 

Fibromata  are  rounded  growths  of  small  or  large  size,  always  exceed- 
ing, when  at  all  developed,  that  of  the  tumors  of  molluscum  contagiosum, 
and  are  situated  deeply  in  the  skin,  or  even  in  the  subcutaneous  tissue; 
the  lesions  of  molluscum  contagiosum  are  superficial,  seated  in  the  upper 
skin  and  epidermal  tissues,  and  are,  comparatively  speaking,  small  in 
size;  the  tumors  of  the  former  have  no  central  orifice,  depression,  or 
opening,  while  these  are  usually  quite  distinct  in  the  latter  disease. 

Milia  resemble  the  small  molluscum  growths  to  some  extent,  but 
are  usually  whitish,  and  lack  the  pearly  or  waxy  appearance  and  the 
central  orifice  of  the  latter.  These  latter  characters  will  also  serve  to 
differentiate  it  from  small  warts,  to  which  it  bears  a  rough  resemblance; 
moreover,  warts  are  harder  and  more  solid.  It  is  scarcely  possible  to 
mistake  the  disease  for  acne  —  small  papular  acne  —  as  the  lesions  in  this 
latter  disease  are  usually  seen  in  all  stages  of  papulation  and  pustulation. 

Prognosis  and  Treatment.  —  The  prognosis  of  molluscum 
contagiosum  is  favorable,  and  it  is  only  exceptionally  that  any  per- 
manent trace  of  the  disease  is  left.  In  many  instances  the  tumors 
will  disappear  spontaneously  in  the  course  of  several  weeks  or  a  few 
months.  In  others,  active  measures  are  necessary  to  bring  about  their 
removal.  All  cases  should,  however,  receive  prompt  treatment,  in 
order  that  a  possible  source  of  contagion  may  be  removed. 

If  there  are  but  a  few  lesions,  their  contents  may  be  immediately 
pressed  out,  and  a  deep  application,  through  the  central  orifice,  be 
made  with  a  strong  solution  of  silver  nitrate  or  carbolic  acid  by  means 
of  a  sharply  pointed  stick;  or  the  lesions  may  first  be  incised,  and  then 

1  Bellinger,  Virchow's  Archiv,  1873,  vol.  Iviii,  p.  349  (with  colored  plate). 

2  Salzer,  Munch,  med.  Wochenschr.,  1896,  No  36,  p.  841. 

3  Colcott  Fox,  Trans.  London  Patholog.  Soc'y,  1898,  vol.  xhx,  p.  393  (witt 


ibid  p  394  (with  illustrations).  Recently  Lipschtitz  (Ehrmann's 
z^fvA  xiv,  H.  8,  has  repeatedly  found  ^  ^owths  mmute 
diplococcoid  bodies,  the  two  bodies  appearing  as  if  close  together,  but  separate,  yet 
joined  by  a  scarcely  recognizable  connection. 


652  NEW  GROWTHS 

the  cauterization  made.  If  the  formations  are  numerous,  and  especially 
when  seated  on  a  limited  region,  a  mild  stimulating  or  parasiticide 
ointment  should  be  tried  before  operating  upon  individual  growths; 
for  this  purpose  one  containing  20  to  40  grains  (1.35-2.65)  of  white 
precipitate  or  sulphur  to  the  ounce  (32.)  should  be  rather  vigorously 
rubbed  into  the  affected  parts  once  or  twice  daily;  or  a  drying  lotion, 
such  as  the  calamin-zinc-oxid  lotion,  with  boric  acid  solution  as  the 
basis,  can  be  applied  freely  once  or  twice  daily.  A  number  of  my  cases 
have  gone  on  to  recovery  under  such  measures.  If  this  method  should, 
after  trial,  prove  without  effect,  the  mild  operative  and  cauterizing 
applications  mentioned  are  to  be  resorted  to.  Lesions  which  have 
become  pedunculated  may  be  snipped  off  with  scissors  and  the  base 
touched  with  silver  nitrate. 

MULTIPLE  BENIGN  CYSTIC  EPITHELIOMA l 

Synonyms. — Epithelioma  adenoides  cysticum  (Brooke);  Adenoma  of  the  sweat- 
glands  (Perry) ;  Acanthoma  adenoides  cysticum  (Unna) ;  Tricho-epithelioma  papillosum 
multiplex  (Jarisch);  Fr.,  Hydradenomes  eruptifs  (Jacquet  and  Darier);  Syringo- 
cystadenome  (Torok);  Cellulome  epithelial  eruptif  kystique  (Quinquaud);  Cystade- 
nomes  epithe'lieux  benins  (Besnier) ;  Naevi  epitheliaux  kystiques  (Besnier);  Ger.,  Gutar- 
tiges  Epithelioma,  mit  kolloider  Degeneration  (Philippson) .  Syringocystoma.  Syrin- 
goma. 

Symptoms. — In  recent  years  a  malady  has  been  described  char- 
acterized by  small,  tubercular  or  nodular  lesions,  of  a  pinkish,  pearly,  or 
pale-yellowish  color,  and  usually  seated  about  the  face,  upper  part  of 
the  trunk,  anteriorly  or  posteriorly,  and  less  frequently  on  the  arms. 
In  size  they  vary  from  a  pin-head  to  a  pea,  rarely  exceeding  the  latter, 
projecting  above  the  surface,  and  have  a  shining,  semitranslucent  ap- 
pearance. They  are  usually  rounded  or  conic,  smooth,  with  sometimes, 

1  Literature:  Jacquet  and  Darier,  "Hydradenomes  eruptifs,"  Annales,  1887,  p.  317 
(2  colored  case  illustrations  and  2  colored  histologic  cuts);  Torok,  "Das  Syringo-cyst- 
adenom,"  Monatshefte,  1889,  vol.  viii,  p.  116;  Quinquaud,  "Le  Cellulome  epithelial 
eruptif,"  Trans.  Internal.  Cong.  Dermatolog.,  Paris,  1889,  p.  412  (case  demonstration); 
Jacquet,  "Epitheliome  kystique  benin  de  la  peau,"  ibid.,  p.  416  (case  demonstration); 
Perry,  "Adenomata  of  the  Sweat-glands,"  Internal.  Atlas  Rare  Skin  Diseases,  iii, 
1890,  plate  ix.;  Brooke,  "Epithelioma  Adenoides  Cysticum,"  Brit.  Jour.  Derm.,  1892, 
p.  269  (with  3  case  illustrations  and  7  histologic  cuts  and  references);  Fordyce,  "Mul- 
tiple Benign  Cystic  Epithelioma,"  Jour.  Cutan.  Dis.,  1892,  p.  459  (with  colored  plate 
case  illustration  and  7  photomicrographs);  J.  C.  White,  "Multiple  Benign  Cystic 
Epithelioma,"  ibid.,  1894,  p.  477  (with  case  illustration,  histologic  examination  and 
cut  by  Bowen);  Dyer,  New  Orleans  Med.  and  Surg.  Jour.,  1897-98,  vol.  1,  p.  530  (with 
case  illustration);  see  also  Besnier's  article  in  Besnier-Doyon's  French  translation  of 
Kaposi,  vol.  ii,  p.  367;  W.  Pick  (its  relation  to  adenoma  of  the  sebaceous  glands), 
Archiv,  1901,  vol.  Iviii,  p.  201;  Hartzell  (2  cases  with  unusual  features,  with  review  and 
references),  Amer.Jour.  Med.  Sci.,  Sept.,  1902,  and  (its  relationship  to  so-called  syringo- 
cystadenoma,  syringocystoma,  and  hsemangio-endothelioma) ,  Brit.  Jour.  Derm.,  1904, 
p.  361  (with  histologic  cuts);  C.  J.  White,  Jour.  Cutan.  Dis.,  Feb.,  1907,  p.  50  (case 
report  with  illustrations  and  histologic  cuts;  analytical  review  and  bibliography) ;  Fernet, 
Brit.  Jour.  Derm.,  1907,  p.  67  (case  report);  Heidingsfeld,  Jour.  Cutan.  Dis.,  1908,  p. 
18,  report  of  6  cases,  with  2  case  illustrations  and  several  histologic  cuts,  review  of  the 
subject,  and  bibliography;  Stockmann,  Archiv,  1908,  vol.  xcii,  p.  145,  3  cases,  his- 
tologic examination;  discussion  of  the  Torok,  Max  Joseph,  Csillag,  White,  and  some 
other  cases;  he  believes  the  growths  are  to  be  regarded  as  "naevi  tardivi,"  originating 
in  abnormally  placed  sweat-glands;  Schopper,  Archiv,  October,  1909,  xcviii  (discusses 
the  Brooke  group  of  cases;  bibliography);  Ormsby,  Jour.  Cutan.  Dis.,  1910  p.  433  (ex- 
tensive, more  or  less  generalized  case;  sweat-gland  duct  origin;  involution  of  some  le- 
sions; excellent  case  and  histologic  illustrations). 


MULTIPLE  BENIGN  CYSTIC  EPITHELIOMA  653 

in  the  largest  growths,  a  slight  central  depression.  Occasionally  they 
are  somewhat  flattened.  Some  of  the  lesions  may  have  a  distinctly 
translucent  aspect  and  look  like  vesicles;  others  have  a  milium-like 
appearance,  or  the  surface  of  the  large  one  may  show  several  milium-like 
bodies.  In  some  the  surface,  and  occasionally  the  immediately  adjacent 
surrounding  skin,  shows  minute  capillaries.  They  are  painless,  not 
sensitive  to  the  touch,  nor  tender  upon  pressure.  Usually  the  lesions 
are  somewhat  numerous,  discrete,  or  somewhat  crowded  together,  and 
sometimes  coalescent  or  bunched. 

They  appear  first  as  pin-point-  to  pin-head-sized  lesions,  similar  in 
their  features  to  the  more  advanced  lesions;  in  others  the  earliest  forma- 
tions resemble  small  papules  or  black  dots  (Brooke),  sometimes  small 
scaling  papules.  While  ordinarily  in  color  they  are,  as  already  stated, 


-Multiple  benign  cystic  epithelioma;  the  coalescent  group  showing  degen- 

prative  chances. 


erative  changes. 


pinkish,  pearly,  or  pale  yellowish,  occasionally  it  is  that  of  the  normal 
skin,  and  in  some  instances  there  is  a  bluish  tinge.  They  are  firmly 
imbedded.  Their  growth  is  slow,  and,  after  reaching  the  size  of  a  small 
or  large  pea,  remain  stationary.  It  has  been  commonly  thought  that 
no  degenerative  or  ulcerative  changes  ever  take  place,  and  this  absence 
of  malignancy  is  the  rule,  but  in  White's  case,  in  one  observed  by  Jansch, 
and  also  in  mine,  the  large  or  bunched  lesions  exhibited  surface  degenera- 
tion with  ulceration,  and  approached  closely  to  the  rolled,  pearly-horde  ed 
superficial  epitheliomata.  The  growths  show  no  tendency  to  myoluti 
While  sometimes  presenting  a  pseudovesicular  appearance  they  are 
usually  firm  and  apparently  solid  in  character,  and  if  pricked,  si 


s  %££$  involution,  and  in  Dyer's  case  there  was  a 

tendency  to  "self-destruction  and  self-elimination. 


NEW  GROWTHS 

few  reported  exceptions  (Dyer,  Perry),  no  liquid  contents,  but  simply 

bleed  slightly. 

The  face  is  the  most  common  site,  and  here  there  usually  is  a  pre- 
dilection shown  for  the  region  of  the  eyelids,  forehead,  cheeks,  root  of 
the  nose,  chin,  ears,  and  interpalpebral  space.  The  interscapular 
region,  breast,  and  arms  are  also  not  uncommon  sites,  and  the  lesions 
have,  'moreover,  been  found  on  other  regions;  Ormsby's  exceptional 
case  was  more  or  less  generalized.  There  are  no  subjective  symptoms, 
nor  is  there  any  disturbance  of  the  general  health,  the  cases  coming  chiefly 
under  observation  owing  to  the  disfigurement  produced. 

Etiology  and  Pathology.— The  cause  of  the  disease  is  un- 
known. Both  sexes  are  liable,  and  almost  any  age,  although  it  usu- 
ally has  its  beginning  during  adolescence,  and  is  much  more  common  in 
females.  Brooke's  3  cases  consisted  of  mother  and  two  daughters,  and 
Fordyce's,  of  a  mother  and  daughter,  with  the  history  in  the  latter 
instance  of  a  similar  condition  in  a  preceding  generation.  Colcott 
Fox1  also  noted  probable  examples,  clinically  viewed,  of  the  malady 
in  mother  and  daughter.  Quinquaud's  patient  stated  that  a  sister 
presented  similar  growths. 

Crocker,2  in  a  recent  valuable  contribution,  expresses  the  opinion 
that  the  cases  reported  really  constitute  two  distinct  types  or  affec- 
tions, for  which  he  suggests,  for  the  sake  of  convenience,  of  holding 
to  the  names  given  to  the  representative  of  the  one  class  by  Kaposi— 
lymphangioma  tuberosum  multiplex — and,  to  the  other  class,  that  by 
Brooke,  acanthoma  adenoides  cysticum;  including,  in  the  former, 
without  necessarily  implying  that  the  condition  is  lymphangiomatous, 
the  cases  of  Kaposi,  Jacquet  and  Darier,  Torok,  Quinquaud,  Lesser 
and  Beneke,  and  others,3  and,  in  the  latter,  those  of  Perry,  Brooke, 
Fordyce,  White,  and  some  others.  It  is  true  that  a  study  of  these 
various  cases  suggests  some  clinical,  although  probably  unimportant, 
differences.  Crocker  gives  the  chief  of  these:  in  lymphangioma  tubero- 
sum— mainly  on  the  trunk,  discrete  and  not  grouped,  bilateral  and  not 
symmetric,  distinctly  colored,  in  males  and  females  alike,  and  not 
hereditary;  and  for  acanthoma  adenoides  cysticum — mainly  on  face, 
discrete,  but  very  closely  grouped,  closely  symmetric,  almost  or  quite 
pearly  white,  or  a  faint  bluish  or  yellowish  tinge,  most  of  them  hereditary, 
and  all  females.  Jarisch's  case  and  my  case,  however,  which  come  in 
this  latter  group,  were  males.  To  these  Crocker  would  add  anatomic 
dissimilarity — the  former  consisting  of  "cysts  in  the  derma,  with  straight 
processes  of  non-epidermic  origin,"  and  the  latter,  "solid,  coil-like  masses 
with  small  cysts  scattered  through  them  and  of  epidermic  origin."  Hart- 

1  Colcott  Fox,  Brit.  Jour.  Derm.,  1897,  p.  230  (case  demonstration). 

2  Crocker,  "A  Case  of  Lymphangioma  Tuberosum  Multiplex,"  London  Clin.  Soc'y 
Trans.,  1899,  vol.  xxxii,  p.  151  (with  colored  plate  and  bibliography);  Sutton  and 
Dennie,  "Possible   Interrelationship   of  Acanthoma  Adenoides   Cysticum    (Multiple 
Benign  Cystic  Epithelioma)  and  Syringocystadenoma  (Lymphangioma  Tuberosum 
Multiplex),  four.  Amer.  Med.  Assoc.,  Feb.  3,  1912,  p.  333  (discuss  the  subject,  and 
record  two  cases,  each  representing  distinct  groups;  review  and  references). 

3  Literature  references  to  the  cases  of  Kaposi.  Lesser,  and  Beneke,  and  also  to  Hog- 
gan's  and  Jarisch's  papers,  which  concern  cases  of  benign  cystic  epithelioma,  etc.,  are 
given  under  lymphangioma. 


MULTIPLE  BENIGN  CYSTIC  EPITHELIOMA  655 

zell  and  Heidingsf  eld  believe  that  these  (or  most  of  these)  variously  named 
cases  are  simply  varieties  of  the  one  and  same  affection,  while  C.  J. 
White  contends  that  there  are  several  distinct  clinical  and  pathologic 
groups. 

Histologically  (Darier,  Brooke,  Fordyce,  Bowen,  and  others)  the 
lesion  is  shown  to  be  an  epithelial  growth,  being  constituted  of 
irregularly  rounded,  oval,  and  elongated  masses  and  tracts  of  epithe- 
lial cells  corresponding  to  those  in  the  lowermost  layer  of  the 
epidermis  and  external  root-sheath  of  the  hair-follicle;  these  masses 
being  distinct  or  composed  of  intercommunicating  bands  and  tracts, 
in  some  places  resembling  coil-ducts;  cell-nests  are  to  be  seen,  as  in 
malignant  epithelioma  (Fordyce).  Colloid  degeneration  is  also  noted. 
Lying  in  the  tracts,  or  more  generally  in  the  masses,  were  cysts  of  circular 
or  oval  shape,  sometimes  elementary,  others  well  formed,  filled  with  either 
purely  colloid  matter  or  partly  with  colloid  and  partly  with  concentric 
layers  of  apparently  horned  epithelium  (Brooke).  It  is  generally  believed 
(Quinquaud,  Jacquet,  Darier,  Philippson,  Fordyce)  that  the  growths 
take  their  start  from  embryonic  epithelial  germs  misplaced  during  fetal 
life,  and  remaining  in  a  latent  condition  until  excited  by  some  influence 
into  active  proliferation  (Fordyce),  and  this  excitation  is  apparently 
furnished  most  frequently  at  the  period  of  puberty,  doubtless  by  the 
tissue  changes  and  glandular  activity  at  this  time  of  life.  In  Hartzell's 
cases  the  growth  had  its  origin  in  the  epithelium  of  the  hair-follicle,  and 
C.  J.  White's  investigation  showed  his  to  be  a  new  growth  and  cystic 
dilation  of  sweat  ducts.  Its  relation  to  superficial  epithelioma  or  rodent 
ulcer  is  probably  a  close  one,  and  although  the  lesions  are  thought  benign 
and  to  show  no  destructive  changes,  the  exceptional  cases  of  White, 
Jarisch,  and  my  own  furnish,  in  my  judgment,  connecting  examples.1 
Philippson,2  in  his  report  of  a  case,  has  endeavored  to  show  that  colloid 
degeneration  of  the  skin  and  benign  cystic  epithelioma  are  essentially 
pathologically  identical,  a  view,  however,  that  has  received  no  support. 

Diagnosis.—  The  lesions  bear  some  resemblance  to  molluscum 
contagiosum,  but  are  distinguished  from  the  latter  by  the  fact  that 
they  are  persistent,  showing  no  tendency  to  disappear,  and  have,  as  a 
rule,  no  central  depression,  and  have  no  central  aperture.  Molluscum 

i  Adamson,  Lancet,  Oct.  17,  1908,  in  an  interesting  analytical  and  critical  paper 
discusses  this  question.  He  considers  that  the  Jansch  White,  and  Stelwagon  ,  (mine 
cases  are  closer  to  the  rare  examples  of  multiple  rodent  ulcer  (2  cases  cite  d  and  .p  ictured) 
than  to  the  true  (Brooke)  type  of  multiple  benign  cystic  epithelioma  the  latter  c 

»" 


ically  differing  in  these  particulars;  (i)  all  have  occurred  farf 

appeared  in  childhood;  (2)  generally  in  mother  and  Daughter;  (3)  distnbut^n  of  e  o 
markedly  symmetrical;  (4)  fairly  uniform  size  of  lesions;  (5  (no  tendency  ol  the  eaons 
to  enlarge  beyond  the  size  of  a  split  pea,  nor  to  break   down,  *.  e    to  become  ^locally 


Monatshefte,  1890,  vol.  xi,  p.  i;  and  also  in  Brit.  Jour.  Derm.,  18 


656  NEW  GROWTHS 

contagiosum  is,  moreover,  more  commonly  a  malady  of  childhood: 
benign  cystic  epithelioma  rarely  presents  before  puberty.  There  is 
also  a  resemblance  to  hydrocystoma,  but  in  the  latter  the  growths 
have  fluid  contents  and  are  usually  fluctuating  as  to  their  existence, 
disappearing  and  reappearing.  Between  colloid  degeneration  of  the 
skin  and  this  disease  there  is  also  some  clinical  similarity.  The  colloid 
lesion  begins  as  yellow,  translucent,  gelatinous-looking  nodule:  cys- 
tic epithelioma  as  a  small,  skin-colored  papule  or  black  dot,  and 
gradually  progresses;  the  former  may  undergo  involution  and  disap- 
pear without  trace;  the  latter  is  persistent.  Histologically  in  the  for- 
mer the  colloid  material  is  infiltrated  in  the  fibrillae  of  the  connective 
tissue,  enveloping  the  connective- tissue  bundles  and  following  their 
directions,  and  there  are  no  epithelial  tracts  or  cords,  and  no  cysts — 
findings  different  from  those  of  cystic  epithelioma  (Brooke). 

Prognosis  and  Treatment. — There  is  no  tendency  to  sponta- 
neous disappearance,  and  though  the  malady  is  usually  to  be  considered 
benign,  development  of  a  more  active  epithelial  proliferation  and  ulcera- 
tive  degeneration  is  a  possibility.  In  view  of  the  epitheliomatous 
development  in  his  case  White  justly  says,  I  believe,  that  the  correctness 
of  the  appellation  benign  must  be  regarded  as  problematic.  Treatment 
is  surgical.  Fordyce  has  found  that  simple  incision  in  the  smaller 
lesions  and  squeezing  out  the  growth  will  sometimes  be  successful, 
although  stating  that  curetting  constitutes  the  best  plan.  In  a  case  un- 
der the  care  of  Dr.  C.  N.  Davis,  of  Philadelphia,  that  I  had  an  opportu- 
nity of  seeing,  in  spite  of  several  thorough  curettings  there  was  per- 
sistent recurring  tendency.  Electrolysis  and  cauterization  can  also  be 
resorted  to.  In  Ormsby's  case  x-ray  treatment  and  carbon-dioxid  snow 
proved  of  value.  The  method  by  curetting  and  supplementary  cauter- 
ization seems  to  me  the  best. 

ADENOMA  SEBACEUM1 

Synonyms, — Adenoma  of  the  sebaceous  glands;  Vegetations  vasculaires  (Rayer); 
Naevi  vasculaires  et  papillaires  (Vidal);  Adenoma  sebaces  (Balzer  and  M6netrier). 

Definition. — A  rare  affection,  consisting  of  small  tumors  of 
sebaceous  gland  origin,  seated  usually  on  the  face,  more  especially  at 

1  Recent  literature:  Balzer  and  Men6trier,  Arch,  de  physiolog.,  1885,  vol.  vi,  p.  564 
(i  case  with  histologic  cuts);  Balzer  and  Grandhomme  (i  case),  ibid.,  1886,  vol.  viii,  p. 
935  Pringle,  Brit.  Jour.  Derm.,  1890,  p.  i  (with  case  illustration  and  photomicrographs, 
and  a  resum6  of  the  above  2  cases  and  2  by  Vidal  and  i  by  Hallopeau) ;  Caspary, 
Archiv,  1891,  vol.  xxiii,  p.  371  (with  literature,  references,  colored  plate,  and  histo- 
logic cuts);  Crocker,  Trans.  Internal.  Derm.  Cong.,  Vienna,  1892,  p.  505,  and  Diseases 
of  Skin,  second  edit.,  p.  769;  Jamieson,  Brit.  Jour.  Derm.,  1893,  p.  138  (girl,  aged  fifteen 
—most  lesions  on  right  side  of  forehead  close  to  hair  margin) ;  Stanford  Taylor  and 
Barendt,  ibid.,  p.  360  (3  cases  in  one  family — father,  son,  and  daughter,  began  in  all 
about  the  age  of  five — of  defective  mental  development);  Pollitzer,  Jour.  Cutan.  Dis., 
1893,  p.  475  (male  subject — with  case  illustration  and  2  histologic  cuts);  Rosenthal 
(case  demonstration),  Monatsheftc,  1894,  vol.  xix,  p.  374;  Dockrell  (case  demonstra- 
tion), Brit.  Jour.  Derm.,  1895,  P-  340  (epileptic  boy — some  cicatrices  present);  W.  An- 
derson, ibid.,  p.  316  (male  subject,  aged  twenty-seven,  began  at  seven — associated  with 
fibromata);  Brooke,  ibid.,  p.  332  (discussion;  2  cases — i  in  idiot  girl,  the  other  in  epilep- 
tic young  woman);  Perry  (case  demonstration),  ibid.,  1896,  p.  99  (girl,  aged  eleven, 
with  some  fibromata);  G.  H.  Fox  (case  demonstration)  (i  case — young  girl),  Jour. 


ADENOMA   SEBACEUM 


657 


the  sides  of  the  nose.  Originally  recorded  by  Rayer,  Addison,  and  Gull, 
it  has  been  more  recently  described  in  France  by  Balzer,  in  association 
with  Menetrier  and  Grandhomme;  in  England,  by  Pringle,  Crocker,  and 
others;  in  Germany,  by  Caspary,  Rosenthal,  and  a  few  others;  and  in 
this  country  by  Pollitzer. 

Symptoms. — The  malady  is  characterized  by  small  tumors, 
which  are,  as  a  rule,  congenital  or  appear  after  birth.  In  size  they  vary 
from  a  pin-head  to  a  split  pea,  are  rounded  or  convex,  and  may  be  either 
normal  skin  color,  waxy,  brownish  or  reddish — the  latter  most  usually. 
The  epidermal  covering  may  be  smooth,  rough,  or  warty,  with,  in  many 
cases,  the  surface  irregularly  streaked  with  ramifying  dilated  capillaries. 


Fig.  iss  —  Adenoma  sebaceum;  moderate  magnification;  showing  the  striking  hyper- 
trophy and  development  of  the  sebaceous  glands  (courtesy  of  Dr.  J.  A.  IM 

This  latter  character  may  be,  as  in  Vidal's  case,  a  conspicuous  feature. 
In  fact,  their  color  is  measurably  influenced  by  the  degree  of  this 


in  sebaceous  glands);  Krzysztalowicz,  J£^*S^;^t£Vj£lJeSs  glands  which 

MSB 


deviations. 
42 


658  NEW  GROWTHS 

dated  telangiectasis,  although  not  wholly,  as  pressure  causes  but  little, 
if  any,  change.  They  are  more  or  less  grouped  or  bunched  at  either 
side  of  the  nose,  with  outlying  scattered  ones,  or  they  may  be  somewhat 
disseminated  over  the  whole  facial  region,  and  exceptionally  in  the  scalp. 
The  acne  rosacea  regions  are,  however,  its  common  sites.  They  are 
usually  symmetrically  distributed.  The  forehead  is  rarely  the  seat  of 
many  lesions,  although  in  some  instances  those  on  this  region  are  quite 
large.  Pollitzer's  case  was  exceptional  in  that  the  tumors  were  arranged 
in  a  linear  manner,  and,  as  practically  likewise  in  Jamieson's  case,  con- 
fined to  one  side  of  the  forehead.  Their  appearance  and  growth  are 
gradual,  the  latter  usually  noted  to  be  more  active  at  about  puberty, 
at  which  time  especially  there  may  be  also  a  decided  increase  in  num- 
bers. Involution  may  occasionally  be  noted  in  some  of  the  growths, 
and  such  may  completely  disappear,  their  site  being  marked  by  insig- 
nificant atrophic  spots  or  scars.  Other  cutaneous  lesions,  such  as  come- 
dones, pigment  spots,  naevi,  warts,  and  fibromata,  have  been  variously 
noted,  especially  the  first  named,  and  commonly  associated  with  a  coarse, 
pasty-looking,  large-pored  skin.  There  are  no  subjective  symptoms. 

Etiology  and  Pathology.— The  affection  is  believed  to  be  of 
congenital  origin,  although  this  does  not  seem  true  in  all  instances;  in 
Pollitzer's  case  the  lesions  first  presented  when  aged  nineteen.  Its 
subjects,  for  the  most  part,  although  by  no  means  exclusively,  have 
been  noted  to  be  of  defective  mental  development.  It  is  observed 
more  frequently,  too,  among  the  poorer  classes,  and  Crocker  is  inclined 
to  think  that  more  cases  could  probably  be  found  in  asylums.  In  fact, 
according  to  Colcott  Fox,1  the  malady  seems  to  be  quite  common  in 
England,  and  chiefly  met  with  among  children  in  imbecile  asylums. 

The  pathologic  anatomy  has  been  studied  by  Balzer,  Pringle,  Crocker, 
Barendt,  Pollitzer,  and  others,  and  although  there  are  some  minor 
divergences,  all  agree  that  the  process  is  one  of  hyperplasia  of  the  se- 
baceous glands,  and  probably,  too  (Balzer,  Crocker),  of  the  sweat- 
glands.  In  fact,  Crocker's  examination  disclosed  increased  develop- 
ment of  all  the  appendages, — sebaceous  glands,  sweat-glands,  and  hair- 
follicles, — and  he  would  prefer  to  classify  it  as  a  pilosebaceous  hydrade- 
noma.  In  addition  to  the  hyperplasia  of  the  glandular  structures, 
Crocker  found  in  one  lesion  hyperplasia  of  the  fibrous  tissue  also;  Pringle, 
the  upper  papillary  layer  enormously  hyper trophied,  but  without  evi- 
dence of  inflammation  or  cellular  infiltration;  and  Balzer,  in  i  of  his 
cases,  cysts  in  both  sweat-  and  sebaceous  glands.2 

Diagnosis. — The  diagnostic  features  are  the  early  appearance, 
the  region  involved,  and  the  associated  telangiectasis  and  persistent 
course.  The  malady  can  scarcely  be  confounded  with  acne  rosacea, 
although  usually  occupying  the  region  of  the  latter  disease,  but  its  early 
beginning,  lack  of  pustular  tendency,  and  course  are  wholly  different. 
And  only  careless  examination  could  lead  to  a  confusion  with  lupus 

1  Colcott  Fox  (discussion),  Jour.  Cutan.  Dis.,  1897,  p.  88. 

2  Krzysztalowicz  believes  that  four  types  have  been  recognized:    (i)  Caspary's 
sebaceous  tumor;  (2)  Pringle's  sebaceous,  angiomatous,  and  fibromatous  mass;  (3) 
Darier's  angiomatous  structure;  and  (4)  Perry's  sweat-gland  naevus  type. 


ADENOMA    OF  THE  SWEAT-GLAND  659 

vulgaris,  as  the  behavior  and  atrophic  or  ulcerative  tendency  of  the 
latter  would  be  sufficiently  differential.  There  is  more  resemblance 
to  multiple  benign  cystic  epithelioma  and  colloid  milium,  but  the  former 
develops  later  in  life,  is  more  frequently  seated  upon  the  upper  part  of 
the  face  or  upon  other  regions,  especially  the  upper  part  of  the  trunk,  and 
occasionally  tends  to  superficial  ulceration.  Colloid  milium  rarely 
involves  the  lower  part  of  the  face,  being  most  commonly  on  the  upper 
portion,  and  the  lesions  are  free  from  the  surface  dilated  capillaries, 
and  are,  moreover,  more  distinctly  yellow  in  color.  Molluscum  con- 
tagiosum  could  be  readily  differentiated  by  the  central  depression  and 
opening. 

Prognosis  and  Treatment.  —  In  rare  instances  spontaneous  in- 
volution has  been  observed,  but  this  is  scarcely  to  be  expected,  as  the 
disease  is  almost  always  persistent,  the  growths  usually  increasing  in 
number  for  a  tune,  and  then  the  malady  remaining  stationary.  Treat- 
ment is  essentially  and  solely  surgical,  as  no  result  has  yet  been  achieved 
by  local  applications  or  general  treatment.  If  their  removal  is  called 
for,  it  can  be  accomplished  by  means  of  the  knife  or  curet  or  electrolysis. 
This  last  has  been  employed  successfully  by  Crocker,  using  a  current 
of  3  or  4  milliamperes,  the  procedure  being  the  same  as  in  hypertrichosis 
or  telangiectasis—  the  needle  attached  to  the  negative  pole.  Jamieson 
effected  a  removal  of  the  lesions  and  what  seemed  to  be  an  apparent 
cure  by  producing  exfoliation  by  rubbing  in  a  paste  composed  of:  I*. 
Resorcin,  gr.  xx  (1.35);  zinci  oxidi,  gr.  xl  (2.65);  kaolin,  gr.  ij  (0.135); 
adipis  benzoat,  gr.  xxviij  (1.9). 

ADENOMA  OF  THE  SWEAT-GLAND1 

Synonyms—  Spiradenoma;  Spiroma;  Adenoma  sudoriparum. 

Most  of  the  cases  which  have  been  described  under  this  or  an  equiv- 
alent title  are  now  known  to  have  had  no  connection  with  the  sweat- 
glands,  but  represented  what  is  at  present  recognized  as  multiple  benign 
"ystic  epithelioma   <f.m)-     »  *  *ot  improbable,  however,   that  the 
conclusions  on  this  point  have  been  entirely  too  a"*^  "** 
in  a  few  of  the  examples  these  structures  may  have  played  an  importer 
pathologic  part.     It  is  in  some  instances,  tob^<^  **^ 
development,  as  in  the  cases  of  linear  nevus  recorded  by  Peterson  a 
Emot  ^though  the  former  was  of  the  opinion  that  his  cases  represented 
a  primary  adenoma  of  the  sweat-gland.     According  to  Buxton,  who  has 
Lreunfgone  over  the  subject,  the  true  adenoma  must  be  distinguished 
?om  merfhypertrophy  ;  as  an  example  of  this  latter  he  considers  Elliot  s 
aSSSSdZ     Gland  hypertrophy  is  not  infrequent  in  tubercu- 
losis cuds  and  fc  the  neighborhood  of  malignant  tumors;  and  he  himself 

tin  the  herewith  brieipr— 

'>  Fordyce,  Morrow's 


>  , 

'  d  l°  ^ 


Linear  naevus. 


660  NEW  GROWTHS 

gives  a  histologic  example  of  its  occurrence  near  the  site  of  a  carcinoma 
of  the  breast.  Unna  asserts,  however,  that  these  cases,  which  may  be 
considered  as  secondary  adenoma,  and  which  are  relatively  numerous, 
may  also,  in  addition  to  the  actual  hypertrophy,  show  adenomatous 
development.  Genuine  cases,  excluding  the  secondary  cases  and  those 
which  are  rather  to  be  looked  upon  as  examples  of  hypertrophy,  are  rare; 
and,  according  to  Unna,  are  represented  by  those  reported  by  Thier- 
felder,1  Lotzbeck,2  Hoggan,3  Chandeleux,4  and  Audry.5  Unna  also 
quotes  one  by  Krauss,  and  gives  brief  notes  of  one  under  his  own  observa- 
tion. 

The  clinical  appearances  are  simply  those  of  a  subcutaneous  tumor, 
varying  in  size  from  a  pea  to  an  egg  or  larger,  usually  slow  in  develop- 
ment. In  Lotzbeck's  case  it  had  a  pseudo-angiomatous  aspect.  In 
the  cases  of  Chandeleux  and  Hoggan  the  nodules  were  tender  and  liable 
to  spontaneous  attacks  of  pain.  In  both  instances  the  nodule  was  en- 
capsulated by  firm  connective  tissue  and  the  nerves  distributed  outside. 
The  overlying  skin  shows  but  little  departure  from  the  normal.  The 
growth  is  usually  single,  and  may  occur  on  any  region — by  Lotzbeck, 
on  the  cheek;  by  Thierf elder,  at  the  hairy  margin  of  the  forehead;  by 
Krauss,  at  the  outer  border  of  the  foot;  by  Chandeleux,  near  the  elbow; 
by  the  Hoggans,  on  arm;  in  Unna's  case  the  position  is  not  stated.  It 
may  appear  at  any  age  and  in  either  sex. 

Unna  would  distinguish  the  growth  arising  from  the  coil-duct,  to 
which  he  gives  the  name  of  syringadenoma,  from  that  arising  from  and 
involving  the  glandular  structure  proper,  as  an  example  of  the  former 
citing  Peterson's  case,  already  referred  to.  The  origin  and,  in  fact, 
the  diagnosis  from  other  clinically  similar  tumors  in  these  various  cases 
and  histologic  varieties  are  possible  only  through  careful  microscopic 
examination.  In  fact,  their  individuality,  true  position,  and  relation- 
ship to  other  growths  are  still  undetermined.  There  is  scarcely  a  doubt 
that  occasionally  such  a  formation  constitutes  the  starting-point  of  car- 
cinomatous  or  other  malignant  change,6  and  it  is  fairly  questionable  also 
whether,  in  some  of  the  instances  in  which  the  adenomatous  develop- 
ment of  the  coil-glands  was  thought  to  be  secondary  to  malignant  growths, 
it  may  not  have  been  the  primary  affection  and  the  starting-point  of  the 
malignancy. 

The  treatment  of  sweat-gland  adenomata  is  that  of  other  tumor 
formation — complete  excision. 

1  Thierfelder,  Archiv  f.  Heilkunde,  1870,  p.  401  (with  3  histologic  cuts  and  some 
references). 

2  Lotzbeck,  Virchow's  Arckiv,  1859,  vol.  xvi,  p.  160 

3  Hoggan  (G.  and  F.  E.),  ibid.,  1881.  vol.  Ixxxiii,  p.  233. 

4  Chandeleux,  Arch,  de  physiolog.,  1882,  vol.  ix,  p.  639. 

6  Audry  and  Nove-Josserand,  Lyon  Medicale,  1892,  vol.  Ixix,  p.  315. 

8  See  papers  by  Darier,  "Contribution  a  l'6tude  de  1'epithe'liome  des  glands  sudori- 
pares,"  Arch,  de  med.  exper.,  1889,  p.  115  (with  10  histologic  cuts);  Fordyce,  "Adeno- 
carcinomata  of  the  Skin  Originating  in  the  Coil-glands,"  Jour.  Cutan.  Dis.,  1895,  p.  41 
(with  7  excellent  photomicrographs). 


L  YMPHANGIOMA  66 1 

LYMPHANGIOMA 

The  subject  of  lymphangioma  remains  still  an  obscure  one,  to  which 
the  many  conflicting  case  reports  have  as  yet  contributed  but  com- 
paratively little  definite  knowledge.  While,  strictly  speaking,  this  term 
carries  with  it  the  implication  of  new  growth  of  the  lymphatics,  yet  in 
some  recorded  instances  there  is  more  reason  to  believe  that  the  condition 
was  one  of  lymphangiectasis.  It  is  highly  probable,  however,  that  the 
former  does  not  exist  without  the  latter,  and  that,  therefore,  in  most 
cases,  there  is  an  association  of  the  two  processes.  A  reading  of  the 
literature  shows  that  there  are  several  varieties,  some  of  which  may  be 
classed  as  deep-seated  cystic  growths,  others  as  more  superficial  lym- 
phatic varicosities,  consisting  of  more  or  less  tortuous  and  crowded  or 
closely  adjacent  dilated,  and  possibly  new,  lymphatic  channels,  or  dis- 
crete, irregularly  grouped  or  scattered,  pea-  to  cherry-sized,  tumor-like 
dilatations;  and  still  another  in  which  the  lesions  are  within  the  middle 
and  upper  part  of  the  corium,  close  to  the  surface,  and  crowded  or 
bunched  together,  forming  plaques  of  pearly  or  pinkish-red,  thick-walled 
vesicles,  often  dotted  with  minute  telangiectases  or  vascular  tufts. 
These  several  classes  correspond  to  the  divisions  made  by  Wegner,1 
who  placed  the  cases  in  three  groups — simple  lymphangioma,  cystic 
lymphangioma,  and  cavernous  lymphangioma.  Chipault's2  classification 
is  based  chiefly  upon  the  part  especially  involved — whether  affecting  the 
lymph-glands,  the  main  lymphatic  channels,  or  the  plexuses,  and  with 
further  subdivisions,  based  upon  the  superficial  or  deep  situation  of  the 
process.  It  possibly  is  more  in  accord  with  histopathologic  findings, 
but  is  much  more  elaborate,  and,  considering  our  present  knowledge, 
probably  unnecessarily  so,  and  is  certainly  not  so  feasible  or  convenient 
as  that  of  Wegner.  Most  of  the  contributions  are  based  upon  the  latter, 
although  the  relationship  of  one  form  to  another  is  not  infrequently 
observed,  as  shown  in  the  contributions  on  the  subject  by  Hoggan,3 
Jarisch,4  Nasse,5  Leslie  Roberts,6  and  others.7 

In  some  cases  the  lymphatic  vesicular  dilatation  and  dilated  channels, 
or  lymphangiectasis,  are  not  the  consequence  of  a  primary  pathologic 
process  of  these  structures,  but  the  result  of  mechanical  injury  and  ob- 
struction, as  in  the  instances  of  Elliot,8  Besnier,9  and  others.  Lymphan- 

1  Wegner,  Arch.  f.  klin.  Chirurg.,  1877,  vol.  xx,  p.  641. 

2  Chipault,  Gaz.  des  Hop.,  1888,  p.  1329. 

3  Hoggan,  "Multiple  Lymphatic  Naevi  of  the  Skin  and  Their  Relations  to  Some 
Kindred  Diseases  of  the  Lymphatics,"  Jour.  Anal,  and  Phys.,  1884,  vol.  xxviii,  p.  304 
(with  histologic  cuts). 

4  Jarisch,  "Zur  Lehre  von  den  Hautgeschwiilsten,"  Archiv,  1894,  vol.  xxvui,  p.  164 
(with  15  histologic  cuts  and  review  of  the  subject  and  references). 

5  Nasse,  "Ueber  Lymphangiome,"  Arbeit,  aus  der  chirurg.  Klinik  der  Univ.  Berlin 
(Von  Bergmann),  fourth  part,  1890,  p.  i. 

•Leslie  Roberts,  "Five  Cases  of  Lymphangioma,"  Brit.  Jour.  Derm.,  1896,  p.  309 
(with  review  and  references).  8  See  literature  of  Lymphangioma  circumscriptum. 

7  Elliot,  Jour.  Cutan.  Dis.,  1894,  p.  13?  (vesicles  developed  at  the  edge  of  an  old 
scar,  the  manifestation  apparently  clinically  similar  to  lymphangioma  circumscnptum. 
but  histologic  examination  indicated  dilatation  of  the  lymphatic  capillaries,  probably 
due  to  obstruction). 

9  Besnier   quoted   by  Bowen,  Twentieth  Century  Practice,  vol.  v  (Diseases  of  th 
Skin),  p.  685 '(an  acute  form  of  lymphangiectasis  involving  penis  and  scrotum,  vesicles 
and  some  edema  developing  eight  days  after  a  contusion  of  the  penis). 


662  NEW  GROWTHS 

giectasis  is  not  only  sometimes  a  result  of  demonstrable  or  probably 
mechanical  obstruction  following  injuries,  but  it  is  likewise  a  part  of 
certain  maladies  in  which  the  same  factor,  while  doubtless  causative, 
is  not  always  so  evident,  as  in  elephantiasis.  Some  instances  are  also 
observed  in  which,  in  a  more  or  less  limited  region,  there  is  distinct  and 
pronounced  dilatation  of  the  lymphatic  vessels,  forming  elevated, 
doughy-feeling,  compressible,  cord-  or  knotted-chain-like  vessels.  Harda- 
way1  noted  such  a  case  in  a  woman  in  whom  both  thighs,  the  buttocks,  and 
lower  part  of  the  abdomen  presented  innumerable  varices  of  the  superficial 
lymph- vessels.  In  a  somewhat  similar  case  under  my  own  care,  in  a  man 
of  thirty,  the  whole  of  one  thigh,  more  especially  on  the  inner  and  anterior 
aspects,  was  the  seat  of  a  network  of  both  superficial  and  deep-seated  lym- 
phatic dilatations,  with  here  and  there  distinct  cystic  growths,  forming 
tumors  partaking  of  the  nature  of  both  lymphangioma  and  fibroma; 
the  color  of  the  covering  skin  is  usually  normal  or  slightly  purplish. 

Simple  lymphangioma  consists  usually  of  both  dilatation  and  new 
growth,  and  doubtless  the  examples  just  cited,  although  also  illustrating 
lymphangiectasis,  might  be  more  properly  considered  as  belonging  to 
this  group.  Ordinarily,  however,  the  formation  presents  as  isolated, 
or  adjacent  circumscribed,  compressible,  and  somewhat  elastic  swellings, 
variously  sized,  and  with  sometimes  dilated  lymphatic  channels  leading 
into  them.  They  may  be  seen  upon  any  part,  but  the  genitalia  and  lips 
and  mouth  are  the  most  frequent  localities.  Not  uncommonly  there 
may  be  some  edema  and  thickening,  and  a  condition  of  slight  elephan- 
tiasis results.  The  surface  is  sometimes  scantily  or  moderately  abun- 
dantly beset  with  transparent  vesicles,  which,  if  ruptured  or  broken, 
give  exit  to  fluid  exudation,  occasionally  a  more  or  less  prolonged  leakage. 
Bowen  observed  a  case  of  "a  boy  of  eighteen  who  presented  upon  the 
inner  side  of  the  thigh  a  large,  easily  compressible  tumor,  which  was 
surrounded  and  covered  by  small  vesicles,"  from  which,  when  punctured, 
"a  milky  fluid  continued  to  exude  for  a  long  period,  after  which  the  large 
tumor  diminished  greatly  in  size,  but  attained  its  former  dimensions  in 
a  short  time."  Such  lymphangiomata  upon  the  lips  usually  give  rise 
to  a  condition  designated  macrocheilia,  and  when  on  the  tongue,  to  macro- 
glossia.  Under  simple  lymphangioma  should  also  be  included,  I  believe, 
the  cases  reported  by  Van  Harlingen2  and  Pospelow,3  under  the  name 
lymphangioma  tuberosum  cutis  multiplex,  with  the  belief  that  they  repre- 
sented the  malady  previously  described  by  Kaposi.4  Leslie  Roberts5 
has  since  reported  a  similar  case.  Kaposi's  case,  and  also  a  similar  one 
since  described  by  Lesser  and  Beneke,6  belong,  however,  as  now  generally 

1  Hardaway,  quoted  byHersman,  Morrow's  System,  vol.  iii,  (Dermatology),  p.  512. 

2  Van  Harlingen,  "A  Case  of  Lymphangioma  Tuberosum  Cutis  Multiplex,"  Trans. 
Amer.  Derm.  Assoc.,  1881,  p.  28  (abstract  only— full  paper  never  published). 

3  Pospelow,  "Ein  Fall  von  Lymphangioma  tuberosum  cutis  multiplex,"    Arckiv 
1879,  p.  52i>(\\-ith  colored  case  illustration  and  histologic  cut). 

4  Kaposi,  Hebra  and  Kaposi,  Hautkrankheiten,  vol.  ii,  p.  282  (with  histologic  cuts). 
6  Leslie  Roberts,  loc.  tit.  (case  V). 

•  Lesser  and  Beneke,  Virchow's  Archiv,  1891,  vol.  cxxiii,  p.  86  (with  histologic  cuts), 
leidmgsfeld,  "Lymphangioma  Tuberosum  Multiplex,"  Jour.  Cutan.  Dis.,  1908,  p.  441, 
reports  a  case  typical  of  Kaposi's  case,  and  discusses  the  classification  of  the  various 
similar  and  allied  cases  (with  case  illustration,  histologic  cuts,  and  bibliography). 


LYMPHANGIOMA    CIRCUMSCRIPTUM  663 

believed,  to  the  increasing  and  somewhat  confusing  group  of  cases  classed 
under  benign  cystic  epithelioma  (q.  D.),  although  Kaposi  did  not  fully 
concede  this.  In  rare  instances,  as  in  the  cases  reported  by  Thibierge1 
and  Gottheil,2  the  lesions  present  some  clinical  resemblance  to  xanthoma 
growths. 

In  the  3  cases  of  Van  Harlingen  and  Pospelow  and  Roberts,  repre- 
senting apparently  true  lymphangiomatous  development,  the  lesions 
were  somewhat  numerous,  scattered,  varying  in  size  from  a  pin-head  to 
a  hazel-nut,  and  elastic  and  compressible;  the  integumental  covering 
was  apparently  normal,  although  mostly  of  a  rosy  or  a  violaceous  tinge; 
some  lesions  had  a  pale  violaceous  or  bluish,  translucent-looking  center. 
Associated  with  these  formations  was  a  somewhat  dingy  condition  of  the 
skin  and  spots  or  areas  of  pigmentation.  A  few  of  the  tumors  may  re- 
semble small,  flabby,  molluscum  fibrosum  growths,  but  for  the  most 
part  they  are  smooth,  rounded,  or  ovoidal  elevations,  and  so  compressible 
under  the  finger  as  to  feel  like  "bladders  filled  with  air  and  to  give  the 
sensation  similar  to  that  of  an  umbilical  hernia  in  a  child."  They  were 
free  from  inflammatory  action,  and  there  were  no  subjective  symptoms. 
The  three  patients  were  women,  aged  twenty-three,  thirty,  and  thirty- 
two.  Microscopic  examination  showed  the  structure  to  be  composed 
of  fibrous  and  granulation-cell  tissue,  with  numerous  irregular  spaces — 
sections  of  dilated  lymphatic  vessels  (Van  Harlingen). 

Cystic  lymphangioma,  another  of  Wegner's  classes,  needs  to  be  but 
cursorily  referred  to  here,  as  it  rarely  comes  under  the  observation  of 
the  dermatologist,  belonging  essentially  to  the  province  of  surgery,  to 
the  works  on  which  the  reader  is  referred  for  a  descriptive  account.  It 
is  usually  congenital  in  origin,  consisting  of  large  multilocular  cysts, 
most  commonly  seen  on  the  upper  part  of  the  neck,  in  which  region  they 
are  often  known  as  hygromata  colli.  In  this  locality  their  prolongation 
may  extend  somewhat  deeply,  going  in  between  the  muscles,  even  as  far 
as  the  mediastinum  (Bowen). 

Cavernous  lymphangioma,  the  other  group  in  Wegner  s  classification, 
as  it  is  commonly  observed  in  the  domain  of  dermatologic  practice  is 
that  form  of  lymphangioma  to  which  the  name  of  lymphangioma  c 
cumscriptum  is  given,  and  which  is,  therefore,  owing  to  its  importance 
given  separate  description.  While  it  has  in  its  purest  type  well-defined 
and  fairly  uniform  clinical  characteristics,  it  presents  in  some  instances, 
as  an  analytic  study  of  the  cases  reported  will  show  features  indicating 
a  relationship  to  other  types  of  lymphangioma  and  also  to  n^voi 

LYMPHANGIOMA  CIRCUMSCRIPTUM 

SWW,-Lymphangioma  cavernosum  (Besnier);  ^J 

inson);    Lymphangiectodes;    Lymphangioma    Mm£%^i.P5J ngiome7ystique 
simplex  (Unna);  Lymphangioma  capillare  vancosum  (Torok) , .fr. ,y          y 
(de  Smet  and  Bock);  Lymphangiome  circonscnt  vesicu 

Definition.-A  limited,  regional,  or  patch  eruption  connected 
with  the  lymphatics,  characterized  by  pin-head-  to  small  pe, 

1  Thibieige,  Ikonographia  Dermalologica,  1907,  p.  69. 

2  Gottheil,  Jour.  Culan.  Dis.,  1909,  P-  277- 


664  NEW  GROWTHS 

usually  somewhat  deep-seated,  often  red-dotted,  closely  crowded  thick- 
walled  vesicles. 

This  rare  disease,  for  which  the  name  lymphangioma  circumscrip- 
tum,  given  by  Morris,  seems  the  most  appropriate  one,  was  first  de- 
scribed by  Tilbury  Fox,  and  later  by  Hutchinson,  Kobner,  Noyes  and 
Torok,  Morris,  J.  C.  White,  Leslie  Roberts,  Francis,  Elliot,  Hartzell, 
Gilchrist,  and  others.1 

Symptoms. — The  type  of  this  rare  malady  is  represented  by  one 
or  several  contiguous  or  closely  adjacent  patches,  composed  of  vari- 
ously sized,  thick-walled,  frog-spawn-like,  grayish,  pinkish,  or  reddish 
vesicles,  somewhat  thickly  set  or  even  slightly  crowded  or  bunched. 
If  a  single  patch, — probably  the  most  frequently  observed, — it  is  usually 
made  up  of  two  or  three  aggregations,  with  here  and  there  a  few  discrete 
vesicles  between.  The  patch  varies  in  size  and  shape,  generally  i  to 
3  or  4  inches  in  its  largest  diameter,  andt  rather  irregularly  rounded 
or  ovalish.  The  lesions,  more  especially  the  smaller  and  more  recent 
ones,  present  a  glimmering,  translucent,  distinctly  vesicular,  grayish  or 
pearly  aspect;  in  some  cases  some  of  the  older  lesions  very  often  show 
epithelial  thickening  and  roughening,  and  the  translucency  is  lost,  and 
when  such  a  condition  is  predominant,  a  slightly  warty  appearance  is 
given  "to  the  individual  elevations  and  to  the  patch  as  a  whole.  Quite 
commonly,  on  the  covering  wall  of  the  vesicle,  minute  telangiectases  in 
the  form  of  dots  or  striae  are  to  be  seen.  This  feature,  if  conspicuously 

1  Literature:  Tilbury  and  Colcott  Fox,  London  Pathol.  Soc'y  Trans.,  1879,  vol.  xxx, 
p.  470  (with  histology);  Hutchinson,  ibid.,  1880,  vol.  xxxi,  p.  342  (2  cases  with  colored 
plates  and  histologic  report  by  Sangster),  and  Arch.  Surgery,  1889-90,  vol.  i,  plates  xv 
and  xvi  (of  above  2  cases  and  an  additional  one);  Kobner,  Virchow's  Archiv,  1883, 
vol.  xciii,  p.  343  (hand  and  arm,  somewhat  cavernous  development;  with  3  case 
illustrations),  also  full  translation  in  Annales,  1884,  p.  293;  Malcolm  Morris,  Inter- 
national Atlas,  1889,  plate  i  (colored  illustration  of  his  own  case  and  Hutchinson's  3); 
Noyes  and  Torok,  Brit.  Jour.  Derm.,  1890,  p.  359,  and  1891,  p.  8  (r6sume  and  critical 
review  of  cases  (4  of  which  do  not,  however,  come  under  this  disease)  to  date;  with 
histologic  examination,  cuts,  references);  Torok,  Monatshefte,  1892,  vol.  xiv,  p.  169 
(relation  to  angiokeratoma— critical  analysis  of  cases  and  principal  references)— abs. 
analysis  in  Brit.  Jour.  Derm.,  1892,  p.  397;  Schmidt,  Archiv,  1890,  vol.  xxii,  p.  529  (2 
cases,  i  of  upper  lip  and  oral  mucous  membrane;  2  histologic  cuts;  review  and  refer- 
ences)—abs.  analysis  in  Brit.  Jour.  Derm.,  1892,  p.  133;  Jamieson,  Edinburgh  Med. 
Jour.,  1890,  vol.  xxxvi,  p.  269  (case  demonstration,  with  notes) ;  Elliot,  New  York  Med. 
Record,  1891,  vol.  xxxix,  p.  561;  Besnier-Doyon,  French  translation  of  Kaposi,  vol.  ii, 
p.  380;  de  Smet  and  Bock,  Jour,  de  med.  de  chirurg.  et  de  pharmacol.  Bruxelles,  1891 
vol.  xcn  p.  495;  Hartzell,  Medical  News,  1892,  Jan.  16  (with  a  resume  of  8  previously 
reported  cases  and  references);  Epstein,  Jour.  Cutan.  Dis.,  1892,  p.  213  (2  illustrations- 
a  somewhat  anomalous  case,  seated  about  the  genitalia,  lower  abdomen,  and  left 
buttock,  beginning  when  aged  twenty-four,  and  tending  to  disappear);  Francis,  Brit. 
Jour  Derm.  1893,  pp.  33  and  65  (7  cases— i  or  2  not  clearly  denned,  with  resume  and 
analysis  of  all  previously  reported  cases);  another  case,  ibid.,  p.  364;  J.  C.  White,  Jour. 
Lilian.  DM.,  1894,  p.  474;  Leslie  Roberts,  Brit.  Jour.  Derm.,  1896,  p.  309  (c  cases  of 
lymphangioma— various  types);  Gilchrist,  Johns  Hopkins  Hosp.  Bull.,  1896,  p  1*8 
Cwith  histologic  cut);  Colcott  Fox,  Brit.  Jour.  Derm.,  1896  (case  demonstration); 
Malcolm  Morris,  ,btd.,  1898,  p.  52  (case  demonstration);  Walsh,  ibid.,  p.  «8  (case 
demonstration- involving  eye  and  eyelids);  Freudweiler,  Archiv,  1897,  vol.  xli  p.  323 
colored  case  illustration,  histologic  cuts,  review,  and  references);  Brocq  and  Bernard 
Annales,  1898,  p  305,  "Sur  le  lymphangiome  circonscrit  de  la  peau  et  des  muqueuses" 
(an  elaborate  and  exhaustive  review  of  the  whole  subject,  with  resumg  and  references 
histologic  cuts);  Pawlof,  Monatshefte,  1899,  vol.  xxix,  p.  53  (with  2  histologic  cuts, 
and  with  review  of  histologic  findings  and  references);  Waelsch,  Archiv,  1900,  vol  li  p. 
97  (with  2  colored  plates  and  historic  review):  Pollitzer,  Jour.  Cutan.  Dis.,  1906  p. 
493  (2  cases,  histologic  with  illustrations). 


LYMPHANGIOMA    CIRCUMSCRIPTUM  665 

developed,  lends  to  the  lesions  a  pinkish  or  pinkish-red,  opalescent  aspect, 
and  in  some  instances  (Hutchinson)  so  marked  as  more  or  less  completely 
to  mask  their  usual  color.  In  some,  from  rupture  of  these  minute  capil- 
lary vessels  and  admixture  of  the  excaped  blood, — usually  minute  in 
quantity, — a  deep-red,  purplish,  or  blackish  look  is  given  the  vesicles. 
In  a  well-marked  patch  of  long  duration  it  is  usual  to  find,  therefore, 
clear  shining  vesicles,  vesicles  capped  with  red  dots  or  striae,  purplish  or 
blackish  lesions,  and  wart-like  elevations.  The  lesions  are  firm  and,  as 
a  rule,  thick  walled  and  not  easily  ruptured,  although  presenting  a  vesic- 
ular appearance,  which  can  readily  be  corroborated  by  pricking,  the  dis- 
charge being  slight,  but  sometimes  leakage  being  continued  for  some 
minutes  or  an  hour  or  two.  In  occasional  cases,  as  in  White's  patient, 
there  is,  in  places,  crusting  of  very  firm  consistence,  of  a  yellow  or  reddish 
color,  formed  apparently  by  the  coagulation  of  the  contents  of  the  vesicles, 
and  is  quite  tough  and  somewhat  persistent. 

In  several  instances  (Besnier  and  Doyon,  Hutchinson,  J.  C.  White, 
and  others)  the  part  and  immediate  vicinity  have  exhibited  a  recurring 
erysipelatous  inflammation,  in  all  probability  accidental,  or  possibly  of 
the  same  character  as  observed  in  other  maladies  with  lymphatic  in- 
volvement. As  a  rule,  there  is  but  little  if  any  distinct  elevation  of  the 
skin  area  in  which  the  lesions  are  seated;  in  some  cases,  however,  there 
is  an  underlying  naevoid,  tumor-like  elevation,  and  in  others  an  under- 
lying basis  of  lymphatic  dilatation,  and,  on  the  extremities,  a  varicose 
condition  of  the  veins;  these  cases  are  somewhat  questionable  and  anom- 
alous, although  the  surface  lesions  and  characters  are  identical.  The 
eruption  may  be  on  almost  any  part,  but  the  shoulders,  neck,  and  scapu- 
lar region  are  favorite  localities.  According  to  Schmidt  and  Brocq  and 
Bernard,  the  lips  and  mouth  may  also  be  the  seat  of  the  malady.  The 
eruption  is  persistent,  although  some  of  the  vesicles  disappear,  others 
taking  their  place;  and  there  may  be  some  variation,  but,  as  a  rule,  the 
area  is  gradually  extended.  Occasionally,  as  in  i  (Hartzell's  case)  of 
the  2  cases  under  my  observation  for  some  time,  there  was  a  gradual 
shifting  of  the  area,  progressing  at  one  side  and  receding  at  the  other 
and,  according  to  Hartzell,  several  years  later  the  entire  patch  had 
moved  from  the  scapular  region  to  the  summit  of  the  shoulder,  the  former 
site  showing  some  slight  atrophy  of  the  skin,  faint  pigmentation,  and  here 
and  there  a  few  small,  isolated  papules.  There  are  no  subjective  symp- 
toms except  those  due  to  accidental  circumstances.  ^ 

Etiology.— With  few  exceptions  the  malady  has  begun  in  infancy 
or  early  childhood,  and  it  is  quite  probable  that  in  most  of  them  it  was 
congenital.     It  is  observed  in  both  sexes.     In  some  ca ses  it  has  been  as 
sociated  with  n*vi  (Besnier  and  Doyon,  Fox,  Pye-Smith    and  o the    ). 
In  several  instances  lesions  and  lesional  groups  apparently  represent  ng 
this  same  malady,  though  possibly  due  to  mechanical  ^^*£*J 
Ivmphatics    have  developed  at  the  border  of  a  scar  following  surg, 
opratfon      Development-recurrences-at    the    border    of   piously 
cauterized  patches  of  the  disease  has  also  been  not 

t  Pye-Smith,  Diseases  of  the  Skin,  p.  359  (appearing  upon  a  large  congenital  por 
wine-stain). 


666  NEW  GROWTHS 

Pathology. — The  histologic  conditions  have  been  investigated 
by  most  of  the  observers  already  named  (see  literature).  The  process 
has  its  seat  more  especially  in  the  papillary  and  subpapillary  layers  of 
the  corium,  and  is  now  generally  agreed  to  be  of  lymphatic  origin.  It 
consists  of  lymphatic  dilatation  as  well  as  new  growth  of  these  vessels, 
resulting  in  somewhat  flask-  or  funnel-shaped  cavities.  De  Smet  and 
Bock  take  issue  with  this  generally  accepted  conclusion  and  consider  these 
cavities  or  cysts  to  have  their  origin  in  the  capillaries  of  the  papillary 
layer.  Torok  believes  that  both  the  lymphatics  and  blood-vessels  are 
concerned  in  the  process;  mainly,  however,  the  former.  It  would  seem, 
from  a  clinical  standpoint,  as  well  as  from  histologic  findings  by  several 
observers,  that  this  has  considerable  basis,  capillary  dilatation  and  new 
blood-vessel  formation  being  quite  pronounced  in  some  instances,  al- 
though practically  absent  in  others.  In  fact,  Besnier  and  de  Smet  and 
Bock  question  the  propriety  of  classing  all  the  reported  cases  together, 
believing  that  some  are  pseudo-lymphangiomata;  not  lymph  vascular 
growths  at  all,  but  true  hemangiomata,  in  which  the  blood-cysts  have 
become  filled  with  serum  and  converted  into  clear  vesicles  (Jacquet). 
Gilchrist  examined  several  differently  sized  lesions  and  found  them  all 
to  consist  not  only  of  dilated,  but  also  hypertrophied,  lymphatics  of  the 
papillary  (principally)  and  middle  layers  of  the  corium.  Sangster's 
investigations  led  him  to  believe  that  the  deeper  cavities  are  dilated 
lymphatic  channels,  while  those  more  superficially  seated  are  to  be  as- 
cribed to  distention  and  rupture  of  the  lymph-spaces  in  the  papillary  layer. 
The  cavities  are  often  divided  into  several  subdivisions  by  septa  formed 
of  the  unaltered  corium,  and  a  well-marked  layer  of  cells  can  be  traced, 
forming  an  endothelial  lining  to  the  cavities  (Bowen).  Bowen  also  found 
some  infiltration  of  round-cells  around  the  cysts  and  cavities  in  the  earli- 
est stage  of  the  lesions,  but  none  in  other  parts  of  the  cutis,  and  Gilchrist 
also  noted  collections  of  mononuclear  cells  in  the  corium.  The  epidermis 
commonly  shows  but  little  change,  in  some  places  being  slightly  thinned, 
in  others  thickened.  The  vesicular  covering  usually  consists  of  the  entire 
epidermic  layer,  and  sometimes  a  well-defined  thin  layer  of  connective 
tissue ;  hence  their  firm  and  not  readily  ruptured  character.  The  pig- 
ment in  the  deep  cells  of  the  rete  is  frequently  observed  to  be  increased. 
The  contents  of  the  cysts  consists  of  very  finely  granular  matter,  lymph 
coagula,  a  scanty,  though  variable  number  of  leukocytes,  and  occasion- 
ally a  slight  admixture  of  blood. 

Diagnosis. — The  character  of  the  area,  beginning  usually  in 
early  life  and  consisting  of  aggregated  and  crowded  yellowish  or  grayish, 
somewhat  translucent,  deep-seated,  tough  vesicles,  some  often  with  a 
rough,  thickened  covering,  and  others  with  red  dots  or  striae,  and  occa- 
sionally one,  several,  or  more  with  purplish  or  blackish  contents,  are 
sufficiently  striking  as  to  prevent  confusion  with  any  other  malady. 

Prognosis  and  Treatment.— There  is  but  little,  if  any,  tendency 
to  spontaneous  disappearance,  but,  on  the  contrary,  there  is  a  disposition 
to  extend,  although  individual  vesicles  often  disappear.  Treatment 
consists  in  thorough  removal  by  cauterization,  curet,  or  other  means. 
There  is,  however,  a  tendency  to  reappear  at  the  edge  of  the  scar,  and 


MULTIPLE,    BENIGN,    TUMOR- LIKE  NEW  GROWTHS       667 

recurrence  is  almost  a  certainty  if  the  removal  has  not  been  radically 
complete.  In  a  few  instances  electrolysis  has  been  employed  with  a 
favorable  influence;  each  vesicle  should  be  treated,  and  the  whole  area 
gradually  gone  over. 

MULTIPLE,  BENIGN,  TUMOR-LIKE  NEW  GROWTHS 

Under  the  name  of  multiple,  benign,  tumor-like  new  growths  a  case 
has  been  pictured  and  described  by  Schweninger  and  Buzzi,1  charac- 
terized by  lentil-  to  bean-sized,  whitish  or  bluish-white,  rounded  or 
slightly  flattened,  circular  or  oval  projections,  the  larger  somewhat  puck- 
ered. They  seem  hollow,  and  when  one  is  pressed  in  with  the  finger,  it 
can  usually  be  pushed  below  the  level  of  the  surface  into  a  concave  de- 
pression; immediately  upon  withdrawing  the  finger  it  springs  up  again. 
In  short,  they  present  the  physical  characteristics  of  an  elastic,  hollow, 
bladder-like  tumor.  The  smaller  beginning  formation  is  usually  rounded, 
and  when  moderately  developed,  is  frequently  more  elastic  than  the  older, 
larger,  and  often  somewhat  flattened  growth.  A  variable  degree  of  spon- 
taneous involution  takes  place,  although  they  do  not  actually  disappear, 
merely  becoming  more  flaccid,  with  the  skin  slightly  atrophic,  and  with 
usually,  minute  scar-like  depressions  or  striations.  They  appear  slowly, 
and  at  first  there  are  relatively  few,  but  the  addition  of  new  tumors  from 
time  to  time  finally  results  in  a  variable,  but  usually  considerable,  num- 
ber. According  to  Crocker,2  the  malady  has  also  been  observed  by  Mal- 
colm Morris,  Colcott  Fox,  and  Van  Hoorn.  I  have  met  with  a  similar 
instance  in  a  middle-aged  woman,  with  30  to  40  such  bladder-like  tumors 
over  the  region  of  the  right  shoulder  and  immediately  adjacent  part  of 
the  back;  they  were  of  extremely  slow  development,  and,  as  in  the  other 
cases,  gave  rise  to  no  subjective  symptoms.  Over  the  well-developed 
and  older  tumors  the  integument  was  distinctly  atrophic  or  cicatricial 
looking,  but  soft  and  elastic. 

The  shoulders,  trunk,  and  thigh  are  favorite  situations.  There  has 
been  no  recognizable  cause.  Of  the  5  cases,  4  were  women.  Histo- 
logically,  Buzzi's  findings  show  that  the  skin  alone  is  involved  in  their 
formation,  the  elastic  fibers  being  absent  in  the  main  part  of  the  cov- 
ering integument,  and  in  increased  quantity  peripherally.  This  passive 
retraction  or  atrophy  of  the  elastic  tissue  appeared  to  be  the  essential 
and  primary  factor  of  the  pathologic  process,  and  recognizable  in  all 
the  lesions,  whether  small  or  large,  and  this  fact  would  place  the  tumors 
among  the  atrophies,  although  in  their  appearance,  projection,  etc., 
clinically  they  would  naturally  be  placed  among  the  new  growths. 
Round-cell  collections  were  noted  about  the  superficial  horizontal  capil- 
lary network  and  about  the  vessels  of  the  glandular  structures;  the  seba- 
ceous glands  showed  enlargement.  No  influence  is  to  be  expected 
treatment. 

1  Schweninger  and  Buzzi,  International  Atlas  of  Rare  Skin  Diseases,  1891,  vol.  v, 

plate  xv. 

2  Crocker,  Diseases  of  the  Skin,  third  edit.,  p.  702. 


668  NEW  GROWTHS 

XANTHOMA 

Synonyms.— Xanthelasma  (Wilson);  Vitiligoidea  (Addison  and  Gull);  Fibroma 
lipomatodes  (Virchow);  Fr.,  Xanthome;  Plaques  jaunatres  des  paupieres  (Rayer); 
Molluscum  cholesterique  (Bazin). 

Definition.— A  slightly  elevated,  flattened,  or  somewhat  rounded, 
soft,  neoplastic  growth  of  a  yellowish  color,  usually  seated  as  one,  several, 
or  more  lesions  about  the  eyelids,  and  occasionally  of  more  or  less  general 
distribution.  There  are  two  varieties  observed — xanthoma  planum  and 
xanthoma  tuberculatum  seu  tuberosum;  in  the  former  the  lesions  are 
flat  or  plate-like,  and  usually  seated  about  the  eyelids;  in  the  latter, 
rounded  and  nodular,  and  somewhat  general  in  distribution  (xanthoma 
multiplex).  This  last  term  is  also  applied  to  the  mixed  type,  which, 
however,  is  almost  invariably  more  or  less  disseminated. 

Symptoms. — Xanthoma  Planum.1 — This,  the  macular  or  plane 
variety,  is  usually  seen  about  the  eyelids  (xanthoma  palpebrarum), 
and  consists  of  one,  several,  or  more  small  or  large,  round  or  elongated, 
smooth,  opaque,  yellowish  patches,  sharply  defined  and  often  slightly 
raised,  and  looking  not  unlike  pieces  of  chamois  leather  implanted  in 
the  skin.  Their  first  appearance  is  probably  most  commonly  on  or  near 
the  inner  canthus  on  the  upper  lid,  and,  it  is  alleged,  more  frequently  the 
lid  of  the  left  eye.  As  a  rule,  however,  when  medical  attention  is  directed 
to  the  blemish,  the  growth  is  to  be  seen  on  the  lids  of  both  eyes.  From 
my  own  experience  I  cannot  say  that  the  upper  is  more  frequently  in- 
vaded than  the  lower.  Usually  the  patches  are  to  be  found  on  both 
lids,  more  or  less  symmetrically  arranged.  There  may  be  but  several 
present,  or  the  eyes  may  be  more  or  less  surrounded  by  an  apparently 
continuous  band.  In  most  cases,  however,  there  are  several  closely 
contiguous  patches,  which,  unless  closely  inspected,  seem  to  be  fused 
into  one  strip.  The  growth  is  smooth,  scarcely  elevated,  soft  and  com- 
pressible, and  of  a  lemon-  or  orange-yellow  color,  more  frequently  a 
dingy  lemon  hue,  which  becomes  more  pronounced  when  the  skin  is  put 
upon  the  stretch.  Examined  closely,  especially  if  the  skin  is  stretched, 
or  with  a  magnify  ing-glass,  the  patch  resolves  itself  into  numerous, 
crowded,  small  yellowish  spots,  each  with  a  minute  pinkish  or  reddish 
central  point.  The  surface  of  the  skin  overlying  the  yellow  plaques  is 
apparently  normal  and  free  from  scaliness.  Occasionally,  instead  of  a 
yellow  hue,  a  whitish  or  creamy  color  is  observed,  and  exceptionally, 
especially  in  some  lesions,  the  color  may  be  much  darker  than  usually 
observed — from  a  dark  yellow  to  a  deep  brown;  a  rare  instance  of  the 
latter  was  noted  by  G.  H.  Fox,2  in  which  the  xanthoma  band,  in  a  male, 
of  eleven  years'  duration,  was  roughly  suggestive  of  an  ecchymosis. 
Their  growth  is,  as  a  rule,  exceedingly  slow,  several  years  or  more  usually 
elapsing  before  they  have  attained  considerable  dimensions.  Exception- 
ally, in  addition  to  the  patches  on  the  eyelids,  the  spots  are  also  observed 

1  Hutchinson,  London  Med.-Chirurg.  Soc'y  Trans.,  1871,  p.  171,  has  contributed  a 
valuable  paper  on  xanthoma  palpebrarum,  based  upon  36  cases  under  his  own  care — 
cases  are  detailed  and  tabulated:  he  also  gives  another  table  of  7  cases  observed  by 
others,  of  which  3  are  of  the  multiplex  variety. 

2  G.  H.  Fox,  Jour.  Cutan.  Dis.,  1889,  p.  103  (case  demonstration). 


XANTHOMA  669 


beyond  the  lids,  on  other  parts,  and  even  in  the  mouth;  as  a  rule,  however, 
in  the  latter  cases  the  growths  are  of  the  nodular  type,  and  sometimes  of 
mixed  character.  There  are  no  subjective  symptoms,  although  excep- 
tionally occasional  itching  or  burning  is  experienced. 

Xanthoma  tuberculatum  seu  tuberosum  (xanthoma  multiplex)1  is,  as 
the  qualifying  term  signifies,  of  a  nodular  character.  In  most  respects 
the  growths  are  similar  to  those  of  the  plane  variety,  but  they  are  usually 
rounded  in  outline,  somewhat  elevated,  and  are  either  soft  or  of  moder- 
ately firm  consistence.  They  are  rarely  found  about  the  eyes,  but  on 
other  parts,  and  as  a  rule  more  or  less  general  in  distribution.  Excep- 
tionally the  palms  are  also  involved,  presenting  a  yellowish  white,  flat- 
tened infiltration  along  the  main  lines.  The  growths  average  a  small 
pea,  but  are  often  crowded  together  into  groups,  bunches,  or  almost 
solid  plaques.  In  some  cases  the  nodules  are  noted  to  have  a  pinkish 
periphery,  especially  in  their  formative  period.  Exceptionally  they  may 
reach  considerable  dimensions,  usually  due  to  coalescence  of  several  of 
the  growths.  An  instance  of  this  kind  was  observed  by  Lehzen  and 
Knauss,2  the  patient  being  a  child,  some  of  the  growths  reaching  the  size 
of  an  egg.  Similar  tumors,  although  not  quite  so  large,  have  also  been 
observed  by  Carry  and  Chambard.3  In  general  cases  certain  parts  are 
most  frequently  the  sites  of  the  lesions,  such  as  the  hands,  about  the  el- 

i  Xanthoma  multiplex-important  literature:  Committee  Report  (Hutchinson 
Sangster  and  Crocker)  of  London  Patholog.  Soc'y,  Transactions  for  1882  p  37.6  (with 
an  analytic  tabulation  of  23  cases  in  adults,  with  associated  jaundice,  a  tabulation  of  5 
SsesTn  adults  without  jaundice,  and  a  tabulation  of  8  cases  in  which  the  disease  was  con- 
Snlaror  appeared  before  puberty) ;  Torok  («De  la  nature  des  ^^^"jfe 
T8n?  nr>  i  TOO  and  1261  (an  exhaustive  report  with  references,  and  a  detailed  analytic 

&iESSSSE^fe"^SS 

during  the  past  few  years  by  Dehot   . Richter,  Farkes  weoe  ^  in 

Sheaths,  Brit.  Jour   Derm.,  wo,?.    op>,«l      « ftma  ^uberosum  Multiplex  Mistaken 


cutis  disseminata,  with  good  blH1OgyaS,,  'rRRn  vol  cxvi  p.  85  (with  case  illustration 

2  Lehzen  and  Knauss,  Virchow's  Archtv,  18 

and  4  histologic  cuts).  rhambard   Arch  de  phys.  norm,  et  pathol.,  1879,  P- 

"       '  '  -  -  •  "-d 


chin,  and  5  colored  histologic  cuts). 


670 


GROWTHS 


bows  and  knees,  the  buttocks,  and  the  feet;  the  face,  and  especially  about 
the  eyes,  also  frequently  shares  in  the  eruption.  Occasionally  the  dis- 
tribution or  grouping  is  somewhat  unusual  or  anomalous.  In  Morrow's1 
case  the  lesions,  which  were  somewhat  hard,  were,  for  the  most  part, 
limited  to  the  soles,  with  some  lesions  about  the  knees  and  some  pre- 
viously upon  the  palms.  In  2  instances  —  brothers  —  of  somewhat  ex- 
tensive eruption  observed  by  Mackenzie,2  some  was  disposed  in  ridges 
and  lines,  and  in  both  cases  with  an  almost  continuous  band  of  some  width 
around  the  neck. 

Jaundice  is  a  usual  precursory  or  associated  symptom  in  xanthoma 
multiplex  in  the  adult,  although  not  invariably  present;  in  children,  in 
whom,  however,  the  malady  is  less  frequent,  it  is  always  wanting.  The 
eruption  in  the  latter  is  quite  extensive,  usually  more  so  than  in  adults, 
a  most  remarkable  example  of  which  has  been  reported  in  recent  years 
by  Jackson,3  in  a  young  child,  covering  a  greater  part  of  the  surface. 
In  children  the  eruption  exhibits  nothing  in  any  way  different  from  that 
in  adults;  while  usually  abundant,  it  is  sometimes  quite  scanty,  consisting 
of  but  one,  several,  or  more  patches,  as  in  the  cases  referred  to  by  Crocker,4 
Torok,  and  others;  and  in  some  of  these  instances  the  patches  were  small, 
several  of  the  patients  coming  under  medical  inspection  accidentally. 
Doubtless  some  of  the  reported  cases  in  children  have  been  anomalous 
or  striking  types  of  nodular  pigmented  urticaria,  and  a  few  possibly 
similar  to  cases  recently  recorded  by  McDonagh5  as  "Naevo-Xanthoma- 
endotheliomata,"  in  which  the  lesions  were  distinctly  xanthoma-like. 
There  is  no  question  at  all  that  other  organs  than  the  skin  can  also  be 
the  seat  of  xanthoma,  as  shown  in  some  autopsies.  The  mouth  and  lips, 
as  already  referred  to,  sometimes  share  in  the  eruption,  although  seldom 
and  only  to  a  slight  extent.  The  eye  itself,  in  rare  instances,  has  been 
noted  to  become  involved.  In  von  Graefe's  case,  quoted  by  Virchow,6 
and  also  referred  to  by  Pye-Smith,7  the  growths  were  observed  on  the 
cornea  as  well  as  in  other  parts. 

Ordinarily  xanthoma  develops  gradually:  xanthoma  palpebrarum 
always  slowly;  occasionally,  however,  in  the  multiplex  variety  several 
months  suffice  to  show  considerable  eruption,  and  exceptionally,  as 
in  Korach's8  case,  extensive  development  was  reached  in  a  few  weeks. 
The  course  of  xanthoma  of  either  variety  is  chronic  and  slowly  progres- 
sive, with  but  little,  if  any,  tendency  to  undergo  involution,  although  this 

1  Morrow,  Jour.  Cutan.  Dis.,  1893,  p.  i  (with  colored  plate). 

2  Mackenzie,  London  Patholog.  Soc'y  Trans.,  1882,  p.  370. 

3  G.  T.  Jackson,  Jour.  Cutan.  Dis.,  1890,  p.  241  (with  colored  plate,  with  references 
to  other  general  cases). 

4  Crocker,  Diseases  of  the  Skin,  third  edit.,  p.  742. 

'McDonagh,  Brit.  Jour.  Derm.,  1912,  p.  87  (with  case  and  histologic  illustrations; 
special  form  of  multiple  growths  in  the  skin,  which  are  conspicuous  from  their  yellow 
color;  sometimes  commencing  as  red  tumors,  like  angiomata,  to  become  yellow  later; 
present  at  birth  or  appearing  later;  they  may  persist  for  many  years,  but  tend  to  ulti- 
mate spontaneous  cure;  histologic  examinations  indicate  that  they  are  naevi  of  the 
type  endothelioma,  and  owing  to  a  fatty  change  occurring  in  the  cells  during  their 
dissolution  xanthoma-like  condition  is  produced). 

8  Virchow,  Virchow'  s  Archiv,  1871,  vol.  Hi,  p.  504. 

7  Pye-Smith,  Guy's  Hasp.  Reps.,  1877,  vol.  xxii,  p.  97,  refers  also  to  various  other 
xanthoma  cases. 

8Korach,  Deutsche  med.  Wochenschr.,  1881,  p.  329. 


XANTHOMA  6?  I 

is  sometimes  observed  in  a  few  lesions  in  the  multiplex  variety,  and  ex- 
ceptionally this  latter  has  shown  a  tendency  to  complete  disappearance 
(Fagge,  F.  Smith,  Legg,  and  Kaposi).1 

Htiology. — While  xanthoma  planum  (xanthoma  palpebrarum) 
and  xanthoma  multiplex  have  been  thought  to  be  the  same  disease, — 
certainly  in  their  clinical  aspects  suggestive, — yet  they  differ  in  some  of 
their  etiologic  factors,  and  these  varieties  can  be  more  conveniently  con- 
sidered separately.  Xanthoma  palpebrarum  is  not  uncommon  and  is 
essentially  a  disease  of  adults,  rarely  being  observed  in  children,  and  it  is, 
moreover,  much  more  frequent  in  females.  Hutchinson's  analytic  table 
makes  the  proportion  3  women  to  2  men,  but  this  seems  much  larger  than 
dermatologic  observation  would  indicate.  This  careful  observer  also  states 
that  in  half  of  his  cases  the  patients  were  subjects  of  migraine,  and  one- 
sixth  had  suffered  with  jaundice.  Gouty  and  rheumatic  conditions, 
utero-ovarian  derangements,  and  other  affections  have  variously  seemed 
in  certain  cases  to  be  of  influence,  but  it  is  doubtful  whether  they  are  more 
than  accidental,  or,  at  the  most,  contributory.  There  is,  however,  a 
factor  which  is  noted  sufficiently  often  to  be  of  probable  import,  and  that 
is  heredity.  In  Church's2  cases,  often  quoted,  there  were  3  cases  in  each 
of  two  succeeding  generations;  and  Wilks3  also  observed  it  in  mother  and 
daughter;  Fagge4  also  in  mother  and  daughter,  in  whose  family  there 
was  a  history  of  the  malady  for  four  generations.  Hutchinson8  observed 
it  in  two  brothers  whose  paternal  grandfather  had  also  had  it. 

Xanthoma  multiplex  is  rare,  although  recorded  cases  are  gradually 
approaching  a  considerable  number.  It  is  met  with  both  in  children 
and  adults  and  in  both  sexes.  In  children  it  may  be  congenital,  or  de- 
velop in  the  earlier  years  of  life,  and  the  eyelids  do  not  commonly  share 
in  the  eruption  nor  is  jaundice  observed.  In  some  of  these  instances 
(children)  there  seems  to  be  a  family  prevalence;  Mackenzie6  had  under 
observation  3  cases  in  a  family  of  7  children,  and  Startin7  a  brother  and 
sister,  and  Thibierge8  two  brothers.  The  tabulations  referred  to  fur- 
nish additional  examples. 

Jaundice  is,  as  before  remarked,  often  associated  with  multiple 
xanthoma  in  the  adult— in  23  out  of  the  28  cases  tabulated  by  the  London 
Pathological  Society  Committee.  Schwimmer9  quotes  the  following 
proportions,  based,  however,  upon  totals  of  both  varieties  combined: 
Kaposi,  15  in  27  cases;  Chambard,  22  in  58  cases;  in  10  consecutive  cases 
of  his  own,  including  2  cases  of  xanthoma  multiplex,  icterus  was  not 
observed  in  a  single  instance. 

Kaposi,  Hardaway,  and  others  are  inclined  to  consider  the  jaundice 
not  as  a  causative  factor,  but  as  probably  due  to  development  . 

1  London  Path.  Soc'y  Committee  Report  (loc.cit). 

2  Church,  quoted  by  Mackenzie,  London  Patholog.  Soc  y  Trans.,  i* 

P'  3'°Wilks,  ibid.,  vol.  xix,  p.  446  (also  quoted  by  Mackenzie). 

4  Fagge,  quoted  by  Crocker,  Diseases  of  Skin. 

5  Hutchinson,  loc.  cit. 

*  Trans.,  l882,P.373  (with  colored  plate). 

Handbook  of  Diseases  of the  Skin,p.  577- 


672  NEW  GROWTHS 

xanthoma  growths  in  the  liver,  a  view  which,  I  believe,  has  much  in  its 
support.  Autopsies  have  furnished  evidence  both  for  and  against  its 
causative  influence,  the  liver  often  being  found  uninvolved,  and  in  other 
cases  exhibiting  various  diseased  conditions.  According  to  Besnier 
and  a  few  others,  the  yellow  color  is  not  always  due  to  jaundice,  but  the 
disease  itself  may  be  responsible  for  the  cutaneous  discoloration — 
xanthodermic,  as  Besnier  designates  it. 

Pathology.— Xanthoma  is  a  benign,  connective-tissue,  new- 
growth  development,  possibly  of  mildly  inflammatory  origin,  with  con- 
comitant or  subsequent,  but  usually  partial,  fatty  degeneration.  The 
suggestion  of  a  diathesis  originating  in  the  digestive  apparatus,  leading 
to  hepatic  derangement,  has  been  advanced  as  a  pathologic  factor;  and 
Quinquaud's  assumption  that  there  may  be,  from  some  unknown  cause, 
a  surcharge  of  the  blood  with  fatty  elements,  is  practically  supported 
in  part  by  Pollitzer's  investigations.  Under  such  a  supposition  the 
xanthoma  multiplex  cases  could  readily  be  explained  by  the  additional 
determining  factor  of  local  irritation,  as  those  sites— hands,  elbows, 
buttocks,  knees,  and  feet — which  are  always  subject  to  knocks,  frictions, 
and  the  like  are  the  parts  upon  which  the  eruption  is  commonly  or  most 
abundantly  seen.  Histologic  studies  made  by  Pavy,  Chambard,  Balzer,1 
Teuton,2  Crocker,  Pollitzer,3  Torok,  and  others  are  all  agreed  in  essential 
facts  as  to  conditions  found,  but  differ  as  to  whether  or  not  the  process  is 
primarily  an  inflammatory  one,  an  opinion  supported  by  Chambard, 
Crocker,  and  others,  while  Teuton  is  the  most  insistent  as  to  the  opposite 
view.  Up  to  recent  years  there  was  more  or  less  unanimity  as  to  the 
histologic  identity  of  the  two  types,  but  Pollitzer's  and  Unna's  investiga- 
tions indicate  that  the  two  types  are  quite  distinctive;  Pollitzer  believing 
xanthoma  tuberosum  represents  an  irritative  connective-tissue  hyper- 
plasia,  in  which  the  extravasation  of  cholesterol-fatty-acid-ester  present 
in  excess  in  the  blood,  serves  as  the  stimulus;  and  it  is  this  particular 
lipoid  which  constitutes  the  greater  portion  of  the  fatty  substance  in  the 
cells.  Excepting  sometimes  slight  thinning  and  some  pigment  staining 
and  deposit  of  yellowish  pigment  granules  in  the  rete,  the  epidermis  shows 
but  little  alteration,  at  times  some  of  the  lower  rete  cells  showing  slight 
atrophic  changes  and  vacuolation.  The  chief  changes  are  noted  in  the 
corium,  especially  in  the  middle  and  lower  layers.  Large  cells  rilled  with 
fat  granules  and  closely  aggregated  fat-drops  having  a  defined  membrane 
and  a  large,  sometimes  several  or  more,  nuclei,  are  found  lying  between 
the  bundles  of  connective  tissue,  constituting  the  so-called  "xanthoma 
cells" — "xanthoma  giant-cells."  Transition  cell-formations  are  also  to 
be  seen.  These  cells  vary  somewhat  in  size,  some  being  small,  others 
quite  large,  and  are  found  in  considerable  numbers,  sometimes  massed 
together  in  groups,  frequently  around  and  following  a  blood-vessel ;  some 
may  at  times  be  found  in  the  subcutaneous  tissue,  although  this  latter 

1  Balzer,  Arch,  de  physiologic,  1884,  vol.  iv,  p.  65  (with  references). 

2  Teuton,  Archiv,  1885,  vol.  xii,  p.  3,  with  histologic  illustrations  and  references. 

3  Pollitzer,  "Nature  of  the  Xanthomata,"  New  York  Med.  Jour.,  1809,  ii,  p.  73  (a 
histologic  study,  with  1 1  illustrations  and  references) ;  "  The  Nature  of  Eyelid  Xantho- 
mata," Jour.  Culan.  Dis.,  1910,  p.  633,  with  histologic  plates;  and  Pollitzer  and  Wile, 
ibid.,  1912,  p.  235  (with  histologic  plates). 


XANTHOMA  673 

structure  is,  as  a  rule,  practically  unchanged.  The  glandular  structures 
show  but  little  alteration.  Connective-tissue  increase  is  usually  a  pro- 
nounced feature,  varying  considerably  in  degree. 

Pollitzer,  from  investigations  of  tissue  from  xanthoma  palpebrarum, 
believes  the  xanthoma  cells  to  be  fragments  of  degenerated  muscle- 
fibers,  and  the  process  a  slow,  fatty,  muscle-fiber  degeneration  of  the 
orbicularis  muscle— and  that  it  belongs  not  to  the  neoplasms,  but  to  the 
degenerations,  like  colloid  degeneration  of  the  skin.  Unna  also  considers 
this  muscle  an  important  factor,  believing  that  the  fatty  bodies  were 
simply  deposits  of  a  peculiar  fatty  substance  between  the  muscular  and 
collagenous  bundles  into  which  naked  endothelial  nuclei  had  escaped. 
The  color  of  xanthoma  is  assumed  to  be  due  to  the  abundant  fat-granules 
present.  According  to  investigations  by  both  Torok  and  Unna  it  would 
seem  that  in  xanthoma  we  have  a  special  form  of  fat.  In  autopsies 
xanthoma  growths  have  been  found  in  the  esophagus,  in  the  trachea  and 
capsule  of  spleen,  in  the  liver,  aorta,  heart,  and  other  situations. 

Diagnosis. — The  characters  of  the  malady  are  usually  so  pro- 
nounced that  confusion  with  other  diseases  is  scarcely  possible.  The 
chamois-leather-colored  patch  or  patches  about  the  eyelids,  sometimes 
band-like  and  partially  or  almost  completely  surrounding  it,  and  occurring 
in  middle  and  late  adult  life,  is,  for  this  type,  sufficiently  diagnostic. 
Possibly  upon  hurried  examination  beginning  minute  lesions  might  sug- 
gest milium,  but  this  latter  is  cystic,  usually  white  in  color,  and  if  punc- 
tured, permits  easy  expression  of  the  sebaceous  contents.  Xanthoma 
multiplex  would  scarcely  be  confused  with  the  xanthoma-like  lesions  seen 
in  some  cases  of  urticaria  pigmentosa,  although  this  latter  affection  has 
been  in  a  few  instances  reported  as  xanthoma.  Xanthoma  multiplex 
lesions  are,  however,  of  fairly  uniform  character  as  to  color,  possibly  vary- 
ing somewhat  in  shade,  whereas  in  urticaria  pigmentosa  the  active  lesions 
are  distinctly  urticarial,  and  there  is  usually  an  urticarial  condition  of 
the  skin.  Pollitzer1  has  called  attention  to  the  possibility  of  some  cases 
of  multiple  dermoid  cysts  being  mistaken  for  xanthoma,  and,  in  addition 
to  the  one  coming  under  Sangster's  and  his  own  observation,  refers  to 
several  similar  instances,  and  suggests,  in  order  to  avoid  such  an  error, 
the  puncturing  of  a  lesion  in  xanthoma-like  eruptions  or  histologic  exami- 
nation, a  dermoid  cyst  being  thus  readily  recognized.  A  fact  to  be 
remembered  in  xanthoma  multiplex  is  that  almost  all  cases  in  adults 
have  an  associated  jaundice.  Its  differentiation  from  xanthoma  diabet- 
icorum  will  be  considered  under  this  latter  disease. 

Prognosis. — There  is  practically  no  prospect  for  spontaneous 
disappearance  of  the  malady;  the  several  instances  already  referred  to 
in  which  involutionary  changes  were  observed  are  rare  exceptions  to  the 
rule  that  the  disease  is  persistent,  and  up  to  a  variable  point  progressive. 
After  reaching  a  certain  development  the  progress  seems  stayed,  and  the 
growths  remain  stationary.  In  some  cases,  however,  of  limited  extent, 
treatment  has  been  effectual  in  removing  the  blemish. 

Treatment.— Xanthoma   palpebrarum   may  be   removed   by  ex- 

1  Pollitzer,  "Multiple  Dermoid  Cysts  Simulating  Xanthoma  Tuberosum,"  Jour. 
Culan.  Dis.,  1891,  p.  281. 


674  NEW  GROWTHS 

cision  or  the  curet,  and  in  some  instances  by  mildly  caustic  applications 
and  electrolysis.  I  have  employed  two  methods:  The  application  of 
trichloracetic  acid  and  electrolysis.  The  trichloracetic  acid  is  applied 
in  scant  quantity,  limiting  it  to  the  area  of  the  disease  (only  to  a  small 
part  at  one  time  if  the  area  is  large),  and  in  those  of  very  delicate  skin  it 
should  be  first  tried  diluted  with  an  equal  part  of  water;  considerable 
surface  reaction  follows  in  some  cases,  with  superficial  crusting.  Vaselin 
or  cold  cream  can  be  applied  till  the  irritation  subsides  and  the  crust 
comes  away.  A  second  or  third  application  may  be  necessary.  Some- 
times the  blemish  is  thus  completely  removed,  but  more  commonly  only 
rendered  less  conspicuous;  sooner  or  later  it  shows  a  disposition  to  return. 
Electrolysis  requires  a  current  of  i  to  5  milliamperes,  the  growth  being 
punctured  superficially  and,  if  large,  at  several  points.  The  operation 
in  some  cases  must  be  repeated  at  intervals  of  two  to  four  weeks  before 
a  final  result  is  reached,  and  in  most  cases  the  effect,  while  favorable,  is 
not  permanent,  although  more  frequently  than  with  the  trichloracetic 
acid  method.  If  the  growth  is  extensive,  but  a  portion  should  be  treated 
at  a  time.  McGuire1  has  reported  good  results  from  monochloracetic 
acid.  Stern's2  method  of  applying  a  10  per  cent,  solution  of  corrosive 
sublimate  in  collodion  has  not  met  with  favor.  Morrow,3  in  his  case  of 
xanthoma  multiplex,  used  successfully  a  25  per  cent,  salicylic  acid  plaster, 
worn  continuously  for  several  days  or  longer,  after  which  a  considerable 
part  of  the  growth  was  found  softened  and  could  be  readily  removed, 
after  which  the  part  is  washed  or  soaked  in  hot  water,  and  a  plain  diachy- 
lon ointment  applied  for  a  day  or  two,  when  the  plaster  is  to  be  resumed. 
Leslie  Roberts4  employed  a  somewhat  similar  application,  a  compound 
salicylated  collodion  paint:  !$.  Ac.  salicylici,  3j  (4.);  chrysarobini,  3ss 
(2.);  ol.  ricini,  3ss  (2.);  collod.  flex.,  ad  5j  (32.).  Evans  and  Whitehouse 
had  good  results  from  the  arrays;  the  latter  also  from  the  high-fre- 
quency current. 

Internal  treatment  is  apparently  fruitless  in  xanthoma,  although 
Besnier5  saw  good  results  from  the  administration  of  phosphorus  in  in- 
creasing dosage,  given  in  cod-liver  oil,  for  a  few  weeks,  to  be  followed  by 
turpentine. 

XANTHOMA  DIABETICORUM6 

Definition. — A  rare  eruption  observed  in  diabetic  individuals, 
consisting  of  scattered,  sometimes  grouped  and  aggregated,  somewhat 

1  McGuire,  Jour.  Cutan.  Dis.,  1898,  p.  328. 

2  Stern,  Berlin,  klin.  Wochenschr.,  1888,  p.  393. 

3  Morrow,  loc.  cit. 

4  Roberts,  Brit.  Jour.  Derm.,  1894,  p.  148. 

5  Besnier,  Jour,  de  med.  el  de  chirnrg.,  April,  1886 — quoted  hy  Jackson. 

8  Literature:  Malcolm  Morris,  London  Patholog.  Soc'y  Trans.,  1883,  vol.  xxxvi, 
p.  278,  with  histologic  plate  (committee  report  on  the  subject,  p.  284);  a  second  case, 
with  histologic  examination,  by  J.  C.  Clarke  (with  histologic  cuts),  Brit.  Jour.  Derm., 
1892,  p.  237.  In  this  case  Morris  gives  an  abstract  and  literature  references  of  the  cases 
reported  by  Addison  and  Gull,  Bristowe,  Hillairet,  Chambard,  Hardaway,  Barlow, 
Cavafy,  Colcott  Fox,  Besnier,  and  Robinson.  Johnston  ("Xanthoma  Diabeticorum; 
Its  Place  among  the  Dermatoses") , /<w.  Cutan.  Dis.,  1895,  p.  401,  reviews  the  subject 
and  gives  full  bibliography  (both  as  to  cases  and  other  pertinent  literature)  to  date — 
including,  in  addition  to  the  above  cases,  those  since  reported  by  Crocker,  Payne,  Tims, 
Pollitzer,  Jamieson,  Hallopeau,  and  Schamberg.  I  am  indebted  to  this  exhaustive 


XANTHOMA   DIABETICORUM  675 

inflammatory  papular  or  nodular  elevations,  with  usually,  in  most  lesions 
the  basal  portion  reddish  and  the  apex  of  a  yellowish  or  yellowish-white 
color,  and  generally  accompanied  by  slight  subjective  symptoms  of  itch- 
ing and  pricking. 

Until  recent  years  this  malady  had  scarcely  been  known,  but  since 
the  clear  exposition  by  Malcolm  Morris  its  clinical  individuality  has 
been  generally  recognized,  and,  in  addition  to  Morris's  case,  and  the  few 
previously  reported,  numerous  new  examples  have  been  recorded  by  other 
observers,  among  whom  Colcott  Fox,  Hutchinson,  Cavafy,  and  others 
in  England,  Besnier  and  Vidal  in  France,  and  Hardaway,  Robinson, 
Pollitzer,  Schamberg,  Johnston,  and  others  in  America. 

Symptoms.— The  eruption  may  present  itself  gradually,  or  it 
may  be  more  or  less  abundant  from  the  start.  In  their  earliest  devel- 
opment the  lesions  are  usually  dull  reddish  or  of  inflammatory  hue,  some- 
times a  raw-beef  color,  with  very  soon,  in  most  or  many  of  them,  a  yellow- 
ish or  yellowish-white  apex,  somewhat  suggestive  of  a  minute  pustule, 
and  later  a  fading  of  the  peripheral  and  basal  portion  to  a  pinkish  color, 
and  usually  a  widening-out  of  the  yellow  tint.  The  lesions  are  somewhat 
firm  or  hard,  pin-head-  to  small  split-pea-sized,  rounded  or  conic,  rather 
sharply  defined,  papules;  discrete  for  the  most  part,  although  often 
aggregated,  and  sometimes  crowded  close  together  into  patches.  Some 
papules  may  be  pierced  by  a  hair,  and  there  may  be  also  some  showing 
red  points  or  lines  due  to  capillary  dilatation.  Some  of  the  lesions  may 
undergo  involution  and  disappear  without  trace,  and  new  papules  may 
continue  to  appear  from  time  to  time.  Exceptionally  the  yellowish 
xanthoma  color  is  quite  conspicuous  or  predominant.  The  lesions 
sometimes  occur  in  ill-defined  streaks  or  seem  to  follow,  in  some  regions, 
the  cutaneous  nerve  distribution.  Some  of  the  lesions  may  be  more 
or  less  flattened,  as  in  Hardaway's l  case,  and  the  whole  aspect  be  some- 
what similar  to  ordinary  xanthoma.  While  scarcely  any  portion  of  the 
body  is  free  from  the  possibility  of  being  the  seat  of  lesions,  the  buttocks, 
the  extensor  surfaces  of  the  forearms,  the  elbows,  knees,  and  the  back 
are  favorite  situations;  in  some  of  the  less  extensive  cases  they  may  be 
more  or  less  limited  to  these  regions,  with  other  parts  sometimes  showing 
a  slight  sprinkling  only.  The  feet,  legs,  hands,  and  face  also  frequently 

paper  for  much  of  the  description  of  the  disease  here  given.     Other  cases  and  literature 
since  recorded:  Robinson  (another  case — woman),  Trans.  Amer.  Derm.  Assoc.for  1896; 
Norman  Walker,  Brit.  Jour.  Derm.,  1897,  p.  461,  with  colored  plate  and  a^aluable 
analytic  table  and  literature  references  of  all  cases  above  (except  Robinson's  second 
case),  and  those  since  recorded  by  Darier,  Colombini,  Toepfer,  Geger,  making  in  all 
30  cases;  Abraham,  ibid.,  p.  484  (case  demonstration — male,  aged  forty-five);  Sher- 
well,  with  histologic  report  by  Johnston  (case,  woman,  aged  forty),  Jour.  Cutan.  Dis., 
1900,  p.  387;  Schwenter-Trachsler,  Monatshefte,  1898,  vol.  xxvii,  p.  209  (male— colored 
plate  and  an  abstract  resume  and  references  of  most  of  the  reported  cases);  Krzyszlalo- 
wicz,  ibid.,  i8og,  vol.  xxix,  p.  201  (male— with  8  colored  histologic  cuts  and  bibhoj 
raphy);  Sequeira,  Bril.  Jour.  Derm.,  1901,  p.  56  (case  demonstration— male— free  from 
glyrosuria) ;  total,  36  cases.     Abstracts  of  several  interesting  cases,  reported  in  the  pas 
three  years  by  Abraham,  Antonino,  and  Bossellini  (3  cases),  are  given  in  Jour.  Cutan. 
Dis    1005   pp   186-190;  Lancashire,  Brit.  Jour.  Derm.,  1907,  P-  269  (with  illustrati 
cf  palms;'  eruption  consisted  of  streaks  and  nodules  on  palms  and  fingers,  and  nodul 
on  wrists  and  elbows);  Pusey  and  Johnston,  Jour.  Cuian.  Dis.,  1908,  p.  553  (patii 
also  had  a  lipoma  multiplex:  case  and  histologic  illustrations). 
1  Hardaway,  Si.  Louis  Courier  of  Medicine,  Oct.,  1884. 


676  NEW  GROWTHS 

show  the  characteristic  discrete  and  bunched  papules.  In  Hutchinson's  * 
case,  in  which  the  eruption  was  extremely  extensive,  the  scalp,  face,  and 
lips  were  the  seat  of  numerous  and  well-developed  lesions,  the  scalp 
especially  being  thickly  covered. 

In  most  patients  the  eruption  is  not  abundant,  but  in  that  just  named, 
and  in  those  of  Hardaway,  Morris  (second  case),  Johnston,  and  a  few 
others,  it  was  present  in  great  profusion,  and  tended  in  places  to  coalesce 
and  form  plaques,  the  latter  being  usually  dotted  over  with  the  yellowish 
points  showing  the  individual  component  lesions.  The  eruption  is  rarely 
on  the  eyelids, — the  common  site  of  ordinary  xanthoma, — Besnier's  and 
Hardaway's  cases  being  exceptional  in  this  respect.  Occasionally  the 
eruption  has  also  been  seen  in  the  mouth.  In  some  instances  the  itching 
and  burning,  usually  present  to  a  variable  degree,  may  be  quite  trouble- 
some. The  papules  are,  especially  when  appearing,  often  quite  tender. 
The  course  of  the  disease  varies  somewhat,  but  in  most  instances,  after 
lasting  several  months  or  a  few  years,  during  which  time  there  is  apt  to 
be  irregular  accession  of  new  lesions  and  involution  of  some  of  the  old  ones 
the  eruption  gradually  disappears.  No  permanent  traces  are  left. 

Etiology. — There  has  been  an  associated  diabetes  mellitus  in 
most  patients,  and  this  has,  therefore,  been  looked  upon  as  etiologic;  it 
was,  however,  wanting  in  the  cases  of  Cavafy,  Hutchinson,  Vidal,  Geyer, 
Sequeira,  and  a  few  others,  and  extremely  slight  in  some  instances. 
The  extent  of  eruption  has,  however,  been  usually  noted  to  vary  accord- 
ing to  the  amount  of  sugar  in  the  urine;  this  was  especially  noticeable  in 
Johnston's  patient.  In  one  instance  (Colombini)2  there  was  pentosuria. 
In  some  of  those  cases  in  which  sugar  was  not  found,  as  well  as  in  a  few 
others,  albumin  was  noted  to  be  present — Cavafy's  case  had  suffered 
from  nephritis.  Jaundice  was  present  in  Hardaway's  patient,  and  the 
urine  showed  but  a  trace  of  sugar.  The  malady  is  seen  chiefly  in  the 
male  sex — out  of  the  total  of  36  reported3  cases  there  were  only  5  women 
(Hillairet  (2),  Walker,  Robinson  (second  case),  and  Sherwell).  Its  sub- 
jects are  commonly  of  the  florid  and  obese  type,  and  many  in  apparently 
good  health;  almost  all  were  between  the  ages  of  twenty-five  and  fifty, 
Pollitzer's  case,  a  boy  aged  seventeen,  being  the  youngest. 

Pathology. — The  proper  position  of  this  affection  is  not  yet 
determined,  some  holding  that  it  is  essentially  a  form  of  ordinary  xan- 
thoma, others  that  it  is  a  distinct  affection.  Both  the  clinical  and  his- 
tologic  aspects  furnish  some  support  to  either  view.  Besnier  and  Doyon4 
are  the  most  pronounced  in  their  belief  that  the  malady  is  not  separable, 
except  as  a  variety,  from  ordinary  xanthoma,  and  believe  that  the  gly- 
cosuria  is  merely  the  determining  factor  in  the  clinical  differences. 
Torok,5  on  the  contrary,  from  his  study  of  the  various  types,  takes  a 
diametrically  opposite  view;  most  other  investigators  lean  one  way  or 

1  Hutchinson,  Arch,  of  Surgery,  vol.  i  (1889-90),  p.  381. 

2  Colombini,  Monatshtfie,  1897,  vol.  xxiv,  p.  129. 

3  Hyde  (discussion,  Trans.  Amer.  Derm.  Assoc.  for  1897)  also  refers  briefly  to  2 
cases,  which  would  make  the  total  38;  in  i  of  his  cases  there  was  abundant  glycosuria 
associated  with  albuminuria.     Since  the  above  date  new  cases  have  been  gradually 
added. 

4  Besnier  and  Doyon  in  French  translation  of  Kaposi's  treatise,  vol.  ii,  p.  335. 
6  Torok,  loc.  cit. 


XANTHOMA  DIABETICORUM 


677 


the  other,  but  apparently  their  convictions  are  not  as  yet  of  a  decided 
character.  The  lack  of  involvement  of  the  eyelids  would  seem  to  indi- 
cate individuality,  although  Hardaway's  case  presented  many  features 
common  to  both.  Its  apparent  relationship  to  diabetes  mellitus  and 
its  disappearance  under  treatment  for  the  latter,  shows  pretty  strongly 
that  there  is  a  common  underlying  cause,  and  this  fact  would,  moreover 
seem  to  separate  the  malady  from  ordinary  xanthoma,  which  is  persistent 
and  unresponsive  to  any  general  treatment,  and  is  rarely  associated 
with  glycosuna.  Preverted  liver  function,  however,  seems  to  be  a  factor 
in  both  varieties  of  the  multiform  xanthomatous  process.  Torok, 
Kaposi,  Johnston,  and  a  few  others  (quoting  from  Johnston's  paper) 
believe  the  cutaneous  phenomena  are  due  to  an  irritative  process,  the 
irritation  being  supplied  by  the  excess  of  glucose  or  some  faulty  product 
of  metabolism  circulating  in  the  blood;  Johnston  believes  that  this  has 
some  support  in  the  fact  that  the  nodules  begin  in  the  corium  in  the 
neighborhood  of  the  sweat-glands  and  the  hair-follicles,  with  their  at- 
tached sebaceous  structures,  all  of  which  are  supplied  by  the  same  set 
of  vessels,  part  of  the  excretory  apparatus  of  the  skin. 

The  pathologic  histology  has  been  studied  by  Robinson,  Crocker, 
Clarke,  Payne,  Schamberg,  Pollitzer,  Walker,  and  others,  and  with 
few  exceptions  the  conclusions  are  that  microscopically  the  process 
closely  resembles  that  of  ordinary  xanthoma,  except  that  the  inflam- 
matory element  is  clearly  evident  and  the  connective-tissue  growth  less 
pronounced — according  to  Crocker  there  is  no  actual  connective-tissue 
growth.  This  latter,  however,  is  not  in  accord  with  the  investigations 
of  Robinson  and  others.  The  changes  are  especially  conspicuous  about 
the  hair-follicles.  The  "xanthoma  cells"  are  also  found.  The  process 
is  practically  confined  to  the  corium,  and  apparently  the  first  step  is 
vascular  dilatation,  followed  by  other  evidences  of  inflammatory  action. 
Central  degenerative  changes  of  a  fatty  nature  take  place,  and  to  this 
mass  of  fatty  granules  is  due  the  central  yellowish  color.  Pollitzer,1 
who  has  made  extensive  histologic  studies  of  the  various  xanthomata, 
considers  the  two  varieties  of  generalized  xanthoma  as  histologically 
identical,  the  process  in  the  diabetic  form  being  a  little  more  diffuse  and 
the  tendency  toward  fatty  degeneration  more  marked  than  in  the  non- 
diabetic  variety;  in  the  Cohnheim  sense  he  scarcely  thought  the  process 
could  be  considered  an  inflammatory  one,  but  an  irritative  hyperplastic 
development  of  connective  tissue,  with  a  tendency  to  fatty  degeneration. 
Walker  agrees  with  Pollitzer  in  not  viewing  the  process  as  inflammatory; 
he  considers  it  approaches  nearest  to  the  chronic  granulomata,  and  sug- 
gests the  possibility  of  some  organismal  cause. 

Diagnosis. — The  color  of  the  growths, — the  reddish  or  pinkish 
peripheral  and  basal  portion,  and  the  yellowish  central  apex — their 
sudden  evolution,  absence  from  the  eyelids,  the  firm,  solid  character  of 
the  lesions,  the  occasional  follicular  origin,  the  involutionary  changes, 
often  quite  noticeable,  and  the  accompanying  glycosuria  and  the  sub- 
jective symptoms,  together  with  the  tendency,  after  months  or  a  few 
years,  to  spontaneous  disappearance — are  all  different  from  the  symp- 

1  Pollitzer,  loc.  tit. 


678  NEW  GROWTHS 

toms  of  ordinary  xanthoma  multiplex,  and  will  serve  to  distinguish  the 
one  from  the  other. 

Prognosis  and  Treatment.— Probably  sufficient  has  already 
been  said  as  to  prognosis.  The  malady  frequently  disappears  sponta- 
neously in  a  few  months  or  years,  more  quickly  by  treatment.  Instances 
of  long  duration — over  seven  or  eight  years  in  Cavafy's  case — and  of 
the  tendency  to  extensive  relapse  in  Johnston's  case,  are  of  exceptional 
occurrence. 

The  treatment  consists  in  the  adoption  of  measures  for  the  cure  or 
palliation  of  the  associated  glycosuria,  more  especially  by  means  of 
regulation  of  the  diet  and  the  administration  of  such  remedies  as  arsenic 
and  codein,  or  other  drugs  if  indicated  by  other  conditions.  For  relief 
of  the  itching,  often  present,  lotions  of  carbolic  acid,  of  liquor  carbonis 
detergens,  with  or  without  saturated  boric  acid  solution  as  a  basis,  or 
any  of  the  milder  lotions  or  ointments  employed  in  acute  eczema  or  in 
pruritus,  would  doubtless  answer  the  purpose. 

COLLOID  DEGENERATION  OF  THE  SKIN 

Synonyms.— Colloid  milium  (Wagner);  Hyaloma;  Fr.,  Degenerescence  colloide 
du  derme;  Colloidome  miliaire  (Besnier);  Colloid  milium;  Hyalome  (Vidal  and  Leloir); 
Ger.,  Hyaloma  der  Haut  (Auspitz);  Colloide  Degeneration. 

Definition. — An  affection  characterized  by  pin-head-  to  split- 
pea-sized  nodules,  of  a  yellowish  color,  having  a  translucent  appearance, 
and  usually  observed  on  the  upper  part  of  the  face,  and  due  to  colloid 
degeneration  of  the  dermal  connective  tissue.  The  literature1  of  this 

literature:  Wagner,  Arch,  der  Heilkunde,  1866,  p.  463;  Besnier,  Annales,  vol.  x 
(1877-80),  p.  461;  Balzer,  ibid.,  p.  468  (histologic  examination  of  Besnier's  case); 
Feulard-Balzer,  ibid.,  1885,  p.  342;  Liveing,  Brit.Med.  Jour.,  1886,  i,  p.  586;  Philipp- 
son,  "The  Relationship  of  Colloid  Milium  (Wagner),  Colloid  Degeneration  of  the 
Skin  (Besnier),  and  Hydradenoma  (Darier-Jacquet)  to  One  Another,"  Brit.  Jour.  Derm. 
1891,  p.  35,  and  Monatshefte,  1890,  vol.  xi,  p.  i  (a  histologic  and  clinical  study  with 
case  citations  and  references);  Perrin-Reboul,  Trans.  Second  Internal.  Dermal.  Cong., 
Vienna,  1892,  pp.  435  and  438  (with  references);  G.  H.  Fox's  case,  Jour.  Cutan.  Dis., 
1893  (with  illustration),  seems  more  probably  a  case  of  disseminated  lupus,  which 
Dr.  Fox  was  at  first  inclined  to  believe,  and  which  is  supported  by  Elliot's  histologic 
examination.  The  curet  was  used  in  some  lesions;  others  disappeared  spontaneously. 
C.  J.  White,  ibid.,  1902,  p.  49,  reports  a  case,  with  histologic  examination  and  cut,  and 
concludes,  from  an  analytic  study  of  cases  on  record,  that,  including  his  own,  there 
seem  to  be  only  5  which  can  be  considered  genuine  cases  of  this  malady;  Bossellini 
(Annales,  1906,  p.  751,  2  cases;  brothers,  histologic,  and  review,  with  bibliography) 
found  the  disease  a  degenerative  process  primarily,  and  involving  the  collagenous  and 
elastic  connective  tissue  of  the  subpapillary  zone. 

Hardaway,  ibid.,  1884,  p.  169,  records  5  cases  (4  children,  i  adult)  of  "an  unusual 
papular  eruption,"  in  which  the  lesions,  pseudovesicular  in  appearance,  but  solid  in 
character  and  lemon-yellow  in  color,  were  suggestive  of  colloid  milium,  but  upon  punc- 
ture simply  a  drop  of  blood  could  be  pressed  out.  They  were  not  numerous,  and 
variously  seated  upon  the  face,  neck,  or  arms,  and  had  been  of  months' duration,  and 
some  with  associated  itching,  although  slight.  An  ointment  containing  i  dram  (4.) 
each  of  ammoniated  mercury  and  liquor  picis  alkalinus  to  the  ounce  (32.)  of  vaselin, 
rubbed  in,  proved  effectual  in  a  few  weeks. 

C.  J.  White,  Jour.  Cutan.  Dis.,  1908,  p.  295,  under  the  title,  "Dermolysis — an  Un- 
described  Dissolution  of  the  Skin,"  reports  a  case  (with  case  illustrations  and  histologic 
cuts,  and  review  of  resembling  cases,  with  references)  seemingly  distinct,  and  yet  having 
some  histologic  resemblance  to  colloid  degeneration;  consisting,  clinically,  of  pea-sized, 
dome-shaped,  cherry-colored  papules,  which  evolve  into  hitherto  underscribed  flattened, 
muddy-white  lesions,  isolated  or  grouped  around  a  relatively  depressed,  bluish-red, 
velvety  center;  these  features,  of  long  standing,  developed  on  non-exposed  regions  and 
without  subjective  symptoms. 


COLLOID  DEGENERATION  OF  THE  SKIN  6/9 

rare  malady  is  scanty,  but  few  unquestioned  cases  being  recorded,  of 
which  the  first  was  described  by  Wagner.  Besnier,  Balzer,  and  Feulard 
have  done  most  to  give  the  disease  the  stamp  of  individuality. 

Symptoms.— The  favorite  sites  are  the  forehead,  about  the  orbits, 
the  nose,  and  cheeks — usually  the  upper  half  or  two-thirds  of  the  face. 
In  one  of  Liveing's  patients  the  neck  and  arms  were  also  the  seat  of  the 
growths.  In  Perrin's  patient,  in  addition  to  the  upper  part  of  the  face, 
some  were  seen  on  the  ocular  conjunctiva,  near  the  inner  canthus,  and 
on  the  backs  of  the  hands.  In  C.  J.  White's  case  the  growths  were  on  the 
backs  of  the  hands  and  face.  The  lesions  are  of  slow  development, 
commonly  appearing  in  groups  of  two  or  more,  and  occasionally  two  or 
three  may  tend  to  fuse  together,  but  the  individual  character  of  such 
component  tumors  remains  recognizable.  In  size  they  vary  from  that 
of  a  pin-head  to  a  small  split-pea,  rarely  larger,  and  while  well  seated  in 
the  derma  show  elevation,  although  usually  slight,  above  the  surface. 
They  are  lemon-yellow  or  yellowish-white  in  color,  and  are  translucent 
in  appearance,  suggestive  of  a  vesicular  formation.  They  are,  however, 
of  firm  consistence;  if  punctured  or  incised,  only  a  small  amount  of  gelat- 
inous material  and  a  droplet  of  blood  can  be  pressed  out.  With  some 
there  is  surrounding  capillary  dilatation,  giving  a  reddish  hue.  There 
are  no  subjective  symptoms.  The  malady  is  persistent;  in  only  one  in- 
stance— one  of  Liveing's  cases — did  the  disease  disappear  spontaneously. 
In  some  lesions  involution  has  been  noticed,  beginning  in  the  central 
surface  portion,  giving  rise  to  central  depression,  and  the  growths  thus 
gradually  pass  away,  leaving  a  slight  depression.  In  one  instance 
(Liveing)  some  of  the  growths  became  inflamed,  crusted  over,  and  dis- 
appeared, leaving  an  atrophic  or  scar-like  mark.  Jarisch1  exhibited  before 
the  German  Dermatological  Society  a  case  he  thought  to  be  an  example 
of  this  disease,  in  which  destructive  action  was  also  noticed,  but  the  cor- 
rectness of  the  diagnosis  was  questioned,  and  Jarisch  himself  has  since 
spoken  of  it  with  implied  reservation.2 

Etiology  and  Pathology.— The  youngest  case  (Liveing)  of  the 
few  reported  was  over  fifteen;  the  others  were  adults  of  various  ages. 
Sex  apparently  has  no  influence.  Beyond  the  possibility  of  weather 
exposure,  to  which  most  of  the  patients  were  subjected,  and  precursory 
and  associated  headache  or  neuralgia  in  2  instances  being  of  some  influ- 
ence, no  cause  could  be  assigned.  Wagner  called  the  disease  colloid 
milium,  believing  that  it  was  allied  to  ordinary  milium,  and  that  it 
was  a  degeneration  of  the  sebaceous  gland  structure.  His  observations 
were,  however,  purely  clinical.  The  careful  histologic  studies— by 
Balzer  of  the  2  cases  of  Besnier  and  Feulard,  by  Reboul  of  Perrin's  case, 
and  by  C  J  White  of  his  case— show  clearly  that  the  disease  is  independ- 
ent of  the  glands  and  epithelial  structures,  and  that  it  is  purely  a  degen- 
erative process,  involving  the  connective-tissue  bundles  and  cells  of  t 
corium  and  the  fibers  surrounding  the  blood-vessels  and  nerves- 
degenerative  process  changing  this  tissue  into  so-called  colic 

1  Jarisch,  "Colloidoma  ulcerosum,"   Vcrhandl.  d.   V.  Cong.  Deutsch.  dermatolog. 
Gesellsch.,  Vienna,  1896  (case  demonstration). 

2  Jarisch,  Die  Hautkrankheiten,  1900,  p.  927- 


680  NEW  GROWTHS 

Although  Philippson  has  endeavored  to  show  that  the  cases  described 
variously  as  hydradenoma,  benign  cystic  epithelioma,  etc.,  and  colloid 
degeneration  are  the  same  histologically,  such  a  conclusion  is  not  war- 
ranted by  the  investigations  of  the  several  careful  observers  referred  to, 
and  whose  opinion  is  supported  by  Besnier,1  who  has  observed  examples 
of  both  affections,  and  who  is  firmly  convinced  of  their  non-identity, 
presenting  a  clear  exposition  of  the  clinical  and  pathologic  differences. 

Diagnosis. — The  disease  is  to  be  distinguished  from  xanthoma, 
hydrocystoma,  and  benign  cystic  epithelioma.  The  soft  character, 
non-translucent  appearance,  and  the  practical  limitation  to  the  eyelids 
of  xanthoma  will  serve  to  prevent  error  with  this  latter  disease.  The 
distribution  alone  of  xanthoma  multiplex  is  essentially  different.  The 
lesions  of  hydrocystoma  lack  the  yellow  or  yellowish  color  of  colloid 
degeneration,  and,  moreover,  contain  fluid  which  can  readily  be  demon- 
strated by  pricking.  Benign  cystic  epithelioma  may  show  some  re- 
semblance, but  the  latter  is  usually  lacking  any  yellowish  color,  generally 
appears  early  in  life, — in  most  cases  about  puberty, — and  is  sometimes 
seen  in  more  than  one  member  of  the  family,  and  while  often  on  the  face, 
may  be  elsewhere,  especially  about  the  clavicular  region  and  upper  trunk, 
In  some  instances  a  histologic  examination  would  be  necessary  for  a 
positive  conclusion.  The  color  of  ordinary  milium,  its  commonly  much 
smaller  size,  and  its  cystic  character  will  prevent  a  mistake  in  this  direc- 
tion. The  possibility  of  confusion  with  disseminated  lupus  is  also  to  be 
kept  in  mind. 

Treatment. — As  the  lesions  show  no  tendency  to  disappearance 
(Liveing's  i  case  an  exception),  their  removal,  if  desired,  must  be  effected 
by  operative  measures,  such  as  the  curet,  as  successfully  employed  in 
Feulard's  patient,  or  by  electrolysis.  This  latter  certainly  deserves  a 
trial  before  other  more  positive  procedures  are  adopted. 

NAEVUS  VASCULOSUS 

Synonyms. — Angioma;  Naevus  vascularis;  Naevus  sanguineus;  Mother's  mark; 
Birth-mark;  Fr.,  Angiome;  Naevus  vasculaire;  Ger.,  Angiome;  Feuermal;  Gefassmal. 

Definition. — A  congenital  new  growth  and  hypertrophy  of  the 
vascular  tissues  of  the  corium  and  subcutaneous  tissues,  of  a  light  red 
to  a  deep  bluish  or  purplish  color,  exceptionally  making  its  appearance 
a  few  weeks  or  later  after  birth. 

Various  divisions  of  the  blood-vessel  growths,  or  angiomata,  are 
made  by  different  writers.  Kaposi  divides  the  cases  into  four  classes: 
(i)  Telangiectasis ;  (2)  vascular  naevus;  (3)  angio-elephantiasis  (also 
called  elephantiasis  telangiectodes) ;  (4)  cavernous  tumor.  Unna2 
makes  a  complete  division  between  certain  cases,  which  he  designates 
vascular  moles  (vascular  naevi),  both  the  flat  and  the  elevated,  from  the 
angiomata  proper,  the  former  being  histologically  primary  angiectases, 
without  any  capillary  budding,  consisting  of  dilatation  of  previously 
existing  vessels,  and  predominantly  of  the  venous  capillaries;  angioma 

1  Besnier  and  Doyon,  French  translation  of  Kaposi's  treatise,  vol.  ii,  p.  370. 
*•  Unna,  Histo pathology,  to  whose  article  I  am  indebted. 


N&VUS    VASCULOSUS  68  1 

proper  is  characterized  by  both  a  new  growth  of  capillaries,  predominantly 
the  arterial  capillaries,  and  dilatation.  The  former  are  in  some  forms 
congenital  and  in  others  acquired,  while  the  angiomata  proper  are  mostly 
congenital,  but  develop  materially  or  mainly  after  birth.  The  latter 
class  is  represented  by  the  angioma  simplex  hyperplasticum  of  Virchow 
(or  the  angioma  plexiforme  of  Winiwarter,  or  the  angioma  simplex  sen 
glomeruliforme  of  Unna)  ;  and  by  the  so-called  cavernous  angioma  (angi- 
oma cavernosum).  The  latter,  excluding  those  examples  now  believed 
to  be  partly  or  wholly  lymphangiomatous  in  character,  according  to 
Winiwarter,1  is  anatomically  analogous  to  the  corpora  cavernosa,  and 
consists  of  soft  tumors  of  lobular  formation  and  semispheric  or  protruding 
surface,  and  of  a  steely-blue,  rarely  a  reddish,  color.  The  simple  an- 
gioma consists  of  a  variously  sized,  smooth,  nodular  or  lumpy,  compres- 
sible growth,  of  a  bluish-red  to  a  bluish-black  color,  and  is  the  common 
angiomatous  tumor  (or,  as  more  usually  called,  vascular  naevus,  capillary 
naevus),  noticed  in  infants  chiefly  about  the  head.  As  representing  the 
angiectases  may  be  mentioned  the  telangiectases,  consisting  of  capillary 
dilatation,  so  common  about  the  nose  in  acne  rosacea;  the  papillary 
capillary  varices  of  old  people,  seen  chiefly  on  the  trunk,  the  vascular 
naevi  proper,  of  which  an  example  is  the  so-called  port-wine  mark,  and 
finally  the  varicosities  and  cavernous  changes  observed  in  the  veins  of 
the  lower  part  of  the  legs.2 

While  these  various  distinctions  and  divisions  are  more  scientifically 
exact,  to  the  clinician  a  description  of  the  various  conditions  under  the 
two  headings  adopted  by  Duhring,  Crocker,  Hardaway,  and  others— 
naevus  vasculosus  and  telangiectasis—  seems  more  satisfactory  and  suffi- 
ciently comprehensive,  and  is  the  plan  here  followed,  the  former  including 
the  congenital  vascular  new  growths  and  all  tumor-like  formations,  and 
the  latter  the  acquired  capillary  dilatations,  with  which  may  also  be  in- 
cluded the  others  of  Unna's  angiectases,  excepting  the  vascular  naevi 
proper. 

Symptoms.—  One  of  the  most  common  forms  of  the  vascular 
naevi  encountered  is  that  known  as  angioma  simplex,  angioma  simplex 
hyperplasticum,  capillary  naevus,  etc.,  already  briefly  referred  to,  con- 
sisting of  red  to  bluish  or  purplish-red,  slightly  to  considerably  elevated, 
usually  readily  compressible,  growths  observed  in  young  infants. 
surface  is  either  smooth,  irregular,  lumpy,  or  nodular;  it  may  be  smooth 
at  first,  and  then  become  subsequently  uneven.  It  is  of  congenital  ong 
although  not  infrequently  at  birth  it  is  quite  insignificant,  and  sometimes 
scarcely  perceptible,  increasing  rapidly  in  size  in  the  first  days  or  weeks 
of  life  It  is  most  frequently  seen  about  the  head,  either  upon  the  scalp 
or  face,  although  it  may  also  occur  elsewhere.  It  is  vanable  as  to  size- 
from  that  of  a  bean  to  an  area  as  large  as  the  palm  or  greater. 


i  Winiwarter   Die  chirureischen  KrankMten  der  Haul,  1892,  p.  534-  . 

4heo  called  «L.  anvnicus  might  be  mentioned  ^J^S&SStiSi 

laries;  not  infrequently  there  are  associated  telangiectatic  nasvi. 


682  NEW  GROWTHS 

mains  stationary  or  increases  in  extent,  but  usually,  after  reaching  vari- 
able dimensions,  ceases  to  grow.  In  some  instances,  after  a  time, — 
several  months  or  longer, — retrogression  takes  place,  the  naevus  becomes 
gradually  smaller,  and  finally  disappears  without  trace  or  leaving  a 
slightly  thinned  looking  or  atrophic  patch.  In  others  the  growth  is, 
unless  treated,  persistent.  Anything  that  disturbs  or  impedes  the  circu- 
lation of  the  part,  as  coughing,  crying,  position  (gravity),  leads  to  tem- 
porary increased  prominence.  As  a  rule,  it  is  somewhat  spongy  to  the 
touch,  usually,  however,  quite  soft  and  readily  compressible;  in  other 
cases  comparatively  firm.  In  exceptional  instances,  more  especially 
when  involving  a  greater  part  of  a  region,  as  the  ear  or  extremity,  a  firm 
spongy  character  is  noticed,  connective-tissue  increase  being  equally 
present  and  of  pronounced  character, — the  so-called  angio-elephantiasis 
elephantiasis  telangiectodes ,  etc., — in  which,  doubtless,  too,  in  some  cases 
at  least,  there  is  also  lyrnphangiomatous  development  (see  also  Elephan- 
tiasis). Occasionally  the  surface  is  accidentally  broken,  or  this  takes 
place  spontaneously,  and  some  hemorrhage  results,  sometimes  of  an  ap- 
parently dangerous  character.  Occasionally  sloughing  gradually  ensues, 
limiting  itself  to  the  naevus  area,  and  this  leads  to  cure,  with  slight  scar- 
ring. If  the  growth  is  a  pronounced  one,  and  especially  when  over  bony 
prominences,  pulsation  can  usually  be  felt. 

In  occasional  instances  a  naevus  may  undergo  cystic  or  cavernous 
changes,  and  it  has  been  stated  that  it  may  possibly  develop  into  the 
angioma  cavernosum  of  Winiwarter.  This  latter,  a  rare  formation,  is, 
however,  usually,  and  probably  always,  primary,  arising  commonly 
in  the  first  year  of  life,  and  in  most  instances  having  its  start  in  a  trauma, 
even  of  a  mild  or  insignificant  character.  Rarely  is  it  congenital.  It 
may  be  diffused  or  defined,  soft,  lobulated,  protruding,  or  hemispheric, 
sometimes  distinctly  encapsulated.  It  is  turgescent,  often  quite  painful, 
and  tends  to  increase  in  size,  in  exceptional  instances  invading  soft 
tissues,  cartilage,  and  even  bone. 

A  form  of  naevus  which  is  occasionally  congenital,  but  usually  ac- 
quired, and  therefore  to  be  more  especially  referred  to  under  Telangiec- 
tasis  (q.  v.),  is  that  known  as  naevus  araneus,  or  spider  naevus,  consist- 
ing of  a  red  dot  or  spot  with  radiating  red  lines.  A  well-known,  but 
fortunately  not  very  common,  form  of  naevus  is  that  known  as  the  port- 
wine  mark,  port-wine  stain,  claret  stain,  birth-mark,  naevus  flammeus, 
naevus  simplex  (Feuermal  of  the  Germans,  and  tache  de  feu  of  the 
French).  The  terms  angioma  and  angioma  simplex  are  likewise  occa- 
sionally used  to  designate  it.  It  is  congenital,  although  in  some  in- 
stances there  is  variable  increase  after  birth.  In  size  it  varies  from  that 
of  a  small,  insignificant  spot  to  several  inches  or  more  in  diameter;  and 
exceptionally  it  may  involve  a  whole  region.  The  face  is  its  common 
site.  It  is  rounded,  ovalish,  or  irregular  in  shape,  of  a  bright  or  dark- 
red  color,  usually  flattened,  and  often  not  perceptibly  elevated.  It  may, 
however,  be  raised  above  the  surface,  and  present  a  smooth,  uneven, 
nodular  surface,  and  sometimes  with  here  and  there  verrucous-like 
thickening  or  projections.  Between  this  type  and  that  first  described, 
angioma  simplex  or  capillary  naevus,  all  gradations  are  met  with. 


NJEVUS    VASCULOSUS  683 

To  these  several  forms  of  naevi  other  terms  are  sometimes  given, 
when  additional  peculiarities  or  properties  are  present  or  associated! 
Thus  in  some  instances  pulsations  are  quite  distinct,  and  hence  the  term 
pulsating  naws;  in  others  the  color  is  dark,  the  blood-vessel  growth 
deep  seated  and  chiefly  venous,— venous  naws,  angioma  varicosum,— 
the  surface  is  predominantly  rough  and  tubercular,— nows  tuberosus, 
—slightly  fungoidal  or  mulberry-like  in  appearance,— mulberry  navus, 
strawberry-mark  (the  latter  also  used  with  flat  forms  of  strawberry  color), 
—and  so  on.  Not  only,  however,  may  a  naevus  be  turgescent  and  pul- 
sating, but  it  may  exceptionally  be  erectile,  and  rarely  there  is  also  more 
or  less  hairy  growth  noticeable.  In  fact  any  or  all  constituents  of  the 
integument  may  be  participants  along  with  the  blood-vessel  dilatation 
and  new  growth. 

As  a  rule  but  one  naevus  is  present  in  a  case,  but  occasionally  there 
may  be  two  or  three,  and  exceptionally,  as  in  the  remarkable  instances 
recorded  by  Ullmann,1  Kopp,2  Pollitzer,3  and  Post,4  they  may  be  numer- 
ous and  of  wide  distribution,  those  of  the  first  two  presenting  some  char- 
acters of  telangiectases.  Besnier  and  Doyon5  are  of  the  opinion  that 
generalized  angiomatous  or  telangiectatic  lesions  are  the  forerunners  or 
first  signs  of  malignant  development,  probably  based  upon  the  signifi- 
cance of  the  early  telangiectases  observed  in  xeroderma  pigmentosum. 

Etiology  and  Pathology.— The  cause  of  these  blemishes  is 
not  known.  According  to  Gessler's6  study  of  1265  collated  cases,  the 
affection  is  doubly  as  frequent  in  females  as  in  males.  Various  factors 
have  been  suggested,  among  which,  more  especially,  are  maternal  im- 
pressions and  intra-uterine  pressure,  but  neither  will  bear  the  scrutiny 
of  searching  analysis,  although  as  to  the  influence  of  maternal  impres- 
sions during  pregnancy  various  striking  instances  are  recorded,  but  even 
in  such  the  chances  of  pure  coincidence  or  misinterpretation  are  so  great 
as  to  throw  doubt  upon  relationship.  Unna  (loc.  tit.)  is  a  strong  advo- 
cate of  the  pressure  theory,  stating  that  "the  almost  entire  limitation  of 
the  congenital  angiomata  to  the  superficial  layers  would  seem  to  point 
out  that  they  are  developed  by  the  action  of  some  external  cause."  His 
clinical  observations  concerning  this  point  have,  he  adds,  shown  him  that 
these  growths  are  practically  always  on  regions  which  are  most  likely 
to  suffer  from  pressure  during  intra-uterine  life;  and  in  support  of  this  he 

1  Ullmann,  Archiv,  1896,  vol.  xxxv,  p.  195  (with  case  illustrations  and  histologic 
cut;  patient,  a  woman  of  forty-four;  numerous  bluish-red,  small  pea-  to  small  hazel-nut- 
sized  growths  on  the  face,  coming  out  crop-like  at  irregular  intervals;  began  apparently 
as  telangiectases;  first  appearance  when  verging  on  forty  years). 

2  Kopp,  ibid.,  1897,  vol.  xxxviii,  p.  69  (patient  a  young  man  aged  nineteen;  numer- 
ous flat  and  nodular  compressible  lesions  about  genitalia  and  legs,  and  also  appearing 
on  trunk  and  upper  extremities;  to  some  extent,  especially  in  the  flat  lesions,  of  tl 
ture  of  telangiectases,  and  tending  to  bleed  easily;  began  about  puberty).  _ 

3  Pollitzer  Internal.  Atlas,  1899,  plate  xlii  (patient,  male  aged  twenty-five;  notic 

a  few  weeks  after  birth,  and  no  change  since;  numerous,  closely  contiguous  naevi,  aver- 
aging the  size  of  a  dime,  over  the  entire  surface,  except  head,  palms,  and  soles). 

4  Post,  Jour.  Cutan.  Dis.,  1903,  P-  498  (with  illustration). 

5  Besnier  and  Doyon,  French  translation  of  Kaposi's  treatise,  second  ed.,  p.  357J 
Campbell  records  (Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlviii,  p.  2000)  a  case  of  venou 
angioma  of  skin,  showing  beginning  malignancy.  .,..,,      ,  *,.*,. 

•Gessler,  Inaug.  Dissertation,  Tubingen,  1889,  brief  abs.  in  Monatshffte, 

vol.  x,  p.  241. 


684  NEW 

states  that  "an  extraordinary  percentage  (10  to  20  per  cent.)  of  individ- 
uals have  a  naevus  in  the  neighborhood  of  the  occipital  fontanel,  hidden 
by  the  hair,  though  often  only  traces  of  it  are  to  be  found  in  adults." 
Out  "of  114  newborn  infants  examined  by  Pollitzer1  for  the  purpose 
of  investigation  of  this  point,  40,  or  35  per  cent.,  had  naevi  in  this  region. 
These  observations  are  more  or  less  confirmatory  of  Depaul's2  state- 
ment, which  has  always  seemed  open  to  question,  that  naevi  were  found 
in  about  one-third  of  the  children  born  at  the  Paris  Clinique,  in  most 
of  them,  however,  disappearing  within  a  month.  Gessler's  analysis 
shows  76  per  cent,  about  the  head,  3  per  cent,  on  the  neck,  n  per  cent. 
on  the  trunk,  and  9  per  cent,  on  the  extremities.  It  is  not  improbable, 
therefore,  that  pressure  may  be  an  important  factor,  but  it  would  seem 
that  Virchow's  belief,  quoted  by  Unna  (whose  words  I  repeat),  is  more 
probably  the  more  influential  one.  "Virchow  was  the  first  to  indicate  a 
possible  anatomic  cause,  namely  a  connection  of  the  embryonic  fissures 
of  the  skin,  especially  the  branchial  fissures,  with  the  appearance  of 
angiomata  at  their  areas  of  predilection  (eyelids,  cheeks,  ears,  nose, 
lips),  which  he  names  the  'fissural  angiomata';  and,  according  to  him, 
'a  very  slight  irritative  condition  at  the  borders  of  these  fissures,  which 
are  very  abundantly  supplied  with  vessels,  is  sufficient  to  induce  a  greater 
vascular  development,  which  might  possibly  be  recognized  as  a  naevus, 
but  which  remains  latent  and  only  later  becomes  manifest.'  ' 

Anatomically  vascular  naevi  have  their  seat  principally  in  the  papil- 
lary layers  of  the  corium.  In  some  instances,  however,  the  whole  corium 
as  well  as  the  hypoderm  are  involved.  According  to  Billroth,3  the  new 
formation  starts  first  from  the  capillary  plexuses  of  the  hair-follicles, 
the  sweat-glands,  the  sebaceous  glands,  or  the  fat-lobules.  The  growth 
consists,  according  to  its  nature  and  development,  of  dilated  as  well  as 
newly  formed  blood-vessels,  which  may  be  but  slightly,  moderately, 
or  markedly  dilated  and  abundant,  in  extreme  instances  reaching  pouch- 
like  or  cavernous  distention  and  sinuses;  in  some  lesions  the  process  is 
chiefly  or  wholly  limited  to  the  arterial  capillaries,  while  in  others  (venous 
naevi)  the  veins  are  predominantly  implicated.  Babes  states  that  "in 
many  cases,  however,  the  newly  formed  vessels  correspond  neither  to 
veins  nor  to  capillaries,  and  form  manifold  convolutions  and  networks." 
In  addition  to  the  vascular  dilatation  and  new  growth,  the  connective 
tissue,  especially  about  the  vessels,  may  be  increased  slightly  or  consid- 
erably; in  some  instances,  in  fact,  all  tissues  may  participate.  The 
cavernous  variety,  as  already  remarked,  according  to  Winiwarter,  bears 
some  resemblance  to  the  cavernous  tissue  of  the  penis. 

Diagnosis  and  Prognosis.— These  formations  offer  no  dif- 
ficulty as  to  recognition — they  could  scarcely  be  confused  with  other 
lesions.  The  prognosis  as  to  effect  upon  health  or  life  is,  of  course, 
wholly  favorable,  although  exceptionally  dangerous  hemorrhage  has 
been  noted  in  the  elevated,  growing  capillary  naevi  in  infants,  but  a  fatal 
outcome  would  certainly  be  a  great  rarity;  in  these  instances,  very  usually 

1  Pollitzer,  Bangs- H ardaway's  American  Text-book,  p.  1000.. 

2  Depaul,  quoted  by  Crocker,  Diseases  of  the  Skin,  third  ed.,  p.  962. 

3  Billroth,  quoted  by  Babes,  Ziemssen's  Handbook  of  Skin  Diseases,  p.  601. 


VASCULOSUS  685 

from  the  pressure  immediately  made  and  the  clotting  which  ensues, 
retrogressive  tendency  is  shown  and  the  lesion  may  gradually  disappear. 
In  an  instance  under  my  casual  observation  (not  under  my  care),  in- 
volving the  ear  in  an  adult,  which  began  in  early  life,  there  has  been  a 
gradual  aneurysm-like  distention  in  late  years,  which,  from  its  threat- 
eningly dangerous  character,  has  required  surgical  attention,  the  chief 
supplying  arteries  being  cut  down  upon  and  tied;  temporary  improve- 
ment resulted,  but  the  vascular  dilatation,  growth,  distention,  and  tissue 
thinning  soon  presented  again,  and  a  third  operation,  of  tying  the  main 
truncal  artery,  has  recently  been  resorted  to.  In  some  cases  of  capillary 
naevus,  as  already  stated  in  describing  it,  there  is  not  infrequently  a 
tendency,  after  a  time,  to  undergo  involution  and  to  disappear,  leaving 
a  faint  atrophy  or  no  trace  at  all ;  and  this  tendency  is  sometimes  appar- 
ently started  by  a  slight  knock  or  injury  to  the  part  or  attempts  at  treat- 
ment. Occasionally  superficial  ulcer  ation  ensues,  and  this  is  usually  the 
beginning  of  a  spontaneous  cure;  the  possibility  of  hemorrhage  is  to 
be  kept  in  view,  but  while  this  is  sometimes  temporarily  alarming,  it  is 
rarely  dangerous.  The  firm,  slightly  elevated  growth  and  the  various 
grades  of  the  port-wine  mark,  as  well  as  the  larger  cavernous  naevi,  are 
persistent,  although  they  seldom  show  any  disposition  to  increase.  In 
the  smaller  capillary  naevi  and  in  the  other  circumscribed  forms  much 
can  usually  be  accomplished  by  treatment,  and  frequently  a  cure  be 
brought  about;  but  in  the  large  growths  and  in  the  port-wine  varieties, 
not  much  is  to  be  expected. 

Treatment.— The  cases  most  commonly  coming  under  dermato- 
logic  observation  are  those  known  as  angioma  simplex,  or  capillary 
naevus,  and  the  so-called  port-wine  mark;  the  former  being  that  type 
brought  for  treatment  during  the  first  weeks  or  months  of  infantile 
life,  either  because  it  is  growing  larger  or  simply  as  a  blemish  desirable 
to  be  removed.  In  the  last  few  years  treatment  by  means  of  the  appli- 
cation of  liquid  air  or  carbon-dioxid  snow  (q.  ».)  has  been  warmly  extolled; 
I  have  used  it  (snow)  satisfactorily  in  the  angioma  simplex  type  in  infants 
and  young  children;  as  yet  I  have  had  no  opportunity  with  other  types 
Wickham1  has  of  late  relied  entirely  on  the  use  of  radium  for  the  removal 
of  this  as  well  as  other  forms,  and  his  results  have  certainly  seemed  sati 

Awhile  in  the  angioma  simplex  types  liquid  air  and  carbon-dioxid 
snow  method  has  largely  supplanted  other  forms  of  treatment 
latter  are  still  resorted  to,  and  are  well  worthy  of  continued  notice 
The  most  satisfactory  methods  have  heretofore  been,  according  to  my 
experience,  those  of  pressure,  electrolysis,  and  Pouring  with  a  needle 
or  sharpened  stick  charged  with  nitric  acid.    There  can  be n doubt 
that  in  some  of  the  cases  but  a  slight  impetus  is  needed  to  start  the  proc- 


rWcVU^tingrwitnollodion,  continued  for  some  days 
i  Wickham  and  Degrais,  "Radiumtherapie,"  Pans,  i< 


686  NEW  GROWTHS 

or  longer.  This  pressure  method  can  also  be  combined  with  discrete 
puncturing,  the  latter  being  done  in  several  places  over  the  growth,  \  to 
\  inch  apart,  with  an  ordinary  needle  or,  better,  a  triangular-edged 
needle,  slightly  breaking  up  the  tissues  within,  and  then,  with  due  aseptic 
precautions,  immediately  applying  the  several  coatings  of  collodion.  The 
"electric  needle"  can  also  be  used  in  the  same  manner  in  conjunction 
with  pressure.  The  slight  local  disturbance  so  caused  gives  rise,  when 
pressure  is  continuously  exerted,  to  more  or  less  plastic  exudation  and 
agglutination  and  gradual  obliteration  of  the  growth. 

In  many  cases,  however,  the  pressure  plan,  as  thus  outlined,  is  not 
successful,  and  when  the  child  has  already  passed  the  second  or  third 
month,  the  growth  seems  to  have  become  permanently  established, 
losing,  as  a  rule,  the  disposition,  often  noticed  earlier,  to  spontaneous 
or  easily  provoked  disappearance,  and  more  energetic  measures  are  nec- 
essary, and  which  are  also  applicable  at  an  earlier  date  when  thought 
preferable  to  the  pressure  plan.  The  two  methods  I  have  employed  are 
those  of  electrolysis  and  punctures  by  a  needle  charged  with  nitric  acid. 
Electrolysis,  a  method  which  has  been  favorably  used  by  many,  and 
strongly  advocated  by  Hardaway,  Duhring,  Fox,  Jackson,  and  others, 
answers  well  in  some  instances,  as  I  also  can  testify;  it  occasionally  brings 
about  a  rapid  result.  The  method1  by  electrolysis  is  not  difficult, 
although,  as  a  rule,  it  is  tedious,  and  must  often  be  repeated,  at  intervals, 
several  or  more  times. 

1  In  the  smaller  growths  a  current  of  from  i  to  3  or  4  milliamperes  is  sufficient,  but 
in  the  larger  and  more  pronounced  formations  a  stronger  current  may  be  necessary.  In 
the  former  cases,  and  if  the  child  is  quite  young  and  can  be  easily  and  firmly  held,  an 
anesthetic  is  not  necessary,  but  in  older  children  and  in  extensive  growths,  electrolysis, 
owing  to  the  pain  of  the  operation,  cannot  be  satisfactorily  managed  without  anes- 
thesia. The  needle,  ordinarily  in  my  practice,  is  attached  to  the  negative  electrode, 
although  others  prefer  the  positive  as  more  likely  to  bring  about  coagulation,  and  I 
am  not  yet  convinced  which  is  the  bettterplan;  the  other  electrode  with  wet  sponge  or 
cotton  covering  can  be  applied  nearby,  as  on  the  neck  or  arm.  In  all  electrolysis 
operations  about  the  head,  especially  the  upper  part,  the  current  should  be  increased 
gradually,  and  also  broken  off  slowly,  in  order  to  avoid  dizziness  and  other  disagreeable 
effects.  When  possible,  needles  can  be  attached  to  both  electrodes  and  inserted  in  the 
naevus.  If  attached  to  the  positive  electrode,  the  needle  should  be  of  gold  or  iridopla- 
tinum,  as  a  steel  one  undergoes  oxidation  (see  Hypertrichosis) .  Some  are  in  the  habit 
of  coating  the  needle  with  rubber  or  other  insulating  substance,  such  as  shellac,  up  to 
within  5  inch  of  the  point,  in  order  to  prevent  action  on  the  skin  at  the  point  of  entrance. 
The  needle  is  inserted  into  the  growth,  preferably  somewhat  slantingly,  and  down  to 
the  base,  the  current  then  allowed  to  act  for  one-half  to  two  or  three  minutes;  it  is  then 
withdrawn  and  reintroduced  at  another  part,  and  so  the  naevus  gone  over,  the  punctures 
being  J  to  |  inch  apart.  They  should  not  be  made  too  close,  lest  too  much  surface 
action  ensue.  If  the  growth  is  small,  the  needle  can  be  introduced  at  the  center,  going 
slantingly  toward  the  side,  allowed  to  act,  then  almost  completely  withdrawn,  and  then 
thrust  in  another  direction,  after  the  manner  of  the  "Marshall-Hall  method,"  and  so 
on.  In  some  instances  more  influence  is  noted  to  result  from  the  introductign  of  the 
needle  just  at  or  outside  of  the  edge  of  the  growth,  and  thus  going  completely  around 
it  at  |  to  \  inch  intervals,  encompassing  the  growth  in  this  manner  with  the  idea  of 
cutting  over  the  basal  vascular  supply.  In  the  larger  growths  treated  by  electrolysis 
under  anesthesia  several  needles  can  be  attached  to  the  electrode  and  inserted  at  differ- 
ent points  of  the  naevus.  I  have  always  preferred  to  do  too  little  than  too  much  at  one 
time,  and  then  to  repeat  the  treatment  at  intervals  of  one  to  three  weeks;  in  this  way 
there  is  less  risk  of  unnecessary  destruction,  and,  moreover,  in  occasional  instances  a 
trifling  amount  of  such  treatment  will  start  involution  changes  in  the  growth.  When, 
in  the  cases  stated,  anesthesia  is  necessary,  as  much  as  possible  should,  of  course,  be 
done  at  the  one  time.  The  application  of  pressure  for  several  hours  or  more  after  the 
treatment  is,  I  believe,  of  considerable  value  in  aiding  toward  a  good  result. 


N&VUS    VASCULOSUS  68/ 

Instead  of  electrolysis,  or  conjointly  with  it,  punctures  with  a  needle 
dipped  m  nitric  acid  can  be  employed;  or  the  hard,  smooth,  sharp-pointed 
wooden  tooth-picks  can  also  be  used  for  this  purpose.  The  needle  or 
tooth-pick  is  merely  moistened  with  acid,  and  then  gently  and  slowly 
pressed  into  the  growth  from  above,  and  the  nsevus  thus  gone  over, 
punctures  being  made  about  the  same  distance  apart  as  in  electrolysis! 
As  with  this  latter,  frequent  repetitions  are  sometimes  necessary,  and 
subsequent  pressure  is  of  material  advantage. 

The  removal  of  the  so-called  port-wine  mark  has  been  essayed  from 
time  to  time,  and  when  the  blemish  is  of  small  compass,  much  can  be 
done;  but  if  at  all  of  extensive  area,  the  outlook  is  unpromising,  and 
usually  the  effort  inadvisable.  For  the  treatment  of  this  blemish  the 
various  plans  already  noted,  except  that  of  pressure  alone,  which  would 
be  without  influence,  have  been  employed,  in  limited  cases,  with  varying 
results;  unless  done  thoroughly  enough  to  produce  scarring,  sometimes 
more  disfiguring  than  the  original  blemish,  the  amelioration  or  relief, 
as  a  rule,  scarcely  justifies  the  trial.  An  exception  to  this,  however,  may 
possibly  be  made  in  favor  of  the  method  by  electrolysis  as  suggested  and 
practised  by  Hardaway,1  and  also  favorably  spoken  of  by  Piffard,  G.  H. 
Fox,  and  others,  by  which  often  a  distinct  lessening  in  the  depth  of  the 
color  is  attained.  My  experience  has  been  about  as  Hardaway's — occa- 
sional partial  and  fairly  satisfactory  success,  but  usually,  in  my  opinion, 
scarcely  sufficient  amelioration  to  compensate  for  the  trouble;  in  exten- 
sive cases  I  should  hesitate  to  advise  it,  certainly  not  without  a  clear  and 
candid  statement  to  the  patient  as  to  its  tediousness  and  chances  of  fail- 
ure and  at  the  most  only  partial  success.  Wickham  relies  upon  radium. 
Liquid  air  and  carbon-dioxid  snow  have  also  been  employed  with  mod- 
erate success. 

Among  other  plans  of  treatment  of  some  of  the  varieties  already 
mentioned,  as  well  as  the  deeper  and  more  pronounced  growths,  may 
be  mentioned  those  by  excision  and  galvanocautery,  both  of  which  have 
been  employed  successfully  in  some  instances.  In  a  few  rebellious  cases 
I  have  had  recourse  to  puncturing  with  the  galvanocautery  needle, 
combined  with  pressure,  and  found  the  plan  of  service.  Well-defined 
circumscribed  growths  could,  as  often  practised  by  surgeons,  be  excised. 
In  larger  naevi,  excision,  if  practised,  needs  to  be  supplemented  by  the 
Thiersch  method  of  skin-grafting.  The  plan  formerly  much  in  vogue, 
of  injecting  irritating  liquids  into  the  growth,  needs  to  be  mentioned  only 
to  be  condemned.  Recently  good  results  have  been  claimed  from  *-ray 
exposures,  pushed  to  the  point  of  a  moderate  dermatitis.  The  high- 
frequency  current,  with  the  point  electrode,  is  also  capable  of  lessening 
the  port-wine  blemish,  but  not  without  some  scarring. 

In  the  smaller  port-wine  marks  as  well  as  the  other  highly-colored 
forms  an  excellent  method  of  concealment  is  by  the  use  of  a  properly 
tinted  theatrical  grease  paint;  the  patient  becomes  skilled  in  its  applica- 
tion, so  that  the  blemish  can  be  pretty  well  masked. 

1  Hardaway,  Si.  Louis  Cwrier  r>f  Medicine,  188^.  vol.  xv,  r.  201,  and  Trans .Amer. 
Derm.  A ssoc.,  1885,  p.  18  (with  discussion);  also  Morrow's  System,  vol.  111 
tology),  p.  498. 


688  NEW  GROWTHS 

TELANGIECTASIS 

Synonyms. — Acquired  vascular  dilatations;  Fr.,  T61angiectasie. 

Definition. — An  enlargement,  and  probably  new  growth  as  well, 
of  the  cutaneous  capillaries,  usually  appearing  during  middle  life,  and 
seated,  for  the  most  part,  about  the  face. 

Symptoms. — Dilatations  or  new  formation  of  capillary  vessels 
are  not  at  all  uncommon  in  association  with  certain  diseases,  such  as 
acne  rosacea,  sometimes  constituting  the  predominant  or  whole  feature 
of  the  case,  and  then  usually  designated  rosacea.  They  are  also  seen  in 
association  with  angiokeratoma,  xeroderma  pigmentosum,  some  cases 
of  lupus,  syphilis,  lupus  erythematosus,  and  similar  disorders,  in  which 
a  prolonged,  persistent  hyperemia  has  existed.  Telangiectases  occur, 
however,  as  an  entirely  independent  affection,  and  most  commonly  about 
the  cheeks  and  alae  of  nose,  especially  in  individuals  in  middle  and  ad- 
vanced life,  and  more  particularly  in  those  of  plethoric  habit,  or  in  those 
who  naturally,  or  through  diet,  indigestion,  and  alcoholic  stimulants  (not 
necessarily  in  excess),  are  subject  to  repeated  facial  flushings.  They 
are,  probably,  as  an  independent  condition,  most  common  or  numerous 
in  the  middle  region  of  the  cheek,  which  Hutchinson  calls  the  flush-patch. 
They  are  noted  to  be  straight,  zigzag,  or  tortuous,  thread-like,  red  lines, 
|  to  j  inch  long,  sometimes  branching,  in  others  being  simply  irregu- 
larly crowded  together.  In  some  cases  the  dilatations  may  be  much  more 
pronounced  and  slightly  elevated.  The  condition  may  merely  consist 
of  several  such  dilated  capillaries,  or  they  may  be  so  numerous  as  to  give 
the  face  or  part  affected  a  distinctly  rosaceous  or  flushed  appearance, 
due  to  some  of  the  causes  named,  and  occasionally,  especially  when  about 
the  region  of  the  nose,  also  to  possible  vascular  obstruction  due  to  in- 
tranasal  pressure  (see  Acne  rosacea).  In  some  cases,  instead  of  distinctly 
visible  capillaries,  it  consists  of  a  pinkish  or  reddish  spot,  which  only  on 
close  inspection  discloses  the  fact  that  it  is  composed  of  numerous  minute 
capillaries.  While  its  usual  site  is  the  face,  exceptionally  the  develop- 
ment is  seen  on  other  parts.1 

In  some  instances,  and  in  infants  and  children,  as  well  as  in  adults, 
a  not  uncommon  form,  which  is  usually  acquired,  although  it  is  occa- 
sionally congenital,  is  that  known  as  naevus  araneus,  or  spider  naevus 
(also  spider  cancer).  It  consists  of  a  pin-head-  to  small  pea-sized  cen- 
tral red  spot  or  dot,  flattened  or  slightly  elevated  or  rounded,  from  which 
radiate  several  or  more  red  lines  (capillaries),  in  a  more  or  less  straight, 
irregular,  or  tortuous  manner,  extending  one  to  several  lines  outward. 
It  presents,  first,  as  a  scarcely  noticeable  formation,  and  gradually  be- 
comes more  conspicuous,  but  rarely  attains  more  than  small  dimensions. 
After  lasting  for  some  months  or  several  years  or  longer  such  a  blemish 
sometimes  spontaneously  disappears;  in  other  instances, — and  in  the  large 
majority, — however,  persisting  indefinitely,  and  may  undergo  further 
enlargement,  although  seldom  to  a  conspicuous  extent.  One  or  several 
such  formations  may  be  present,  and  usually  about  the  nose  and  the  region 

1  Frick,  Jour.  Cutan.  Dis.,  1912,  p.  334,  reports  a  case  practically  involving  the 
entire  surface,  except  below  the  knee,  beginning  on  face  and  gradually  extending. 


TELANGIECTASIS  689 

under  the  eyes.  In  a  few  rare  exceptions,  as  in  instances  observed  by 
Mandelbaum1  and  Crocker,2  they  were  quite  numerous  and  more  or  less 
general.  Hillairet  and  Vidal3  have  also  each  observed  an  instance 
of  more  or  less  generalization.  In  the  anomalous  cases  of  multiple 
vascular  naevus  recorded  by  Ullmann  and  Kopp,  referred  to  under  the 
latter  heading,  the  telangiectases,  primarily  of  the  striated,  stellate,  or 
spider-naevus  characters,  underwent  development,  and  changed  into 
small,  vascular,  tumor-like  growths.  Vidal's  case,  according  to  Kopp, 
was  partly  of  this  character,  bearing  resemblance  to  his  own. 

The  papillary  varices,  usually  involving  the  capillary  loops  of  a 
number  of  contiguous  papillae,  consist  of  pin-head-  to  small  pea-sized, 
pale  to  dark  or  purplish  red,  flattened  or  rounded  elevations.  They 
are  commonly  seen  on  the  trunk,  especially  the  upper  part,  and  usually 
in  adult  life,  more  particularly  in  those  of  middle  age  or  advanced  years, 
and  are  suggestive  of  blood  extravasation  and  the  so-called  blood-blister. 
They  are  frequently  moderately  soft  and  somewhat  compressible,  with, 
as  a  rule,  no  striae  peripherally,  as  in  the  spider  naevus.  Some  of  them, 
on  close  inspection,  are  noted  to  be  composed  of  a  tuft  of  dilated  capil- 
laries, and  which  can  be  emptied  by  pressure;  others  are  somewhat  hard, 
probably  due  to  the  conditions  sometimes  found,  as  described  by  Unna: 
minute  cavities  or  spaces  inclosing  blood  capillaries;  a  number  of  minute 
spaces  filled  with  thrombi;  and,  in  another  instance,  coagulation,  the 
thrombi  consisting  of  fibrin  and  a  few  leukocytes;  and  also,  in  some  of 
them,  in  addition  "the  remaining  space  filled  by  closely  packed  red  cor- 
puscles," In  such  instance  the  blood-lesion  is  more  solid  and  pressure 
makes  but  little  impression. 

The  varicosities  and  cavernous  changes  so  commonly  observed  in 
the  veins  (varicose  veins}  of  the  lower  part  of  the  leg,  especially  in  those 
of  middle  life  and  advancing  years,  and  probably  more  frequently  in 
women  who  have  borne  many  children,  need  scarcely  be  referred  to  here, 
belonging  more  properly  to  the  domain  of  surgery.  It  is  to  be  looked 
upon,  however,  in  some  instances  as  having  an  etiologic  bearing  upon 
the  production  of  eczema  of  these  parts,  and  also  to  impaired  tissue  nu- 
trition which  results  in  ulceration—  the  well-known  leg  ulcer. 

Treatment.—  The  treatment  of  the  ordinarily  observed  telangi- 


il),  1882.  p.  213  (face,  trunk,  and  limbs). 
ofthe  Skin,  third  edit.,  p.  96?  (face,  backs  of  the  hands,  and 

with  both  erythema  and  telangiectases;  pertinent  bibl 


44 


692  NEW  GROWTHS 

reticulated  form,  developing  along  the  vessels,  with  a  tendency  here  and 
there  toward  true  angiomatous  characters.  These  findings  would  seem 
to  indicate,  as  Bowen  states,  the  possibility  of  later  malignant  changes. 
Prognosis  and  Treatment. — The  malady  is  persistent  and 
progressive,  and  in  the  cases  in  which  the  growths  were  destroyed  by 
cauterization  (Hutchinson,  White)  and  excision,  new  lesions  appeared 
peripherally  or  in  the  resulting  scar  tissue.  Possibly  electrolysis  along 
the  borders  of  the  area,  as  Crocker  suggests,  with  the  object  of  causing 
occlusion  of  the  vessels,  might  stay  its  progress,  but  the  failure  of  the 
more  active  methods  already  tried  would  scarcely  lend  much  hope  to  this 
plan. 

GRANULOMA  PYOGENICUM1 

Synonyms. — Granuloma  telangiectodes;  Granuloma  pediculum;  Granuloma  pedic- 
ulatum;  Pseudobotryomycosis;  Fr.,  Botryomycose  humaine;  Pseudobotryomycose; 
Granulome  pedicule;  Ger.,  Telangiektatische  granulome. 

This  rather  rare,  usually  pea-  to  nut-sized,  more  or  less  thinly  pedic- 
ulated  growth  was  first  described  by  Poncet  and  Dor  and  later  by  other 
French  observers,  who  looked  upon  it  as  analogous  to  botryomycosis 
observed  in  bovines  and  other  animals,  in  short,  as  human  botryomycosis. 
Soon  afterward,  however,  Sabrazes  and  Laubie,  Jaboulay,  Brault,  Bodin, 
and  others  succeeded  in  showing  conclusively  that  the  so-called  botryo- 
mycetes  were  in  reality  staphylococci,  and  since  then  the  designation 
"botryomycosis  hominis"  has  given  place  in  French  writings  to  that  of 
"pseudobotryomycosis."  More  recent  investigations  by  Hartzell  and 
Wile  in  this  country,  Lenormant  in  France,  and  Heuck  and  others  in 
Germany  have  emphasized  the  correctness  of  these  later  findings.  The 
lesion  is  single  and,  as  a  rule,  appears  insidiously  and  grows  slowly;  minute 
in  the  beginning,  the  outer  portion — the  portion  projecting  beyond  and 
above  the  skin — expands  and  may  reach  the  size  of  a  pea  to  a  cherry  or 
somewhat  larger;  the  short  pedicle,  or  portion  in  and  immediately  on 
and  above  the  surface,  remaining  slender,  sometimes  almost  thread-like, 
seemingly  serving  the  purpose  of  a  channel  through  which  goes  material 
for  nourishing  and  increasing  the  size  of  the  growth,  and  for  keeping  the 
latter  attached  to  the  skin.  The  pedicle  may  be  extremely  short,  so  that 
the  growth  may  appear  to  be  sessile.  The  surface  of  the  small  tumor 
may  be  more  or  less  rounded  and  smooth,  or  irregular  and  fungoidal, 
and  even  lobulated,  its  enveloping  membrane  thin,  frequently  shiny  and 

important  Literature:  "Poncet  et  Dor,  Botryomycose  humaine,"  Trans.  XI, 
French Surg.  Cong.,  1897;  Bodin,  "  Sur  la botryomycose  humaine,"  Annales,  1902,  iii,  p. 
289,  and  Semainemed.,  1902,  No.  14,  p.  14;  Hartzell, '' Granuloma  pyogenicum,"  Jour. 
Culan.  Dis.,  1904,  p.  520  (4  cases  with  brief  review  and  case  and  histolog.  illustrations) ; 
Kuttner,  "Ueber,  telangiektatische  Granulome,"  Brun's  Beitrdge  z.  klin.  Chir.,  1905, 
xlvii,  p.  i  (4 cases);  Kreibich,  "Ueber  Granulome,"  Archiv.  1909,  xciv,  p.  121  (4  cases); 
Wile,  "Granuloma  pyogenicum,"  Jour.  Cutan.  Dis.,  1910,  p.  662  (2  cases,  with  brief 
review  of  the  Hartzell,  Kuttner,  Reitmann,  Kreibich  and  Jacquet  and  Barre  cases; 
with  histolog.  illustrations,  and  bibliography) ;  Lenormant,  "Sur  la  pretendue  botryomy- 
cose humaine,"  Annales,  April,  1910,  p.  161  (5  cases  with  case  and  histolog.  illustrations; 
full  resume  and  review  with  references — collected  126  cases  of  the  disease  from  litera- 
ture); Heuck,  "Ueber  Granuloma  pediculatum" ;  Sogenannte,  "Menschliche  Botrymy- 
lose,"  Dermatolog.  Zeitschr.,  March,  April,  and  May,  1912  (an  exhaustive  paper; 
records  2  cases  of  his  own,  with  histolog.  findings;  reviews  all  the  reported  cases  in  the 
literature). 


FIBROMA  693 

usually  bright  to  dark  red  in  color,  and  either  dry  or  slightly  damp  or 
moist  to  the  touch;  in  occasional  cases  superficial  ulceration  and  crusting. 
Occasionally  it  is  quite  dark  in  color.  Sometimes  it  has  the  appearance 
of  a  pedicled  proud-flesh  formation;  and  it  may,  in  the  larger  spread- 
out  formation,  present  a  clinical  resemblance  to  the  strawberry-like 
growth  seen  occasionally  developing  at  the  site  of  a  recent  vaccination. 

It  doubtless  takes  its  origin  at  the  point  of  a  slight  abrasion  or 
injury,  is  probably  always  the  result  of  suppuration,  insignificant  or 
unnoticeable,  as  it  may  be.  It  is  a  persistent  formation,  and,  as  a 
rule,  when  torn  off  its  pedicle  immediately  begins  to  grow  again.  It 
is  most  commonly  seen  on  the  hands  and  feet,  but  it  may  occur  on 
any  part  of  the  body  and  even  on  the  lip.  Its  inconvenience  and  its 
being  so  easily  disturbed  and  knocked  are  its  chief  discomforts.  Prac- 
tically all  the  investigators  have  found  the  growth  to  be  a  granuloma, 
consisting  of  granulation  tissue  rich  in  blood-vessels  and,  to  a  somewhat 
less  extent,  in  fibrous  tissue,  with  pus  cocci,  usually  the  staphylococcus 
aureus,  present  in  variable  quantity,  and  which  are  generally  considered 
the  inciting  cause.  The  minor  histologic  differences  depend  largely 
upon  the  degree  of  vascularity  and  inflammation.  Heuck  thinks  his 
histologic  study  warrants  a  division  into  two  groups:  the  simple  type, 
with  conditions  just  described,  and  the  angiomatous  type,  with  similar 
findings  plus  a  marked  tendency  to  the  formation  of  large  blood  chambers. 
The  apparently  etiologic  pyogenic  factor  led  Hartzell  and  Crocker  to 
give  the  malady  the  convenient  name  "granuloma  pyogenicum,"  while 
on  account  of  the  prominence  of  the  vascular  feature  Kiittner,  Reit- 
mann,  Kreibich,  and  other  German  observers  have  favored  the  designa- 
tion "granuloma  telangiectodes." 

Prognosis  and  Treatment. — If  let  alone  the  formation  is  apt  to 
be  persistent,  but  it  usually  yields  quickly  and  successfully  to  removal 
by  curet  or  other  means,  with  supplementary  cauterization  of  the 
point  of  origin;  the  latter  seems  essential  in  most  instances,  otherwise  a 
regrowth  commonly  takes  place. 

FIBROMA 

Synonyms. — Molluscum  simplex;  Molluscum  fibrosum;  Fibroma  molluscum; 
Molluscum  pendulum;  Molluscum  non-con tagiosum;  Fr.,  Fibrome;  Naevus  mollus- 
coide;  Molluscum  vrai;  Ger.,  Fibrom. 

Definition. — Fibroma  is  a  connective-tissue  new  growth,  appear- 
ing as  one  or  more  sessile  or  pedunculated,  pea-  to  egg-sized  or  larger, 
soft  or  firm,  rounded,  sometimes  flattened,  painless  tumors,  seated  be- 
neath and  in  the  skin. 

Symptoms.— The  tumors  appearing  in  this  disease  show  varia- 
tions as  to  size,  shape,  and  numbers.  There  may  be  but  a  single  growth 
or  they  may  be  numerous.  Occurring  as  a  single  tumor,  which  is  the 
more  common,  it  is  usually  more  or  less  pedunculated,  and,  when 
reaching  any  great  size, — and  it  quite  frequently  attains  considerable 
dimensions, — it  becomes  pendulous  (fibroma  pendulum).  In  the  mul- 
tiple cases  the  growths  may  be  somewhat  scanty  in  number,  or  may  exist 


692  NEW  GROWTHS 

reticulated  form,  developing  along  the  vessels,  with  a  tendency  here  and 
there  toward  true  angiomatous  characters.  These  findings  would  seem 
to  indicate,  as  Bowen  states,  the  possibility  of  later  malignant  changes. 
Prognosis  and  Treatment. — The  malady  is  persistent  and 
progressive,  and  in  the  cases  in  which  the  growths  were  destroyed  by 
cauterization  (Hutchinson,  White)  and  excision,  new  lesions  appeared 
peripherally  or  in  the  resulting  scar  tissue.  Possibly  electrolysis  along 
the  borders  of  the  area,  as  Crocker  suggests,  with  the  object  of  causing 
occlusion  of  the  vessels,  might  stay  its  progress,  but  the  failure  of  the 
more  active  methods  already  tried  would  scarcely  lend  much  hope  to  this 
plan. 

GRANULOMA  PYOGENICUM1 

Synonyms. — Granuloma  telangiectodes;  Granuloma  pediculum;  Granuloma  pedic- 
ulatum;  Pseudobotryomycosis;  Fr.,  Botryomycose  humaine;  Pseudobotryomycose; 
Granulome  pedicu!6;  Ger.,  Telangiektatische  granulome. 

This  rather  rare,  usually  pea-  to  nut-sized,  more  or  less  thinly  pedic- 
ulated  growth  was  first  described  by  Poncet  and  Dor  and  later  by  other 
French  observers,  who  looked  upon  it  as  analogous  to  botryomycosis 
observed  in  bovines  and  other  animals,  in  short,  as  human  botryomycosis. 
Soon  afterward,  however,  Sabrazes  and  Laubie,  Jaboulay,  Brault,  Bodin, 
and  others  succeeded  in  showing  conclusively  that  the  so-called  botryo- 
mycetes  were  in  reality  staphylococci,  and  since  then  the  designation 
"botryomycosis  hominis"  has  given  place  in  French  writings  to  that  of 
"pseudobotryomycosis."  More  recent  investigations  by  Hartzell  and 
Wile  in  this  country,  Lenormant  in  France,  and  Heuck  and  others  in 
Germany  have  emphasized  the  correctness  of  these  later  findings.  The 
lesion  is  single  and,  as  a  rule,  appears  insidiously  and  grows  slowly;  minute 
in  the  beginning,  the  outer  portion — the  portion  projecting  beyond  and 
above  the  skin — expands  and  may  reach  the  size  of  a  pea  to  a  cherry  or 
somewhat  larger;  the  short  pedicle,  or  portion  in  and  immediately  on 
and  above  the  surface,  remaining  slender,  sometimes  almost  thread-like, 
seemingly  serving  the  purpose  of  a  channel  through  which  goes  material 
for  nourishing  and  increasing  the  size  of  the  growth,  and  for  keeping  the 
latter  attached  to  the  skin.  The  pedicle  may  be  extremely  short,  so  that 
the  growth  may  appear  to  be  sessile.  The  surface  of  the  small  tumor 
may  be  more  or  less  rounded  and  smooth,  or  irregular  and  fungoidal, 
and  even  lobulated,  its  enveloping  membrane  thin,  frequently  shiny  and 

important  Literature:  "Poncet  et  Dor,  Botryomycose  humaine,"  Trans.  XI, 
FrenchSurg.  Cong.,  1897;  Bodin,  "  Sur  la botryomycose  humaine,"  Annales,  1902,  iii,  p. 
289,  and  Semainemed.,  1902,  No.  14,  p.  14;  Hartzell,  " Granuloma  pyogenicum,"  Jour. 
Cutan.  Dis.,  1904, p.  520  (4  cases  with  brief  review  and  case  and  histolog.  illustrations); 
Kuttner,  "Ueber,  telangiektatische  Granulome,"  Brun's  Beitrage  z.  klin.  Chir.,  1905, 
xlyii,  p.  i  (4 cases);  Kreibich,  "Ueber  Granulome,"  Archiv.  1909,  xciv,  p.  121  (4  cases); 
Wile,  "Granuloma  pyogenicum,"  Jour.  Cutan.  Dis.,  1910,  p.  662  (2  cases,  with  brief 
review  of  the  Hartzell,  Kuttner,  Reitmann,  Kreibich  and  Jacquet  and  Barre  cases; 
with  histolog.  illustrations,  and  bibliography) ;  Lenormant,  "Sur  la  pr6tendue  botryomy- 
cose humaine,"  Annales,  April,  1910,  p.  161  (5  cases  with  case  and  histolog.  illustrations; 
full  resume  and  review  with  references — collected  126  cases  of  the  disease  from  litera- 
ture); Heuck,  "Ueber  Granuloma  pediculatum" ;  Sogenannte,  "Menschliche  Botrymy- 
lose,"  Dermatolog.  Zeitschr.,  March,  April,  and  May,  1912  (an  exhaustive  paper; 
records  2  cases  of  his  own,  with  histolog.  findings;  reviews  all  the  reported  cases  in  the 
literature). 


FIBROMA  693 

usually  bright  to  dark  red  in  color,  and  either  dry  or  slightly  damp  or 
moist  to  the  touch;  in  occasional  cases  superficial  ulceration  and  crusting. 
Occasionally  it  is  quite  dark  in  color.  Sometimes  it  has  the  appearance 
of  a  pedicled  proud-flesh  formation;  and  it  may,  in  the  larger  spread- 
out  formation,  present  a  clinical  resemblance  to  the  strawberry-like 
growth  seen  occasionally  developing  at  the  site  of  a  recent  vaccination. 

It  doubtless  takes  its  origin  at  the  point  of  a  slight  abrasion  or 
injury,  is  probably  always  the  result  of  suppuration,  insignificant  or 
unnoticeable,  as  it  may  be.  It  is  a  persistent  formation,  and,  as  a 
rule,  when  torn  off  its  pedicle  immediately  begins  to  grow  again.  It 
is  most  commonly  seen  on  the  hands  and  feet,  but  it  may  occur  on 
any  part  of  the  body  and  even  on  the  lip.  Its  inconvenience  and  its 
being  so  easily  disturbed  and  knocked  are  its  chief  discomforts.  Prac- 
tically all  the  investigators  have  found  the  growth  to  be  a  granuloma, 
consisting  of  granulation  tissue  rich  in  blood-vessels  and,  to  a  somewhat 
less  extent,  in  fibrous  tissue,  with  pus  cocci,  usually  the  staphylococcus 
aureus,  present  in  variable  quantity,  and  which  are  generally  considered 
the  inciting  cause.  The  minor  histologic  differences  depend  largely 
upon  the  degree  of  vascularity  and  inflammation.  Heuck  thinks  his 
histologic  study  warrants  a  division  into  two  groups:  the  simple  type, 
with  conditions  just  described,  and  the  angiomatous  type,  with  similar 
findings  plus  a  marked  tendency  to  the  formation  of  large  blood  chambers. 
The  apparently  etiologic  pyogenic  factor  led  Hartzell  and  Crocker  to 
give  the  malady  the  convenient  name  "granuloma  pyogenicum,"  while 
on  account  of  the  prominence  of  the  vascular  feature  Kiittner,  Reit- 
mann,  Kreibich,  and  other  German  observers  have  favored  the  designa- 
tion "granuloma  telangiectodes." 

Prognosis  and  Treatment. — If  let  alone  the  formation  is  apt  to 
be  persistent,  but  it  usually  yields  quickly  and  successfully  to  removal 
by  curet  or  other  means,  with  supplementary  cauterization  of  the 
point  of  origin;  the  latter  seems  essential  in  most  instances,  otherwise  a 
regrowth  commonly  takes  place. 

FIBROMA 

Synonyms. — Molluscum  simplex;  Molluscum  fibrosum;  Fibroma  molluscum; 
Molluscum  pendulum;  Molluscum  non-con tagiosum;  Fr.,  Fibrome;  Naevus  mollus- 
coide;  Molluscum  vrai;  Ger.,  Fibrom. 

Definition. — Fibroma  is  a  connective-tissue  new  growth,  appear- 
ing as  one  or  more  sessile  or  pedunculated,  pea-  to  egg-sized  or  larger, 
soft  or  firm,  rounded,  sometimes  flattened,  painless  tumors,  seated  be- 
neath and  in  the  skin. 

Symptoms. — The  tumors  appearing  in  this  disease  show  varia- 
tions as  to  size,  shape,  and  numbers.  There  may  be  but  a  single  growth 
or  they  may  be  numerous.  Occurring  as  a  single  tumor,  which  is  the 
more  common,  it  is  usually  more  or  less  pedunculated,  and,  when 
reaching  any  great  size, — and  it  quite  frequently  attains  considerable 
dimensions, — it  becomes  pendulous  (fibroma  pendulum).  In  the  mul- 
tiple cases  the  growths  may  be  somewhat  scanty  in  number,  or  may  exist 


694  NEW  GROWTHS 

in  great  profusion,  as  in  the  instances  observed  by  Octerlony,1  Hewson, 
and  others;  in  extreme  examples  they  may  be  present  in  such  abundance 
as  to  crowd  the  surface,  as  in  the  case  reported  by  Dunn.2  In  these 
extensive  cases  the  growths  vary  from  a  pea  to  an  egg  or  larger,  and  may 
be  almost  all  more  or  less  rounded  and  sessile,  although  usually  some  show 
a  trifling  or  moderate  tendency  to  narrowing  at  the  base,  giving  the  tu- 
mors a  pear  shape,  and  such,  when  the  narrowing  is  at  all  marked  and 
the  growths  moderately  large,  are  generally  slightly  pendulous.  Others 
may  be  sausage  shaped,  and  exceptionally  show  a  tendency  to  lobulation. 
In  other  cases  the  tumors  will  be,  for  the  most  part,  as  just  described; 
but  one  or  several  extremely  large  pedunculated  growths  (fibroma  pen- 
dulum) will  be  present,  with  a  comparative  small  pedicle  and  a  variously 


Fig.  156. — Fibroma  (front  and  back  view  of  the  same  patient)  (courtesy  of  Dr.  Addinell 

Hewson). 

sized,  pear-shaped,  often  somewhat  flattened,  pendulous  mass,  which 
hangs  down  and  often  covers  up  some  of  the  smaller  tumors.  In  these 
general  cases  the  upper  part  of  the  back  seems  to  be  a  favorite  region 
for  the  pendulous  growth,  as  in  Tappey's  and  lurkewicz's3  patients. 
The  smallest  tumors  project  but  slightly,  in  some  instances  appearing 

Octerlony,  Arch.  Derm.,  1875,  p.  300,  having  2333  growths  (with  illustrations); 
Wigglesworth,  in  the  same  journal  for  1876,  p.  193,  also  records  a  similar  case  (with 
illustration),  having  1193  tumors;  Hashimoto,  Sei-I-Ku'ai  Med.  Jour.,  Dec.,  1888,  p. 
197  (with  illustration),  described  a  case  with  4503  growths;  Pooley,  Jour.  Ciitan.  Dis., 
1894,  p.  117,  has  also  published  an  extensive  case  (with  illustrations). 

2  Dunn,  Med.  Press  and  Circular,  1890,  p.  623  (with  good  illustrations);  a  plate  of 
this  remarkable  case,  credited  to  Hutchinson,  will  also  be  found  in  Morrow's  System, 
vol.  iii  (Dermatology),  op.  p.  478. 

3  Tappey,  Jour.  Cutan.  Dis.,  1889,  p.  179  (with  illustration);  lurkewicz,  Meditzin- 
koieObozrenie,  No.  21,  1891,  p.  738  (with  drawing) — abs.  in  Brit.  Jour.  Derm.,  1891,  p. 
367- 


FIBROMA  695 

to  be  practically  subcutaneous,  although  in  other  cases  they  are  inti- 
mately associated  with  the  skin  proper  and  are  more  elevated.  In  the 
moderate  and  larger  sized  growths  the  elevation  is  conspicuous,  and  when 
narrowing  of  the  base  is  present,  they  are  essentially  situated  wholly 
above  the  surrounding  level. 

The  skin  over  the  tumors  is  generally  normal,  but  it  may  be  tense  or 
lax,  and  of  a  natural  pinkish  or  reddish  color.  The  reddish  color  is 
generally  seen  in  those  growths  which  develop  rapidly,  the  slowly  grow- 
ing tumors — the  usual  course — remaining  more  or  less  normally  colored. 
In  some  tumors,  more  especially  those  of  larger  size,  the  openings  of  the 
sebaceous  glands  are  enlarged  and  hypertrophied,  and  sometimes  con- 
tain blocked-up  secretion  or  plugs.  In  other  instances,  usually  in  those 
lesions  in  which  the  skin  is  tense  and  distended,  the  follicles  may  be 
atrophied  and  the  integument  somewhat  thinned.  To  the  touch  they  usu- 
ally feel  soft  or  doughy  and  slightly  elastic,  and  are  painless.  They  do 
not  undergo  destructive  change,  although  with  the  heavy,  pendulous 
formations,  as  a  result  of  weight  or  pressure,  surface  abrasion  and  ulcera- 
tion  may  occur;  and  when  crowded  together,  owing  to  their  number, 
size,  and  location,  as  a  result  of  interference  with  motion  or  by  accidental 
injury,  the  larger  growths  may  occasionally  become  inflamed,  and  ex- 
ceptionally undergo  ulceration  and  even  become  gangrenous.  In  some 
of  the  rapidly  developing  tumors  the  skin,  which  becomes  red  and  vas- 
cular, may  later  become  excoriated  and  even  ulcerated.  Gangrenous  de- 
struction also  occasionally  occurs  in  the  growths  with  extremely  thin 
pedicle.  Ordinarily,  however,  such  accidents  do  not  occur,  and  except 
for  the  disfigurement  and  discomfort  of  their  presence,  they  give  rise  to 
no  serious  condition.  In  the  course  of  time,  but  usually  slowly,  some 
lesions  continue  to  increase  in  size,  new  ones  may  arise,  while  others, 
having  obtained  variable  dimensions  from  small  to  large,  remain  more  or 
less  stationary,  so  that  there  are  usually  to  be  seen,  in  a  given  case, 
tumors  of  all  sizes  from  that  scarcely  larger  than  a  pin-head  or  small 
pea  to  that  of  considerable  proportions;  the  latter,  especially  the  large 
pendulous  tumors,  sometimes  reaching  huge  size,  and  weighing  many 
pounds.  The  greatest  size  and  weight  are  observed  in  the  single  fibroma, 
although  in  the  multiple  cases  sometimes  one  or  two  tumors  also  attain 
enormous  development.  In  the  average  case  there  seems  to  be  a  steady, 
usually  slow,  increase  in  the  number  of  the  growths,  although  after  a  time 
the  malady  is  apt  to  remain  stationary;  exceptionally,  however,  there 
are  seen  to  be  periods  of  active  increase,  and  this  has  been  more  especially 
noticed  in  women  and  in  connection  with  pregnancy  (Hirst1).  Indeed, 
there  is  a  peculiar  small  type  growth  observed  occasionally  in  pregnant 
women,  presenting  about  the  fourth  to  the  sixth  month  of  pregnancy, 
gradually  increasing,  as  a  rule,  in  numbers  (rarely  exceeding  50)  up  to 
full  term,  and  then  slowly,  in  the  course  of  a  few  months  disappearing 
(Brickner2) ;  they  are  usually  only  seen  about  the  neck,  breast  and  sub- 
mammary  region. 

1  Hirst,  "A  Note  on  the  Etiological  Influence  of  Pregnancy  upon  Molluscum  Fibro- 
sum,"  Amer.  Jour,  of  Obstetrics,  1911,  Ixiii,  p.  256. 

2  Brickner,  "Fibroma  Molluscum  Gravidarum,"  Amer.  Jour,  of  Obstetrics,  1906, 
liii,  p.  191  (with  histologic  report  by  Pollitzer). 


696  NEW  GROWTHS 

Occasionally  the  tumor  growths  are  ill  defined,  consisting  of  irregular 
and  nodular,  confluent,  wrinkled,  and  fold-like  masses,  and  when  such 
formations  are  numerous  and  of  gigantic  size,  they  give  the  patient  in 
regions  an  elephantine  appearance — the  extreme  development,  which 
seems  really  a  combination  of  fibroma,  elephantiasis,  and  dermatolysis, 
giving  rise  to  the  appellation  "elephant  man,"1  In  this  instance  there 
were  also  some  exostoses.  Occasionally  a  growth,  usually  those  of  mod- 
erate size,  undergoes  partial  involution  or  absorption  of  the  interior  por- 
tion, and  hangs  like  a  flaccid,  partly  filled  pouch  or  sac.  This  absorption 
exceptionally  takes  place  in  the  large  pedunculated  or  sessile  growths, 
and  when  more  or  less  complete,  results  in  a  soft  mass  of  pendant,  vari- 
ously hypertrophied  skin— dermatolysis  (q.  v.}.  This  same  change  is 
also  at  times  noted  in  the  small  pea-sized,  isolated  fibromata,  and  fleshy 
moles,  soft  warts,  or  solid,  warty-looking  growths,  in  the  skin  of  those 
advancing  in  years  (see  Atrophia  senilis),  which  are  often  pedunculated, 
and  which  result  in  small,  pendulous  sacs;  to  these  the  name  of  fibroma 
simplex,  or  acrochordon,  is  sometimes  given,  although  the  term  fibroma, 
when  employed,  usually  refers  to  the  more  pretentious  growths,  which 
have  been  described,  but  which,  as  remarked,  may  undergo  similar  invo- 
lutionary  changes.2  Occasionally,  in  a  pea-  to  cherry-sized  growth,  more 
especially  the  smaller,  when  such  absorption  or  involutionary  change 
takes  place,  there  remains  a  slight  projection,  seemingly  hollow  and  read- 
ily compressible,  and  sometimes  of  a  bluish  tinge. 

In  some  instances  neurofibromata  have  coexisted,  as  in  the  cases 
recorded  by  Atkinson,3  von  Recklinghausen,4  Payne,5  Brigidi,6  Briquet,7 
and  others.8  In  some  cases,  as  Recklinghausen  and  some  others  believe, 
the  lesions  are  doubtless  all  neurofibromata  (Recklinghausen's  disease, 
neurofibromatosis).  Other  lesions  sometimes  associated  are  brownish, 
pigmentary  stains,  sometimes  freckle-like,  small  or  large  areas,  and 
occasionally  more  or  less  diffused  discoloration.  While,  as  Wickham9 

1  Editorial  report  of  an  extreme  example  in  Brit.  Med.  Jour.,  1886,  ii,  p.  1188  (with 
illustrations) ;  an  abbreviated  account,  with  illustrations,  also  in  Jour.  Cutan.  Dis.,  1887, 
p.  no. 

2  See  Taylor's  paper,  "Molluscum  fibrosum  and  its  Relation  to  Acrochordon  and 
other  Cutaneous  Outshoots,"/0wr.  Cutan.  Dis.,  1887,  p.  41 ;  and  to  "Keloid,"  ibid.,  p.  161. 

3  Atkinson,  New  York  Med.  Jour.,  1875,  vol.  xxii,  p.  601  (2  cases  in  family). 

4  Von  Recklinghausen,   Ueber  d ie  multiplen  Fibrome  der  Haul,  und  ihre  Beziehung 
zu  den  multiplen  Neuromen,  Berlin,  1882  (a  resume  of  fibroma  cases;  5  plates,  2  of  case 
illustrations  and  3  histologic).  «  Payne,  Brit.  Med.  Jour.,  1889,  i,  p.  592. 

.  ., ..'  Brieidi'  Monatshefte,  1894,  vol.  xix,  pp.  190  and  237  (with  histologic  cuts  and 
bibliography).  ?  Briquet,  Jour.  med.  cutan.,  1898,  p.  219  (with  bibliography). 

8  Whitfield,  Lancet,  Oct.  31, 1903,  p.  1230  (newly  formed  nerve-fibers  were  found  in 
the  growth) ;  Krzystalowicz,  Monatshefte,  1903,  vol.  xxxvi,  p.  421  (case  report,  histologic 
review,  and  bibliography  to  date);  Piolett,  Hospital  Gazette,  1902,  No.  137,  brief  ab- 
stract in  Jour.  Cutan.  Dis.,  1905,  p.  363  (with  more  than  600  tumors) ,  Benaky,  Annales, 
1905,  p.  977;  Merk,  Archi-o,  1905,  vol.  Ixxiii,  p.  139. 

»  Wickham,  Paris  letter,  Brit.  Jour.  Derm.,  1890,  p.  151 ;  Parkes-Weber,  Brit.  Jour. 
Derm.,  1909,  p.  49,  reviewing  the  subject,  calls  attention  to  the  fact  that  cases  of  Reck- 
linghausen's disease  occur  in  which  decided  pigmentation  of  the  skin  is  developed  long 
before  neurofibromata  of  nerve-trunks  or  molluscum  tumors  of  the  skin  are  observed; 
Ravogh,  '  Fibroma  Molluscum,  or  Universal  Neurofibromatosis,"  Jour.  Cutan.  Dis., 
Feb.,  1911  (records  a  case;  illustrations,  review  of  the  subject  in  general,  with  good 
bibliography);  Friedlander,  "Multiple  Neurofibromata"  Jour.  Cutan.  Dis.,  1910,  p. 
497,  reports  a  case  and  gives  review,  based  on -262  cases  reported  in  the  literature 
(good  bibliography). 


FIBROMA  697 

states,  some  authors  touch  upon  this  feature,  present  in  many  cases,  by 
others  it  is  entirely  ignored.  In  Wickham's  8  generalized  cases  such 
pigmentary  conditions  were  present  in  all;  and  in  addition  there  were 
small,  violaceous,  compressible  prominences,  already  noted,  but  which 
Wickham  apparently  considers  arise  as  such,  and  not  necessarily  as  a 
result  of  involutionary  changes. 

Any  part  of  the  surface  may  be  the  seat  of  fibromata,  but,  as  a  rule, 
the  tumors  are  most  numerous  and  largest  on  the  trunk,  both  front 
and  back.  The  scalp1  and  other  parts  of  the  head  are  also  favorite 
localities,  and  the  extremities  usually  show  the  smallest  number.  The 
palms  and  soles  are  rarely  invaded,  and,  when  so,  the  growths  are  small 
and  flattened.  In  some  instances  they  have  also  been  found  on  the  mu- 
cous membranes,  as  on  the  lips,  gums,  hard  palate,  and  tongue. 

Another  form  of  fibroma,  called  hard  fibroma,2  or  desmoids,  in  con- 
tradistinction to  that  which  is  ordinarily  met  with  and  just  described 
(sometimes  called  soft  fibroma)  is  in  many  respects  similar  to  the  more 
solid  small  growths  already  referred  to  as  fibroma  simplex.  They 
are  rarely  larger  than  a  pea,  occur  usually  singly,  or  as  several 
scattered  solid  growths,  covered  by  normal  skin;  are  sharply  defined, 
round  or  oval,  smooth  and  compact,  and  movable.  Their  appearance 
is  insidious  and  their  growth  slow,  and  they  may  appear  at  any  age,  and 
are  even  present,  in  some  instances,  at  birth. 

Etiology. — The  affection  is  not  a  common  one  in  our  own 
country,  England,  or  the  Continent,  but  is,  according  to  Hashimoto, 
quite  frequent  in  the  eastern  countries.  Its  etiology  is  obscure,  although 
it  is  known,  from  the  observations  of  Virchow,3  Konigsdorf,4  Octerlony,5 
Atkinson,6  and  others,  to  have  occurred  in  several  successive  generations, 
or  sometimes  in  more  than  one  member  of  the  same  family.  Heredity 
or  family  tendency  must,  therefore,  be  considered  a  factor.  It  occurs 
in  both  sexes,  in  all  nationalities,  and  usually  begins  in  childhood  and  fre- 
quently in  early  infancy;  in  some  instances  it  is  congenital  (Hahn,  Tap- 
pey,  Hallopeau,  and  others).7  In  early  life  the  lesions  are,  however, 
small  and  relatively  scanty,  and  the  increase  in  size  and  number  takes 
place  very  slowly,  as  a  rule,  not  developing  to  any  extent  until  much 
later.  In  the  cases  of  single  fibroma  its  appearance  is,  as  a  rule,  later  in 
life.  The  subjects  of  the  malady,  as  Hebra  pointed  out,  and  also  shown 
in  those  of  Pooley,  Pringle,8  lurkewicz,  and  many  others,  are  often  of 

1  W.  G.  Smith,  Brit.  Jour.  Derm.,  1896,  p.  115,  describes  and  illustrates  a  case  of 
extensive,  somewhat  lobulated  fibroma,  seated  upon  the  scalp,  with  no  tumors  else- 
where. 

2  Synonymous  with  Unna's  "  Fibroma  simplex."    Recently,  under  the  name  of 
"  Noduli  cutanei,"  Arning  and  Lewandowsky  (Archiv,  1911,  ex,  p.  .3)  reported  aperies 
of  cases  (20  occurring  among  5000  patients)  which  histologic  examinations  indicated 
to  be  the  same  formation;  evidently  this  form  is  not  so  uncommon  as  thought,  but 
from  their  benign  and  painless  character  often  overlooked. 

3  Virchow,  Virchow's  Archiv,  1847,  vol.  i,  p.  226  (according  to  the  patient  s  state- 
ment his  grandfather,  father,  brother,  and  sister  had  the  same  disease). 

4  Konigsdorf,  "Ein  Fall  von  Fibroma  Molluscum  Multiplex,"  Dissertation,  Wiirz- 
burg,  1889  (quoted  by  Jarisch). 

5  Octerlony,  loc.  cit.  (a  brother  also  had  it).  •  Atkinson,  loc.  cil. 

7  Hahn  "Beitrage  zur  Casuistik  des  Fibroma  Molluscum,"  Dissertation,  vVurzburg, 
1888;  Hallopeau,  Annales,  1889,  p.  707  (case  demonstration  and  histologic  examination). 

8  G.  L.  K.  Pringle,  Edinburgh  Med.  Jour.,  1900,  vol.  xlix,  p.  260  (with  plate). 


698  NEW  GROWTHS 

weak  physical  and  of  defective  mental  development,  but  while  so  in  the 
larger  number  of  cases,  it  by  no  means  obtains  in  all.  Moreover,  it 
is  not  improbable,  as  Hutchinson1  suggests,  that  the  mental  apathy  is 
the  indirect  result  of  the  gross  disfigurement,  the  patient  holding  himself 
aloof  and  shunning  his  fellows.  Traumatism  is  thought  a  possible 
determining  factor  in  their  production,  or,  more  probably,  only  in  in- 
fluencing their  location,  more  especially  in  the  single  fibroma  developing 
later  in  life.  Schwimmer,  Taylor,  and  Recklinghausen,  as  well  as  a 
few  others,  have  noted  this,  the  last  calling  attention  to  the  fact  that  those 
parts  of  the  body  most  subject  to  friction,  pressure,  etc.,  usually  show 
the  most  numerous  growths.  In  some  instances  in  women  pregnancy 
seems,  directly  or  indirectly,  of  some  etiologic  influence  (Brickner, 
Hirst). 

Pathology. — According  to  the  investigations  of  Rokitansky, 
Virchow,  Neumann,  Sangster,  Duhring,  Crocker,  and  others,  the  growth 
is  due  to  a  hyperplasia  of  the  connective  tissue,  although  there  is  not 
the  same  unanimity  as  to  its  exact  starting-point,  whether  from  the  con- 
nective tissue  of  the  corium,  of  the  frame-work  of  the  fat-globules,  or 
of  the  walls  of  the  hair-follicles  and  sebaceous  glands.  As  to  what  gives 
rise  to  this  hyperplasia  is  unknown.  Recklinghausen,  from  his  investi- 
gations of  multiple  fibromata,  believes  that  they  are  really  neurofibro- 
mata,  and  that  they  are  formed  primarily  by  proliferation  of  the  con- 
nective-tissue sheaths  of  the  nerves,  and  subsequently  added  to  by  pro- 
liferation of  the  same  tissue  of  sweat-glands,  sebaceous  glands,  and  blood- 
vessel sheaths.  The  admixture  of  neurofibromata  in  some  cases  is 
generally  recognized,  but  that  fibromata,  as  commonly  met  with,  are 
all  of  the  same  origin  or  nature  is  negatived  by  the  collective  investiga- 
tions of  others.  Both  Pringle2  and  Anderson3  have  also  called  attention 
to  the  fact  that  there  is  sometimes  an  association  of  fibromata  with  ade- 
noma sebaceum,  and  it  is  not  at  all  impossible,  therefore,  as  these  several 
gentlemen  suggest,  that  certain  tumors  of  different  origin  and  character, 
which  are  sometimes  found  together,  may  have  some  common  pathologic 
relationship.  Crocker  suggests  that  the  growth  may  be  due  to  obstruc- 
tion of  the  superficial  lymphatics,  and  that  this,  as  well  as  other,  anatomic 
analogies  bring  it  into  pathologic  relationship  with  elephantiasis. 

As  the  beginning  lesions  grow  and  extend  the  skin  is  pushed  upward, 
and  they  finally  project  as  simple  or  lobulated,  sessile  or  pendent  tumors; 
they  are  adherent  to  the  skin  only  at  their  base,  and  may  thus  be  easily 
enucleated  (Heitzmann).  Crocker  states  that  a  sebaceous  gland  or  hair- 
follicle  forms  the  center  in  many  of  the  small  tumors,  while  these  struc- 
tures in  the  larger  or  older  growths  have  undergone  atrophy  or  disap- 
peared. According  to  Taylor,  in  their  very  earliest  stage  the  tumor  con- 
sists of  a  gelatinous  structure,  which,  under  the  microscope,  is  found 
composed  of  a  succulent,  edematous,  wavy  connective  tissue  with  many 
cells,  while  in  the  older  growths  the  fibers  are  firm  and  not  edematous, 

1  Hutchinson,  "Molluscum  fibrosum,"  Rare  Diseases  of  the  Skin,  p.  205. 

2  Pringle,  "Case  of  Congenital  Adenoma  Sebaceum,"  Brit.  Jour.  Derm.,  1890,  p.  i. 

3  Anderson,  "A  Case  of  Adenoma  Sebaceum  Intermingled  with  Mollusca  Fibrosa," 
ibid.,  1895,  p.  316. 


FIBROMA  699 

and  the  cells  are  less  numerous.  On  cutting  through  a  well-formed 
tumor  of  some  duration,  quoting  chiefly  from  Crocker  and  Heitzmann, 
it  is  found  to  consist  of  a  white,  fibrous  mass,  inclosed  in  a  dense  con- 
nective-tissue capsule,  with  the  central  portion  soft  and  pulpy,  and  from 
which  a  small  quantity  of  clear  yellow  fluid  can  be  pressed  out.  The 
fibrous  tissue  is  firmest  and  most  developed  at  the  base,  the  fibers  becom- 
ing less  firm  and  softer  as  the  interior  is  approached.  Connective-tissue 
cells  with  large  nuclei  are  found  between  the  fibers,  being  most  numerous 
in  the  gelatinous  central  portion.  The  vascular  supply  consists  of  large 
afferent  and  efferent  vessels,  readily  demonstrable  at  the  base,  and  which 
spread  peripherally,  terminating  in  fine  capillaries.  The  epidermis 
remains  unchanged,  although  the  sebaceous  gland-ducts  are  sometimes 
hypertrophied,  patulous,  and  plugged  with  comedones. 

Diagnosis. — In  a  large  single  and  pedunculated  fibroma,  and  in 
cases  of  multiple,  scattered,  variously  sized  growths,  most  of  which  are 
sessile,  and  possibly  a  few  with  a  narrowed  neck  or  pedicle,  a  correct 
diagnosis  is  a  matter  of  no  difficulty.  Confusion  is  most  likely  to  occur 
with  multiple  lipoma,  but  in  this  latter  they  are  commonly  lobular, 
somewhat  flattened,  rarely  present  in  numbers,  and  never  pedunculated. 
From  multiple  neuromata  they  are  to  be  distinguished  by  the  absence 
of  pain,  as  well  as  usually  by  their  more  general  distribution.  A  mistake 
has  sometimes  been  made  with  molluscum  contagiosum,  but  the  growths 
of  the  latter  are  much  smaller,  rarely  numerous,  most  commonly  seated 
about  the  face,  especially  about  the  eyelids,  and,  moreover,  are  super- 
ficial, have  a  central  depression  or  aperture,  and  are  covered  by  skin, 
which  is  usually  thin,  stretched,  and  which  has  a  semitranslucent  appear- 
ance. There  might  also  be  a  possibility  of  confusing  fibroma  with  the 
early  tumor  stage  of  granuloma  fungoides,  but  the  usual  preceding  and 
accompanying  eczematoid  symptoms  of  the  latter,  as  well  as  the  tend- 
ency, in  some  growths,  toward  the  formation  of  fungoidal  ulcerating 
masses,  and  the  late  development  and  sometimes  capricious  behavior 
of  the  tumors, — appearing  and  disappearing, — are  wholly  different  from 
the  features  of  fibroma.  The  soft  and  warty  moles,  sometimes  congenital 
and  sometimes  developing  later  in  life,  can  scarcely  be  confounded  with 
fibroma,  as  commonly  understood,  although  such  growths,  usually  small 
and  few  in  number,  and  generally  more  or  less  pigmented,  are  to  a  great 
extent  to  be  placed  in  the  same  category.  In  the  similar  lesions  observed 
in  old  people  about  the  face  and  back,  the  surface  is,  as  a  rule,  dark  col- 
ored, often  warty,  and  frequently  covered  with  a  greasy  scale  or  crust. 
It  is  scarcely  likely  that  fibromata  could  be  confused  with  the  nodules 
of  leprosy,  sebaceous  cysts,  or  gummata. 

Prognosis. — The  outlook,  so  far  as  life  is  concerned,  is  always  favor- 
able, but  as  to  the  growths  themselves  they  are  persistent,  and  usually 
add  gradually  to  their  size  and  also  increase  in  numbers.  While  not 
therefore,  involving  the  general  health,  still,  by  their  presence,  they  often 
give  rise  to  inconvenience  and  discomfort  by  interfering  with  freedom  of 
motion  and  through  accidental  injury,  besides  being  the  source  of  mental 
worry,  which  sometimes  leads  to  an  apathetic  or  neurasthenic  condition. 
Exceptionally,  in  some  growths, -a  tendency  to  spontaneous  involution 


700 


NEW  GROWTHS 


is  exhibited.  In  single  fibroma,  and  also  in  moderate  multiple  cases, 
there  may  be  relief  or  comparative  freedom  brought  about  through 
operative  procedures.  Unfortunately,  the  malady  is  not  influenced  by 
constitutional  treatment,  although  one  instance  of  great  improvement, 
to  be  later  referred  to,  has  been  recorded. 

Treatment. — Surgical  measures  alone  are  of  any  reliance,  and 
the  method,  whether  by  ligation,  ecraseur,  galvanocautery,  or  excision, 
depends  upon  the  size  and  character  of  the  growths.  Large  pendulous 
tumors  can  always  be  removed  readily,  and  with  great  relief  to  the  pa- 
tient. The  smaller  tumors  also  admit  of  removal  if  not  too  numerous 
and  if  done  a  few  at  a  time.  The  huge,  flabby  growths,  approaching  the 
nature  of  dermatolysis,  have  also  been  excised  with  success.  Whatever 
the  method,  the  tumor  should  be  thoroughly  extirpated  or  a  regrowth 
is  probable.  Electrolysis  has  proved  serviceable  for  the  small  tumors. 

In  multiple  cases,  in  view  of  the  favorable  influence  from  the  long- 
continued  administration  of  arsenic  exceptionally  observed  in  other 
multiple  tumor  growths,  this  drug  might  also  be  tried  in  fibromata, 
more  especially  so  now  in  view  of  the  favorable  influence  apparently 
exerted  in  a  case  under  Whitehouse's1  care. 

LIPOMA 

Synonym. — Fatty  tumor. 

Definition. — A  new  growth  composed  of  fat  tissue,  seated  in  the 
corium  or  subcutaneous  tissue. 

Symptoms. — This  formation,  which  usually  comes  under  the 
domain  of  surgery,  is  observed  in  two  forms — the  circumscribed  and  the 
diffused.  The  circumscribed  lipoma  appears  as  one,  several,  or  more 
rounded,  usually  lobulated  elevations,  and  covered  with  normal  or  slightly 
pigmented  integument,  although  occasionally  somewhat  thickened  and 
raised  in  folds.  They  are,  as  a  rule,  freely  movable,  and  of  soft  consist- 
ence. They  are  of  various  dimensions  from  a  cherry  to  head  size  or 
larger,  and  sometimes,  in  the  larger  growths,  with  a  tendency  to  ill- 
defined  pedunculation.  The  overlying  skin,  if  exposed  to  constant 
rubbing,  irritation,  or  injury,  may  become  firmly  agglutinated  with  the 
tumor  proper,  and  this  is  frequently  noted  as  apparently  a  spontaneous 
occurrence  in  those  of  large  size;  and  exceptionally  surface  ulceration 
may  result.  Their  appearance  is  gradual,  and  after  reaching  variable 
size,  usually  remain  more  or  less  stationary.  They  are  not  painful, 
except  when  nerves  are  involved  or  they  have  received  accidental 
injury.  The  favorite  situations  are  the  neck,  back,  and  buttocks. 

Diffuse  lipoma  is  less  common  than  the  circumscribed  form,  and 
appears  as  soft,  flattened,  variously  elevated,  somewhat  lobular  forma- 
tions, usually  distributed  over  relatively  large  areas,  and  with  no  sharp 
limitation,  but  gradually  merging  into  the  surrounding  uninvolved 
parts.  A  rather  ill-defined  or  mixed  variety  of  lipoma,  lumpy  and 

1  Whitehouse,  "A  Case  of  Generalized  Fibroma  Molluscum;  Tumors  Disappearing 
Rapidly  Under  the  Use  of  Asiatic  Pills,"  Jour.  Cutan.  Dis.,  1899,  p.  383  (case  demon- 
stration). 


LIPOMA  .  701 

infiltrating,  involving  the  neck  (fatty  neck)  and  occurring  in  males,  to 
which  Brodie,1  MacCormac,2  Hutchinson,3  Baker  and  Bowlby,4  and 
Madelung5  have  called  attention,  is  exceptionally  encountered.  The 
condition  sometimes  reaches  enormous  proportions. 

In  connection  with  lipoma  the  rare  and  independent  affection  known 
as  adiposis  dolor -osa  (Dercum's  disease),  which  Dercum,6  and  subse- 
quently Henry,7  Debove,8  and  others,  have  described,  may  be  briefly 
referred  to.  This  malady,  which  has  been  observed  in  middle  life  and 
in  women,  is  characterized  by  large,  irregular,  sometimes  quite  pro- 
nounced, nodular  and  diffused,  or  bolster-like,  fatty  deposits  in  the  sub- 
cutaneous tissues.  The  condition  is  gradual  in  its  progress,  and  usually 
involves  various  portions  of  the  body,  and  is  finally  more  or  less  general. 
With  this  are  associated  great  muscular  weakness,  pain,  nerve  tender- 
ness, diminution,  alteration,  or  abolition,  in  certain  areas,  of  the  tactile 
and  temperature  senses,  and  other  nervous  disturbances,  together  with 
hemorrhages  from  the  mucous  surfaces,  but  more  especially  from  the 
stomach  and  uterus.  Pain  is  usually  an  early  symptom,  and  headache 
common.  The  skin  is  noted  to  be  dry,  with  now  and  then  periods  of  free 
perspiratory  action.  In  i  of  Dercum's  cases  purpura  was  noted,  and  in 
another  a  herpetic  eruption.  In  2  of  the  cases  in  which  a  fatal  termina- 
tion ensued  the  thyroid  gland  was  found  small  and  nodular,  and  ex- 
hibited calcareous  deposits.  It  bears  a  rough,  gross  resemblance  to  myx- 
edema,  but  differs  materially,  especially  in  the  nervous  disturbances  and 
the  muscular  phenomena,  the  muscles  in  adiposis  dolorosa  being  weak, 
flabby,  and  exhibiting  other  features  of  degeneration.  Thyroid  gland 
extract  is  the  most  promising  remedy. 

Etiology  and  Pathology. — Lipomata  are  almost  always  ac- 
quired, only  exceptionally  congenital  cases  being  observed,  several  of 
which  have  been  recorded  by  Jacobi.9  Circumscribed  forms  are  much 
more  common  in  women,  and  usually  in  adult  age.  The  diffused  variety 

1  Brodie,  Lectures  on  Pathol.  and  Surgery,  1846,  p.  202  (Amer.  edit.). 
2MacCormac,  St.  Thomas'  Hosp.  Rep.,  1884,  vol.  xiii,  p.  287  (4  cases,  7  illustra- 
tions). 

3  Hutchinson,  Trans.  London  Ophthal.  Soc'y,  1884,  vol.  iv,  p.  40. 

4  Baker  and  Bowlby,  Trans.  London  Med.-Chir.  Soc'y,  1886,  vol.  Ixix,  p.  41. 

f  Madelung,  Archivf.  klin.  Chirurg.,  1888,  vol.  xxxvii,  p.  106  (4  illustrations). 

6  Dercum  ("Myxedematoid  Dystrophy"),  University  Med.  Magazine,  Dec.,  1888, 
and  Amer.  Jour.  Med.  Sci.  ("Three  Cases  of  a  Hitherto  Unclassified  Affection  Re- 
sembling, in  its  Grosser  Features,  Obesity,  but  Associated  with  Special  Nervous  Symp- 
toms—Adiposis  dolorosa"),  1892,  vol.  civ,  p.  521  (3  cases— former  case,  a  second  case, 
and  Henry's  case;  with  illustrations). 

7  F.  P.  Henry,  "Myxedematoid  Dystrophy  (Paratrophy),"  Jour.  Nero,  and  Mental 
Dis.,  1891,  p.  154. 

8  Debove,  "Lipomatose  douloureuse,"  Gaz.  de  Hop.,  Sept.  27,  1904;  Pnce,    Adi- 
posa  Dolorosa,"  Amer.  Jour.  Med.  Sci.,  May,  1909  (2  cases,  with  necropsy,  review,  and 
bibliography);  I.  P.  Lyon,  "Adiposis   and   Lipomatosis,"    Archiv.   Int.   Med.,   1910, 
vol.  vi,  pp.  28-120  (goes  fully  over  this  and  allied  subjects,  and  especially  "in  reference 
to  their  constitutional  relations  and  symptomatology,"  with  a  number  of  illustrations 
and  full  bibliography). 

9  A.  Jacobi,  "Congenital  Lipoma,"  Arch.  Pediatrics,  1884,  p.  65  (with  resume  and 
references  of  other  reported  cases) .     This  observer  remarks  that  the  shape  in  congenital 
lipoma  is  frequently  irregular,  and  not  spheroid,  as  it  commonly  is  in  the  adult,  nor  is  it 
generally  capsulated;  the  occiput  and  back,  the  abdomen,  upper  extremities,  besides 
the  calves  of  the  legs  and  the  dorsal  and  plantar  surfaces  of  the  feet,  are  the  usual  seats 
of  the  adipose  deposit. 


702 


NEW  GROWTHS 


occurs  almost  invariably  in  males,  and,  as  a  rule,  at  about  middle  life. 
The  etiology  is  obscure.  Anatomically  the  growth  consists  of  masses 
of  fat-globules,  more  or  less  lobularly  arranged,  and  enveloped  in  a 
connective-tissue  framework,  which  also  holds  the  blood-vessels.  The 
consistence  of  the  tumor,  whether  soft  or  moderately  firm,  depends 
upon  the  relative  proportions  of  these  two  constituent  tissues,  the  fatty 
mass  being  softer  in  those  of  loose  and  scant  connective-tissue  structure. 
While  the  tumors  may  persist  unchanged,  in  some  instances  the  connect- 
ive-tissue framework  is  the  seat  of  calcareous  deposits  or  even  of  ossifi- 
cation. Excessive  fat-tissue  formation  is  also  sometimes  noted  in  con- 
nection with  naevus  (naevus  lipomatodes)  and  other  growths,  such  as 
angioma,  sarcoma,  etc.1 

Diagnosis. — The  characteristic  features  of  lipoma  are  their  soft 
consistence,  lobular  character,  painlessness,  and  movability,  and  are 
usually  sufficient  to  prevent  confusion  with  fibromata,  sarcomata,  or 
other  growths.  In  doubtful  cases  microscopic  examination  of  the  com- 
ponent tissue  would  immediately  settle  the  question. 

Prognosis  and  Treatment — Lipomata  are  benign  growths 
and  do  not,  therefore,  involve  life,  and  beyond  their  appearance  and 
the  discomfort  caused  by  their  presence  or  size  are  not  cause  for  anxiety. 
When  treatment  is  sought  or  considered  necessary,  excision  is  the  sole 
efficient  recourse;  and  if  the  tumor  is  completely  removed,  occurrence 
is  not  probable.  In  several  cases  of  "fatty  neck,"  and  in  one  or  two  other 
instances,  Brodie  brought  about  considerable  reduction  by  large  doses 
of  liquor  potassae — \  to  i  dram  (2.-4.) — largely  diluted,  three  times  daily- 
but  Baker  and  Bowlby  found  no  influence  from  its  use. 

MYOMA 

Synonyms. — Dermatomyoma;  Leiomyoma;  Muscle  tumor;  Fr.,  Myome  cutane; 
Ger.,  Myom;  Dermatomyom. 

Definition — Myoma  of  the  skin  is  a  rare  tumor,  consisting  of 
smooth  muscle-fibers  mixed  with  the  fasciculi  of  fibrous  tissue.  Besnier2 

1  Bowen,  Amer.  Jour.  Med.  Sci.,  Aug.,  1912,  p.  189,  reports  a  rare  and  interesting 
case  of  "Multiple  Subcutaneous  Hemangiomas,  together  with  Multiple  Lipomas," 
consisting  of  numerous  well-defined  variously  sized  tumors;  in  the  smaller  and  younger 
lesions  the  hemangiomatous  element  being  most  pronounced,  with  a  gradual  and 
progressive  increase  in  the  amount  of  fat  tissue  as  the  lesions  become  more  developed, 
the  latter  (fat  tissue)  in  time  overshadowing  and  dominating  the  vascular  growth,  so 
that  the  larger  tumors  were  indistinguishable  from  true  lipomas. 

•AV,/ BeSnier'  "L?S  tumeurs  de  la  Peau>  les  dermatomyomes,"  Annales,  1880,  p.  25; 
ibid., ,1885,  vol.  vi,  p.  322;  and  Besnier-Doyon's  notes  to  translation  of  Kaposi's  work, 
vol.  11,  p.  346  (with  reference  to  reported  cases  to  date).  Other  important  literature: 
Crocker,  A  Case  of  Myoma  Multiplex  of  the  Skin,"  Brit.  Jour.  Derm.,  1897,  pp.  i  and 
47  (with  colored  plate  and  histologic  cuts,  and  a  resume'  of  recorded  multiple  cases  to 
date,  which  includes  Hardaway's  case);  Neumann,  1897,  Archiv,  vol.  xxxix,  p.  3  (with 
4  colored  plates— 2  case  illustrations  and  2  histologic);  Audry,  Annales,  1898,  p.  182; 
r?eTZ°«'rt^°"r<  Cutan-  Dis->  l8°8>  P-  527  (with  several  histologic  cuts  and  bibliography); 
C.  J.  White,  ibid.,  1899,  p.  266  (with  case  illustration  and  histologic  cuts;  Leslie  Rob- 
rts,  Brit.  Jour.  Derm.,  1900,  p.  115  (with  a  resume  of  the  preceding  4  cases) ;  Hardaway 
.second  report  on  his  case),  Jour.  Cutan.  Dis.,  1904,  p,  375;  Nobl,  Archiv,  1906,  vol. 
Ixxix,  p.  31  (extreme  case— disseminated) ;  Beatty,  Brit.  Jour.  Derm.,  Jan.,  1907,  p. 
i  (multiple;  with  r6sum6  of  7  multiple  cases  reported  since  Roberts'  paper;  case  and 
ologic  illustrations  with  complete  bibliography);  Heidingsfeld,  Jour.  Amer.  Med. 
Assoc.,  1-eb.  16,  1907  (with  histologic  cuts  and  review  of  literature,  with  references). 


MYOMA 


703 


divides  the  cases  into  two  classes:  simple  myoma,  or  leiomyoma,  which 
is  rare  and  presents  as  small  multiple  growths;  and  dartoic  myoma,  oc- 
curring usually  as  a  large  single  tumor,  and  where  the  cutaneous  muscu- 
lar development  is  more  abundant,  as  about  the  scrotum,  mammae, 
female  genitalia,  and  which  usually  comes  under  the  surgeon's  care. 
The  latter  develops  from  the  cutaneous  muscle-fibers,  while  the  former 
from  the  arrectores  pilorum  muscles  or  tunica  media  of  the  blood- 
vessels. In  multiple  myoma  the  lesions  generally  appear  as  pale  rose- 
colored,  rounded  or  ovalish,  somewhat  elevated  macules  or  papules,  which 
develop  into  pea-sized  tumors.  In  color  they  are  pink,  red,  or  normal, 
elastic  to  the  touch,  and  with  a  smooth  surface.  They  are  usually 
grouped,  and  are  accompanied  by  a  varying  amount  of  pain,  sometimes 
spontaneous  in  character,  sometimes  experienced  only  on  pressure. 
They  may  occur  upon  any  region,  but  the  sides  of  the  face  and  the  arms 
have  been  the  most  frequent  sites.  They  generally  show  a  tendency  to 
increase  in  size  and  number,  and,  as  a  rule,  are  steadily,  though  slowly, 
progressive;  at  times  spontaneous  involution  takes  place. 

The  single — dartoic  myoma — and  more  common  tumor  is  generally 
met  with  as  a  sessile  or  pedunculated  growth,  the  size  of  an  almond 
or  walnut  or  larger.  It  is  situated,  as  stated,  in  such  regions  as  the 
scrotum,  nipple,  or  labia.  As  a  rule,  it  is  painless,  contractile,  and  pro- 
vided with  blood-vessels,  and  grows  slowly.  When  the  tumor  consists 
principally  of  fibrous  tissue,  it  is  known  as  fibromyoma;  when  it  is  highly 
vascular,  containing  many  blood-vessels,  myoma  telangiectodes  (also 
angiomyoma);  and  when  the  lymphatic  structures  are  conspicuously 
involved,  lymphangiomyoma.  This  growth,  being  essentially  of  surgical 
interest,  will  not  be  further  considered  here. 

Beyond  the  fact  that  females,  adults,  and  middle  life  seem  more 
prone  to  the  growths,  nothing  is  known  etiologically.  In  a  few  instances 
they  began  in  childhood.  In  Brigidi's  case  the  growths  began  as  an  ec- 
chymosis.  In  one  of  Jadassohn's  it  was  stated  that  they  followed  vac- 
cination, doubtless  purely  a  coincidence.  Anatomically  the  multiple 
tumors  consist  of  unstriped  muscle-fibers,  surrounded  by  elastic  tissue, 
.and  take  their  origin  from  the  arrectores  pilorum  or  from  the  fibers  of  the 
middle  coat  of  the  blood-vessels.  There  may  in  some  cases  also  be  an 
undue  development  of  vascular,  lymphatic,  and  fibrous  tissue,  giving 
rise  to  the  compound  names  already  referred  to.  Evidences  of  degen- 
eration were  noted  in  White's  case,  and  the  same  can  probably  be  seen 
in  most  of  those  tumors  which  undergo  involution.  In  the  diagnosis  of 
these  tumors  the  microscope  is  generally  essential.  Their  insidious 
appearance,  slow  progress,  and  their  usually  occurring  in  circumscribed 
localities,  with  frequently,  as  they  grow  larger,  considerable  pain,  and 
with  no  tendency  to  ulceration,  will  be  sufficient  for  their  recognition 
in  well-marked  cases.  The  possibility  of  confusing  them  with  xanthoma,1 
lymphangioma,  fibroma,  and  even  with  keloid  and  neurofibroma  is  to 
be  kept  in  mind.  As  to  prognosis  the  growths  are,  of  course,  benign, 

1  See  interesting  paper  by  Sutton,  "Xanthoma  Tuberosum  Multiplex  Mistaken 
for  Myomatosis  Cutis  Disseminata,"  Jour.  Amer.  Med.  Assoc.,  July  20,  1912, 
p.  178. 


704 


NEW  GROWTHS 


and  in  themselves  have  no  influence  on  the  general  health,  but  if  ex- 
tremely painful,  may  indirectly  be  detrimental. 

Treatment  consists  in  their  removal  by  excision.  In  one  instance 
(Jadassohn)  the  pain  persisted  after  extirpation.  If  the  growths^  are 
numerous  and  excision  not  advisable  or  desired,  the  continued  adminis- 
tration of  arsenic  could  be  tried. 

NEUROMA 

Synonyms. — Nerve  tumor;  Fr.,  Nevrome;  Ger.,  Neurom;  Nervenschwamm. 

Definition. — Neuroma  of  the  skin  is  characterized  by  the  for- 
mation of  variously  sized,  usually  numerous,  firm,  immovable,  and 
elastic  fibrous  tubercles  containing  new  nerve-elements,  and  accom- 
panied by  violent  paroxysmal  pain.  It  is  an  exceedingly  rare  disease, 
and  up  to  the  present  time  but  few  cases  in  which  the  skin  was  primarily 
affected  have  been  reported;  one  of  these  was  by  Duhring1  and  another 
by  Kosinski.2  According  to  Duhring,  the  subcutaneous  nodule  of  Wood, 
resembling  neuroma  closely,  differs  in  being  situated  in  the  subcutaneous 
tissue,  is  always  freely  movable  under  the  skin,  and  is  solitary.  This  and 
other  cases  of  subcutaneous  neuromatous  tumors  are  not,  strictly  speak- 
ing, cutaneous  growths,  although  they  are  usually  so  considered  in  the  de- 
scription of  the  disease.  Nor  is  Rump's  case,3  sometimes  quoted,  a  clear 
example  of  the  malady,  consisting  essentially  of  a  fibroid  tumor  of  the 
nerve  (false  neuroma  of  Virchow),  and  was  not  accompanied  by  pain. 

In  Duhring's  case,  a  man  of  seventy,  the  disease  began  at  the  age 
of  sixty  in  the  form  of  small,  rounded  nodules  or  tubercles  upon  the 
shoulder.  For  a  period  of  four  years  they  continued  to  appear  in  in- 
creasing numbers,  the  arm  and  shoulder  becoming  fairly  well  covered 
with  them.  The  lesions  consisted  of  numerous  small,  firm,  flat  tubercles, 
the  size  of  a  split  pea,  situated  on  the  left  scapular  region,  shoulder, 
and  outer  surface  of  the  arm  to  the  elbow.  The  color  of  the  tubercles 
was  purplish  or  pinkish,  and  they  were  irregularly  distributed,  apparently 
without  regard  to  the  course  of  the  nerve.  Over  the  shoulder  and  arm 
they  were  closely  packed  together  and  firmly  imbedded  in  the  skin. 
The  integument  covering  the  growths  was  slightly  scaly.  The  skin 
between  the  tubercles  was  normal.  The  color  of  the  affected  area 
varied,  however,  according  to  the  position  of  the  limb  and  the  presence 
or  absence  of  pain,  becoming  hot  and  violaceous  when  painful.  The 
tumors  did  not  give  rise  to  any  discomfort  until  several  years  after  the 
beginning  of  the  affection,  after  which  pain  then  became  a  troublesome 
symptom,  and  occurred  in  paroxysms,  and  was  of  a  violent  character, 
radiating  down  the  arm,  across  the  chest,  and  up  the  side  of  the  neck  and 
head.  The  paroxysms  generally  lasted  for  an  hour,  and  were  aggravated 
by  exposure  to  cold  air,  mental  emotion,  or  movements.  In  Kosinski's 
case,  a  male  aged  thirty,  the  disease  appeared  when  sixteen  years  of  age. 

1  Duhring,  "Case  of  Painful  Neuroma  of  the  Skin,"  Amer.  Jour.  Med.  Sci.,  Oct., 
1873,  and  Oct.,  1881. 

2  Kosinski,  "Neuroma  Multiplex,"  Centralbl.f.  Chirurgie,  No.  16,  1874,  p.  241. 

3  Rump,  Arch.  Path.  Anal.,  1880,  vol.  Ixxx,  part  i,  p.  177. 


RHINOSCLEROMA  705 

The  lesions  were  situated  on  the  posterior  and  external  aspect  of  the 
right  thigh  and  a  portion  of  the  buttock,  and  numbered  about  one  hun- 
dred. Pain  was  quite  marked,  and  the  lesions  were  exceedingly  sensitive 
when  subjected  to  pressure. 

Etiology  and  Pathology.— As  already  stated,  true  cutaneous 
neuroma  is  rare,  and  in  the  broadest  application  of  the  term  the  malady 
is  not  common.  It  usually  develops  in  adult  life.  The  cause  is  unknown. 
It  is  not  improbable  that  traumatism  and  irritation  play  a  role  in  its 
production.  Virchow  believes  that  tuberculous  patients  are  more  prone 
to  them.  A  family  tendency  has  been  noted.  Histologically  the  growth 
is  found  seated  in  the  corium,  extending  into  the  deeper  structures.  Upon 
examination  it  is  seen  to  be  made  up  of  firm  connective  tissue  containing 
non-medullated  nerve-fibers,  running  up  as  high  as  the  papillary  layer 
of  the  corium,  blood-vessels,  and  lymphoid  cells,  constituting  true 
neuroma  amyelinicum  (Virchow)  of  the  skin.  They  are  in  reality  fibro- 
neuromata.  In  the  diagnosis  the  aid  of  the  microscope  in  determin- 
ing the  exact  nature  of  the  growth  may  have  to  be  resorted  to,  as  it  bears 
a  close  clinical  resemblance  to  myomata,  and  this  is  especially  so  in  some 
cases  of  the  latter,  as  Hardaway's.1 

The  treatment  is  purely  surgical,  consisting  of  excision  of  a  portion 
of  the  nerve-supply.  In  Duhring's  case  resection  of  a  part  of  the  brachial 
plexus  relieved  the  pain  markedly  and  the  growths  diminished  in  size. 
In  Kosinski's  case  removal  of  a  portion  of  the  small  sciatic  nerve  was 
followed  by  immediate  cessation  of  pain  and  almost  entire  disappearance 
of  the  tumors. 


Synonyms. — Gleoscleroma  (Besnier);  Fr.,  Rhinosclerome. 

Definition. — A  neoplastic  chronic  affection,  characterized  by  an 
exceedingly  hard,  tubercular  new  growth  involving  the  anterior  nares 
and  region  of  the  nose. 

Symptoms. — This  disease,  which  was  first  described  by  Hebra 
and  Kaposi  in  1870,  usually  has  its  starting-point  on  the  mucosa  of 
the  nose,  particularly  of  the  alae  and  septum,  and  extends  very  gradually 
to  the  cartilages  and  skin  of  the  nose  and  surrounding  parts.  According 
to  Wolkowitsch,2  in  at  least  90  per  cent,  of  the  cases  the  nose,  both  skin 
and  nares,  is  the  seat  of  the  disease.  In  some  cases  the  posterior  part 
of  the  soft  palate  and  the  neighboring  organs,  as  the  larynx  and  trachea, 
are  the  starting-point.  As  the  growth  enlarges,  the  shape  of  the  nose  is 
gradually  altered,  becoming  broader  and  flatter,  and  feels  rigid  and  hard 
to  the  touch,  resembling  ivory.  The  lumen  of  the  nasal  passages  becomes 
narrowed,  and  in  some  cases  completely  occluded,  due  to  the  inner  walls 
becoming  hypertrophied.  The  growths  in  the  mucous  membrane  of  the 
nose,  pharynx,  and  larynx  are  flattened,  and  appear  puckered  and  con- 
tracted as  they  cicatrize.  The  tumor  tends  to  increase  gradually  in 

1  Hardaway,  Amer.  Jour.  Mcd.  Sci.,  April,  1886,  p.  511. . 

2  Wolkowitsch,  Archiv.  f.  klin.  Chirurg.,  1888,  vol.  xxxviii,  p.  449  (an  exhaustive 
paper  from  every  standpoint). 

45 


-06  NEW  GROWTHS 

size,  and  the  nose,  including  the  lips  and  choanae,  are  implicated  in  the 
process,  resulting  not  only  in  great  disfigurement,  but  interfering  with 
nasal  respiration,  and  also  more  or  less  with  the  mobility  of  the  lips. 

The  cutaneous  growths  are  flat,  slightly  elevated,  sharply  defined, 
isolated  or  confluent  plaques  or  nodules;  they  are  painful  on  pressure, 
and  very  hard,  though  somewhat  elastic,  to  the  touch.  They  are  firmly 
imbedded  in  the  cutis  and  can  only  be  moved  with  it.  Their  surface 
is  normal  or  reddish  in  color,  smooth  or  wrinkled,  and  shiny,  and  is 
traversed  by  blood-vessels  and  devoid  of  hair-follicles.  It  is  impossible 
to  grasp  the  affected  tissue  between  the  fingers,  as  it  is  firmly  bound  down. 
The  epidermis  is  dry,  and  fissures  appear  occasionally,  secreting  a  sticky 
fluid  which  forms  yellowish  crusts.  The  nodules  rarely  ulcerate.1  The 
disease  pursues  a  chronic  course,  extending  over  years,  ordinarily  ex- 
tremely slow,  but  steadily  progressive. 

Btiology  and  Pathology. — It  attacks  both  sexes  alike,  and  is 
usually  observed  between  the  ages  of  fifteen  and  forty.  The  affection 
is  met  with  most  frequently  in  Austria  and  Russia,  and  some  cases  in 
Central  America  and  Brazil.  It  is  quite  rare  in  England  and  Italy. 
In  our  own  country  6  cases  have  been  reported,  and  all  occurred  in  in- 
dividuals of  foreign  birth,  natives  of  Austria  or  Russia,  with  the  excep- 
tion of  2  instances  of  the  disease  in  native-born  Americans,  i  observed 
by  G.  W.  Wende,2  in  a  boy  aged  eleven,  and  i  (woman  aged  forty) 
observed  by  myself.3  Rona4  states  that  the  records  show  21  cases  in 
Hungary,  29  in  Russia,  27  in  Austria,  and  23  in  middle  America. 

The  direct  cause  of  the  disease  is  believed  to  be  a  special  bacillus — 
bacillus  rhinoscleromatis — wrhich  primarily  Frisch,  and  later  Paltauf, 
Cornil  and  Alvarez,  Payne,  Marschalko,  and  others,  found  in  the  tissues. 
The  bacilli  are  usually  non-motile,  occur  in  twros  and  fours;  are  capsu- 
lated  commonly,  and  bear  a  strong  resemblance  to  pneumococci.  Accord- 
ing to  Rona,  the  bacillus  cannot  always  be  found.  Secchi  states  that  two 
forms  of  organisms  are  present,  one  resembling  the  blastomyces  and  the 
other  resembling  a  bacillus;  the  latter,  he  thought,  was  a  degenerative 
form  of  the  blastomyces;  the  Frisch-Paltauf  bacillus  he  considers  a  harm- 

1  Zeissl,  Wien.  med.  Wochenschr.,  1880,  p.  621,  noted  an  instance,  however,  in  which 
considerable  destructive  ulceration  had  ensued;  Rona,  Archiv,  1899,  vol.  xlix,  p.  265, 
also  saw  a  somewhat  similar  case. 

2  G.  W.  Wende,  Jour.  Cutan.  Dis.,  1896,  p.  90,  with  2  cuts.     Among  other  cases 
observed  in  this  country,  in  foreign-born,  may  be  mentioned  by:  Jackson,  in  Hungarian 
woman,  Jour.  Cutan.  Dis.,  1893,  p.  382  (with  colored  plate);  Klotz,  in  German  woman, 
ibid.,  1895,  p.  121  (case  demonstration);  Allen,  ibid.,  1900,  pp.  282  and  379  (2  cases 
— demonstration;  in  one  sloughing  had  occurred — nationality  not  stated). 

3  Stelwagon,   Jour.   Cutan.  Dis.,  1913,  "  Philadelphia   Dennatological    Society's 
Transactions"  (case  demonstration). 

4  The  following  three  recent  papers  give  collectively,  from  a  dermatologic  standpoint, 
a  complete  presentation  of  the  subject  and  the  various  reported  cases  and  pathologic  in- 
vestigations, with  bibliographic  references:  Rona,  "Ueber  Rhinoscleroma,"  loc.  cit. 
describes  16  of  the  Hungarian  cases;  Marschalko,  "Zur  Histologie  des  Rhinoscleroms," 
Archiv,  1900,  vol.  liii.,  p.  163,  and  vol.  liv,  p.  235  (exhaustive  complete  contribution 
on  the  subject  from  every  standpoint — gives  his  own  studies  of  2  cases  and  a  brief 
re'sume'  of  bacteriologic  and  histologic  investigations,  etc.,  of  others,  with  bibliography 
and  with  2  plates  containing  10  histologic  illustrations,  some  colored);  Secchi,  "Osser- 
vazione  sulla  istologica  ed  etiologia  del  Rhinoscleroma,"  Gazetta  della  Cliniche,  Aug. 
i,  1899,  xix,  No.  4,  36,  brief  abs.  in  Archiv,  1899,  vol.  xlix,  p.  438;  Castex,  Jour.  mal. 
cutan.,  1892,  p.  161  (review  paper  with  references). 


RHINOSCLEROMA  707 

less  parasite.  Besnier  and  Doyon  think  the  rarity  of  the  malady  and  its 
practical  limitation  to  certain  countries  are  antagonistic  to  the  accept- 
ance of  the  parasitic  view.  A  peculiar  degenerated  cell  is  also  thought 
to  be  more  or  less  histologically  characteristic.  Mibelli  describes  two 
cells — a  colloidal  and  a  dropsical — practically  corresponding  to  those 
found  by  Mickulicz.  Marschalko  states  that  these  cells  are  connective- 
tissue  cells  which  have  undergone  degeneration  through  the  action  of 
the  bacillus,  which  organism,  primarily  at  least,  is  inclosed  within  these 
cells  singly  or  in  groups.  The  characteristic  cell  he  thinks  resembles 
the  lepra  cell.  Upon  the  whole,  there  is  general  accord  upon  the  histologic 
features,  especially  the  gross  findings.  The  process  is  viewed  as  of 
granulomatous  character,  the  corium,  and  especially  the  papillary  layers, 
is  densely  infiltrated  with  small  cells,  which  Kaposi  regards  as  being 
similar  to  small-celled  sarcoma.  Epithelial  cells  are  also  found,  and 
some  larger  dropsical  and  colloidal  round  cells  already  referred  to.  True 
giant-cells,  however,  are  not  present.  There  is  noted  in  places  very 
dense  fibrous  tissue.  The  epidermis  shows,  as  a  rule,  primarily  at  least, 
but  little  if  any  change,  although  some  observers  have  called  attention 
to  interpapillary  epithelial  downgrowths. 

Diagnosis. — The  great  rarity  of  the  malady  and,  in  England, 
our  own  country,  and  some  other  countries,  its  practical  limitation  to 
foreign-born  subjects  of  certain  nationalities  are  to  be  borne  in  mind 
in  considering  cases  which  may  be  clinically  suggestive.  The  char- 
acteristic hardness  and  the  absence  of  softening  and  ulceration,  its  tumor- 
like  involvement  of  the  nose,  usually  both  within  and  without,  its  slow 
course  and  rebelliousness  to  antisyphilitic  treatment,  serve  to  distin- 
guish it  from  syphilis.  Upon  casual  inspection  it  might  be  mistaken 
for  keloid  or  epithelioma.  Keloid  is  usually  preceded  by  known  trau- 
matism,  and,  moreover,  seldom  occurs  about  the  nose;  in  doubtful 
instances  a  histologic  examination  would  be  decisive,  as  keloid  growths 
are  essentially  different.  Epithelioma  begins,  as  a  rule,  later  in  life, 
rarely  involves  the  upper  lip,  and  usually  has  infiltrated,  often  ele- 
vated, pearly  edges,  and  with  a  clear  tendency  to  ulcerate.  In 
rhinophyma,  the  extreme  development  of  the  third  stage  of  acne 
rosacea,  the  softness  of  the  growth  and  vascular  dilatation,  often  with 
nodules  and  pustules,  are  distinguishing  features. 

Prognosis  and  Treatment.— The  malady  is  usually  pro- 
gressive, and  hence  the  prognosis  is  very  unfavorable.  It  is  extremely 
rebellious  to  treatment.  The  neoplasms  have  invariably  recurred  after 
operation.  Owing  to  stenosis  of  the  nose,  mouth,  and  larynx,  respira- 
tion is  seriously  interfered  with,  and  the  patient  is  unable  to  take  nourish- 
ment properly.  The  general  health  is  not  affected  during  the  earlier 
progress  of  the  malady,  and  later  only  indirectly.  Removal  of  the  forma- 
tion with  the  knife  and  curet  may  be  restored  to,  but  a  permanent  cure 
cannot  be  expected.  The  galvanocautery  can  alsb  be  employed  to  lessen 
the  nasal  stenosis  and  to  check  temporarily  the  invading  growth.  Lang 
speaks  favorably  of  the  repeated  injection  into  the  tumor  of  a  i  per  cent, 
solution  of  salicylic  acid  or  2  per  cent,  solution  of  sodium  salicylate,  the 
drug  also  being  administered  in  full  doses  by  the  mouth  three  times  daily. 


GROWTHS 

X-ray  treatment1  seems  promising — Ranzi,  Freund,  Schein,  Pollitzer, 
and  others  having  seen  favorable  influence.  Vaccine2  treatment  has 
also  been  credited  with  some  influence. 

TUBERCULOSIS  CUTIS 

In  the  class  of  tuberculoses  of  the  skin  must  be  placed  all  those 
cutaneous  lesions  which  are  due  to  the  presence  of  the  bacillus  of  Koch. 
Owing  to  the  work  of  this  latter  observer,  Baumgarten,  and  many  others, 
we  now  know  that  many  of  the  cases  formerly  called  papilloma,  anatomic 
wart,  lupus  vulgaris,  tuberculosis  cutis,  scrofuloderma,  etc.,  are  examples 
of  the  one  and  same  process,  probably  modified  by  the  condition  of  the 
patient,  the  resistance  of  the  tissues,  and  other  factors. 

The  subject  of  tuberculosis,  indeed,  is  becoming  a  broad  one,  and  the 
interest  is  ever  increasing.  The  gravity  of  the  disease,  whether  internal 
or  integumentary,  is  receiving  the  attention  it  deserves.  Its  danger  to 
the  community  is  not  yet,  however,  sufficiently  recognized,  and  the  indif- 
ference of  the  individual,  the  public,  and  the  press  to  the  presence  of 
hundreds  of  cases  of  internal  tuberculosis  contrasts  strikingly  with  the 
hysteric  clamor  aroused  by  the  discovery  of  a  single  leper  in  our  midst. 

There  have  certainly  been  many  cases  of  cutaneous  tuberculosis  which 
could  be  traced  directly  or  indirectly  to  another  in  the  family  having  the 
constitutional  disease,  which,  with  other  evidence,  will  be  touched  upon 
again  in  considering  etiology.  While  many  clinical  phases  have  been 
reported  in  recent  years,  the  cases  of  tuberculosis  of  the  skin  can  prac- 
tically be  included  under  five  heads:  (i)  Tuberculosis  ulcerosa;  (2)  tuber- 
culosis disseminata;  (3)  tuberculosis  verrucosa;  (4)  scrofuloderma;  (5) 
lupus  vulgaris.  The  first  two  are  extremely  rare,  the  third  uncommon, 
the  fourth  not  unusual,  and  the  last — lupus  vulgaris — relatively  quite 
frequent.  These  various  types  deserve  separate  clinical  description; 
consideration  of  their  etiology,  pathology,  and  detailed  methods  of  treat- 
ment will  follow  the  last.3 

1  Danziger  and  Pollitzer,  Festschrift  des  Deutschen  Hospitals,  New  York,  1911,  and 
Pollitzer,  Jour.  Cutan.  Dis.,  1910,  p.  388,  report   a  case  cured  by  *-ray  treatment; 
and  mention  other  recorded  cases  benefited,  with  references.    A  case  (woman,  Ameri- 
can birth)  under  my  care  now  being  treated  by  *-ray  by  Dr.  Manges  at  the  Jefferson 
Hospital  has  shown  some  improvement. 

2  Smith,  Jour.  Cutan.  Dis.  1912,  p.  too  (case  demonstration);  thinks  he  has  had 
slight  favorable  action  in  a  few  trials  with  autogenous  vaccine. 

3  In  recent  years  there  has  been  a  gradual  and  growing  belief  that  certain  eruptions, 
such  as  erythema  induratum,  lichen  scrofulosorum,  the  various  conditions  I  have  re- 
ferred to  under  acne  varioloformis,  lupus  erythematosus,  and  a  few  others,  are  of  tuber- 
culous character,  but  not  due  directly  to  the  tubercle  bacillus,  but  to  its  toxins.     These 
diseases  are  frequently  referred  to  as  toxic  tuber culides,  toxic  tuberculoses,  paratubercu- 
loses.      Experimental  inoculations  and  investigations,  as  well  as  clinical  observations, 
seem  to  bear  out  such  possibility — a  series  in  point  being  those  experiments  and 
investigations  recently  made    by  Zieler   (Munchener  Med.   Wochenschr.,  Aug.,    n, 
1908;  abs.  in  Brit.  Jour.  Derm.,  1909,  p.  162),  indicating  that  tuberculous  changes 
can  be  brought  about  by  products  derived  from  tubercle  bacilli  without  the  presence 
of  corpuscular  or  even  ultramicroscopic  portions  of  the  bacilli.     Zieler  goes  over  the 
subject  still  more  exhaustively  in  "Experimentelle  und  klinische  Untersuchungen  zur 
Frage  der  "toxischen  Tuberkulosen  der  Haut",  Archiv,  1910,  cii,  i  Heft,  (with  review 
and  references);  and  Much's  investigations  (Unna's  "Studium,"  xxi,  p.  95,   (vol.  ii, 
Unna's  "Festschrift")  showing  that  there  are  other  elements  of  tubercle  organisms  beside 
the  ordinary  bacillus,  such  as  a  granular  form  of  bacillus,  rows  of  granules  and  isolated 


TUBERCULOSIS  CUT  IS  709 

J.  TUBERCULOSIS  ULCEROSA 

This  variety,  also  termed  tuberculosis  cutis  vera,  miliary  tuberculosis 
of  the  skin,  tuberculosis  cutis  orificialis  (and  tubereulose  ulcereuse  of 
the  French),  was  at  one  time  thought  to  be  the  only  manifestation  of 
integumentary  tuberculosis,  cases  of  which  have  been  observed  by 
Jarisch,1  Chiari,2  Riehl,3  Schwimmer,4  Zeisler,5  Kaposi,6  and  many  others. 
The  disease  is  almost  exclusively  seated  about  or  close  to  the  mucous 
outlets,  from  which,  in  most  instances,  it  can  be  considered  an  extension 
of  an  already  existing  process.  The  earliest  formation  consists  usually 
in  the  appearance  of  minute  miliary  tubercles,  which  undergo  rapid 
cheesy  softening  and  ulceration.  Cases  are  rarely  seen  before  the  char- 
acteristic ulcers  are  present;  these  are  superficial,  sluggishly  granulating, 
irregularly  rounded  or  oval,  the  edges  soft  and  but  very  slightly  infiltrated, 
and,  as  a  rule,  covered  with  a  thin  crust  which,  on  removal,  discloses 
the  ulcer  floor,  somewhat  uneven  and  of  an  indolent,  reddish-yellow  color, 
with  a  scanty  secretion  of  a  thin,  purulent  character.  They  are  rarely 
painful.  One  or  several  may  be  present,  and  if  the  latter,  after  gradual 
extension,  often  result  in  coalescence  and  serpiginous  configuration. 
There  is  no  tendency  to  healing;  on  the  contrary,  there  is  usually  pro- 
gressive extension,  sometimes  so  slow,  however,  as  to  be  almost  imper- 
ceptible from  day  to  day.  Miliary  tubercles  can  occasionally  be  detected 
upon  the  surface,  especially  in  the  ulcers  on  mucous  surfaces.  It  is  met 
with  exclusively  in  those  with  internal  tuberculosis,  and  chiefly  of  the 
respiratory  tract.  According  to  Kaposi,  however,  its  subjects  are  not 
invariably  those  in  the  last  months  or  cachetic  stage  of  constitutional 
tuberculosis,  as  generally  believed.  Contrary  to  general  observation, 
Kaposi  also  states  that  healing  may  occasionally  take  place,  either  spon- 
taneously, which  is  rare,  or  as  the  result  of  combined  systemic  and  local 
measures.  Almost  without  exception,  however,  the  cutaneous  disease 
is  a  part  of  a  general  tuberculosis  which  goes  on  rapidly  to  a  fatal  end. 
In  the  light  of  Kaposi's  experience  (22  cases),  the  disease  cannot  be  con- 
sidered so  extremely  rare  as  commonly  believed. 

As  to  be  inferred,  the  integumentary  ulcers  are  the  results  of  exten- 
sion or  inoculation  from  mucous  lesions  or  from  the  discharges.  Its  most 
common  locality  is  the  mouth  and  about  the  anus  and  genitalia.  Ehr- 

granules,  requiring  special  methods  to  make  them  recognizable,  may  simplify  future 
study;  Kriiger's  (Miinchen.  Med.  Wochenschr.,  May,  31,  1910,  p.  1165)  experiments 
and  investigations  are  more  or  less  corroborative  of  Much's  work;  Friedlander, 
"The  value  of  Much's  Granules  and  the  Antiformin  Method  in  Determining  the 
^Etiology  of  the  So-called  Tuberculides,  with  especial  reference  to  Lupus  Erythemato- 
sus";  Brit.  Jour.  Derm.,  1912,  p.  13,  gives  his  own  confirmatory  investigations,  and 
reviews  the  work  done  by  Much  and  others,  with  references. 

The  term  tuberculides  includes  not  only  the  above  named,  but  also  the  frank  tuber- 
culoses of  the  skin  here  to  be  described. 

1  Jarisch,  Archiv,  1879,  p.  265. 

2  Chiari,  ibid.,  p.  269,  and  Mediz.  Jahrbiicher,  Wien,  1877,  p.  328. 

3  Riehl,  Wien.  med.  Wochenschr.,  1881,  pp.  1229  and  1260. 

4  Schwimmer,  Archiv,  1887,  p,  37  (5  cases). 
6  Zeisler,  North  Amer.  Practit.,  Mar.,  1889. 

6  Kaposi,  Archiv,  1898,  vol.  xliii  and  xliv  (Festschrift  for  Pick),  "Ueber  Mihartu- 
berkulose  der  Haut  und  der  angrenzenden  Schleimhaut— Tuberculosis  miliaris  seu 
Tuberculosis  propria  cutis  et  mucosae"  (brief  review  of  recorded  cases  and  detailed 
analysis  of  22  cases  under  his  own  observation). 


710 


NEW  GROWTHS 


mann,1  who  has  observed  a  number  of  these  cases  involving  the  genitalia, 
states  that  in  general  there  are  three  modes  of  origin:  (i)  By  contiguity, 
the  disease  extending  from  some  part  of  the  genital  apparatus;  (2)  through 
the  blood  circulation,  tuberculous  material  from  some  internal  focus 
finding  its  way  to  the  integument  of  these  parts;  (3)  infection  from  with- 
out, as  from  saliva  of  tuberculous  individuals — as,  for  instance,  in  ritual 
circumcision.  In  the  first  method  the  disease  may  spread  along  the 
urethra  on  to  the  penis,  or  the  urethra  may  excape  and  be  simply  the 
passage  through  which  morbid  material  finds  its  way  from  tuberculous 
kidneys,  bladder,  prostate,  or  seminal  vesicles. 

The  diagnosis  of  tuberculous  ulcers  is  rarely  one  of  difficulty,  owing 
to  the  presence  of  the  constitutional  affection  and  often  the  associated 
patches  on  the  mucous  membrane.  The  ulcers  themselves  are,  indeed, 
quite  characteristic.  In  doubtful  cases,  however,  microscopic  examina- 
tion can  be  resorted  to,  as  the  bacilli  are  usually  present  in  numbers;  or, 
if  necessary,  recourse  can  be  had  to  animal  inoculation. 

Treatment. — Not  much  is  to  hoped  for  except  in  those  rare 
cases  referred  to  by  Kaposi,  in  which  the  patients  are  not  in  the  last 
stages  of  phthisis.  General  roborant  and  nutritive  remedies,  especially 
cod-liver  oil  and  nourishing  food,  are  the  best,  and  locally  mildly  stimu- 
lating and  antiseptic  applications,  such  as  silver  nitrate  stick  or  solution, 
lactic  acid,  usually  weakened  with  one  to  several  parts  water,  cleansing 
with  weak  corrosive  mercury  solutions,  and,  when  advisable,  the  curet. 

2.  TUBERCULOSIS  DISSEMINATA 

Under  this  head  (tuberculosis  disseminata)  it  is  convenient  to  class 
those  rare  cases  in  which  the  eruption  consists  of  small,  scattered  discrete 
lesions,  regional  or  more  or  less  generalized,  and  of  an  acute  or  subacute 
character.  Several  variations  are  encountered,  and  almost  always  in  chil- 
dren. Heller  and  Gaucher2  have  described  an  acute  tuberculosis  of  the 
skin  in  which  the  lesions  were  of  multiform  character,  consisting  of  mac- 
ules,  papules,  vesicles,  blebs,  and  pustules,  undergoing  ulcerative  changes, 
forming  ulcers  of  a  deep,  irregular,  circinate  type,  usually  crusted,  and 
associated  with  caseation  and  suppuration  of  the  neighboring  lymphatic 
glands;  the  tuberculous  character  of  the  eruption  was  demonstrated  by 
the  presence  of  the  bacilli  and  by  inoculation  experiments.  Another 
type  is  that  of  which  an  example  was  recently  recorded  by  Pelagatti3 
in  a  child  two  years  old,  in  which  the  eruption,  seated  on  the  regions  of 
the  loins,  buttocks,  thighs,  and  legs,  consisted  of  recent  pin-head-sized 
papules,  hemp-seed-sized  papules  of  longer  duration,  both  with  slight 
central  crusting,  and  larger  papular  lesions  undergoing  ulceration. 
They  were  pale  yellow  in  color,  somewhat  elevated,  and  without  areola. 
The  characteristic  bacilli  were  found  in  abundance.  Death  ensued  from 
pulmonary  and  intestinal  tuberculosis. 

1  Ehrmann,  "Zur  Casuistik  der  tuberculosen  Geschwiire  des  aussern  Genitales," 
Wien.  med.  Presse,  1901,  p.  202. 

2  Quoted  from  Hyde  and  Montgomery,  Diseases  of  the  Skin. 

3  Pelagatti,  Giorn.  ital.,  1898,  No.  6;  abs.  in  my  review  of  dermatology  in  Hare's 
Progressive  Medicine,  Sept.,  1899,  p.  225. 


TUBERCULOSIS  CUTIS 


711 


Another  phase  is  presented  by  the  small  to  large  pea-sized  papulo- 
squamous,  papulopustular  or  papulonecrotic  lesions,  representing  Duhr- 
ing's  small  pustular  scrofuloderm1  and  several  of  the  types  described  under 
Acne  varioliformis.  "The  face  and  extremities,  especially  the  face  and 
the  upper  extremities,  are  its  usual  sites.  The  lesions  are  disseminated, 
and,  as  a  rule,  not  abundant.  They  begin  as  pin-head  to  small  pea- 
sized  papulopustules,  resembling  somewhat  closely  the  small  papulo- 
pustular syphiloderm.  The  pustular  character  is  often  slight  and  oc- 
cupies the  central  part  of  the  summit,  the  outer  portion  of  the  lesion 
being  slightly  hard,  and  in  the  beginning  with  an  insignificant  areola. 
The  formation  is  superficial,  not  extending  deeply  into  the  derma. 
"They  crust  over  gradually  in  the  course  of  from  one  to  several  weeks, 
with  depressed,  shrunken,  hard  or  horny,  yellowish  or  grayish,  adherent 
crusts,  which  in  time  drop  off,  leaving  marked,  punched-out-looking, 


Fig.  157. — Represents  Prof.  Duhring's  small  pustular  scrofuloderm,  and  can  be 
also  viewed,  clinically  at  least,  as  an  unusual  acne  varioliformis  of  peculiar  distribution; 
as  follidis;  as  necrotic  granuloma,  tuberculide,  and  other  variously  named  like  or  allied 
affections;  the  lesions  are  of  a  papulopustular  necrotic  type. 

indelible  scars,  resembling  those  of  variola.  The  lesions  are  further 
characterized  by  a  sluggish,  chronic  course,  and  may  last  weeks  or  months. 
They  appear  at  irregular  periods,  new  ones  coming  out  as  the  older  ones 
disappear,  so  that  the  patient  is  rarely  free  from  them.  The  disease 
may  continue  for  years"  (Duhring). 

Another  variety — exanthematic  tuberculosis — presents,  in  its  clinical 
features,  a  rough  resemblance  to  flat  lupus  tubercles,  to  sluggish  acne 
papules,  to  lichen  scrofulosorum,  and  to  the  form  just  described.  It 
usually  follows  the  exanthematous  fevers,  especially  measles.  The 
lesions  are  indolent  and  of  a  dull,  brownish-red  hue;  not  infrequently 
they  are  noted  to  be  connected  with  the  follicles.  The  eruption  is  more  or 

1  Duhring,  Amer.  Jour.  Med.  Sci.,  1882,  vol.  Ixxxiii,  p.  70;  Wallis,  "Cutaneous 
Tuberculosis:  A  Report  of  a  Series  of  Cases  of  Small  Pustular  Scrofulide"  (Duhring), 
Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlix,  p.  134,  reports  a  series  of  9  cases — 2  in  one 
family  and  4  in  another  family.  Cases  all,  with  one  exception,  Hebrews,  foreign  born. 
Lesions  also  appeared  readily  on  the  sites  of  trivial  injuries,  such  as  a  scratch. 


712 


NEW  GROWTHS 


less  disseminated,  but  is  commonly  seen  on  the  face,  arms,  and  legs; 
when  the  trunk  is  invaded  it  is  only  to  a  slight  degree.  It  consists  of 
variously  sized  lesions  from  a  small  papule  to  small  patches  of  a  frac- 
tional part  of  an  inch  in  diameter;  the  latter  usually  resulting  from  an 
aggregation  or  confluence  of  several  of  the  smaller  ones.  They  are  more 
or  less  persistent,  but  may  undergo  involution,  and  may  or  may  not 
leave  scars.  Other  symptoms  of  tuberculosis  are  commonly  present, 
such  as  glandular  enlargements,  suppurating  glands,  chronic  otitis,  hip- 
joint  disease,  or  scrofulous  gummata,  etc.  Subjective  symptoms  are 
generally  wanting.  The  tuberculous  nature  of  the  disease  is  usually 
demonstrable  by  inoculation  experiments,  and  the  lesions  have  also  been 
noted  in  some  instances  to  contain  bacilli.  The  manifestation  is  rare, 
although  several  cases  of  allied  but  varying  character  have  been  recently 
reported,  following  measles,  by  Colcott  Fox,1  Haushalter,2  DuCastel,3 
and  Adamson.4 

Treatment. — There  is  nothing  special  to  be  said  on  this  point 
other  than  that  the  manifestations  are  to  be  treated  as  outlined  later, 
basing  constitutional  measures  upon  general  principles,  and  the  selec- 
tion of  the  local  treatment  according  to  the  character,  extent,  and  type 
of  the  lesions;  salicylic  acid,  mercurial  and  pyrogallol  applications 
usually  being  the  best,  as  well  as  least  painful,  the  curet  and  galvano- 
cautery  playing,  in  certain  lesions,  a  possible  secondary  role. 

3.  TUBERCULOSIS  VERRUCOSA 

Verruca  necrogenica,  or  anatomic  tubercle,  is  the  simplest  and  most 
common  of  this  rare  form  of  cutaneous  tuberculosis.  It  is  a  localized, 
papillary  or  wart-like  formation,  occurring  usually  about  the  knuckles 
or  other  parts  of  the  hand  or  forearm.  Its  most  common  site  is  over  one 
of  the  metacarpophalangeal  joints.  It  begins,  as  a  rule,  as  a  small, 
papule-like  growth,  increasing  gradually,  but  very  slowly,  in  area,  and 
when  well  advanced,  appears  as  a  pea-  or  dime-sized  or  larger,  somewhat 

1  Colcott  Fox,  Brit.  Jour.  Derm.,  1898,  p.  253  (case  demonstration). 

2  Haushalter,  Annales,  1898,  p.  455. 

3  Du  Castel,  ibid.,  1898,  p.  729. 

4  Adamson,  Brit.  Jour.  Derm.,  1899,  p.  20. 

Among  other  pertinent  interesting  reports  are :  Bunch,  "On  Necrotic  Tuberculides," 
Brit.  Jour.  Derm.,  1912,  p.  357  (with  illustration),  described  2  unusual  cases:  first,  aboy 
of  twelve,  in  whom  the  disease  began  at  the  age  of  four  as  a  simple  red,  slightly  scaly 
patch  at  navel  on  which  a  number  of  small  nodules  of  a  superficial  papular  character 
appeared  which  gave  place  to  shallow  scars;  there  were  also  on  the  inner  sides  of  thighs, 
and  around  about  the  axillae  areas  of  a  pinkish  superficial  dermatitis,  which  in  the  course 
of  several  years  became  the  seat  of  similar  shallow  scars,  doubtless  preceded  by  papula- 
tion.  The  second  case,  a  woman  of  twenty-five,  presented  a  number  of  pea-  and  slightly 
larger-sized  pinkish  indurated  nodular  swellings  on  the  legs  and  arms;  they  gradually 
broke  down  and  showed  slight  purulent  discharge;  some  coalescent  in  places,  granulating 
and  healing,  leaving  considerable  scarring;  the  disease  began  ten  years  previously;  some 
time  after  the  appearance  of  these  tuberculous  lesions  the  patient  developed  a  well- 
marked  lupus  erythematosus. 

Leopold  and  Rosenstern,  "The  Significance  of  Tuberculides  in  the  Diagnosis  of 
Tuberculosis  in  Infancy,"  Jour.  Amer.  Med.  Assoc.,  Nov.  12,  1910,  p.  1721,  state  that 
from  their  experience  in  the  Children's  Asylum  in  Berlin  the  small  papulosquamous 
and  papulonecrotic  tuberculides  are  not  uncommon  in  cases  of  tuberculosis  in  infancy 
fin  40  per  cent,  in  their  series) ;  the  lesions  may  be  scanty  and  insignificant  and  unless 
carefully  searched  for  overlooked. 


TUBERCULOSIS   CUTIS 


713 


inflammatory,  red,  elevated,  flattened,  warty  mass,  with  commonly  a 
tendency  to  slight  pus-formation  between  the  papillary  projections,  and 
of  which  small  drops  can,  as  a  rule,  be  made  to  ooze  upon  slight  lateral 
pressure.  The  surface,  which  is  usually  irregular,  may  be  somewhat 
hard  or  horny,  or  the  growth  may  be  covered  with  a  crust.  In  fact, 
the  beginning  papular  lesion  often  becomes  pustular,  and  this  dries  up 
and  forms  a  crusted  covering,  which,  if  removed  by  accident  or  design, 
rapidly  forms  anew;  later  it  acquires  a  warty  aspect  from  papillary  hy- 
pertrophy, and  the  same  condition  results  as  described  above.  The 
border  especially  is  often  superficially  indurated,  rarely  deeply.  There 
is  also  a  disposition  toward  central  healing  and  peripheral  spread, 
although  the  patch  rarely  reaches  more  than  an  inch  or  so  in  area.  The 
growth  is  more  or  less  persistent,  but  in  some  cases,  after  a  variable  time, 
undergoes  involution,  leaving  usually  a  slight  smooth  or  corded  scar. 
While  the  lesion  is,  generally  speaking,  relatively  benign,  it  is  occasion- 
ally followed  by  extension  along  the  lymph-channels,  with  involvement 
of  the  lymphatic  glands  and  constitutional  infection;  according  to  Knick- 
enberg,1  Guizzetti,2  Hallopeau,3  and  others,  this  occurs  more  readily  in 
this  form  than  in  that  known  as  tuberculosis  verrucosa  cutis  (of  Riehl 
and  Paltauf).  Its  usual  subjects  are  those  who  have  to  do  with  decom- 
posing animal  matter;  hence  it  is  chiefly  encountered  among  medical 
students,  physicians,  dissection-room  and  hospital-ward  attendants,  and 
butchers.  Besnier  and  Vidal  originally  noted  its  occurrence  among  those 
making  autopsies  in  tuberculous  subjects,  and  recognized  its  analogy  to 
some  types  of  lupus.  The  investigations  of  Riehl,4  Finger,5  and  others 
demonstrated  that  verruca  necrogenica  is  due  to  tubercle  bacilli  infection. 
Tuberculosis  verrucosa  cutis  (of  Riehl  and  Paltauf),  while  for  some 
years  irregularly  met  with,  was  first  brought  into  prominent  notice 
by  the  classic  paper  by  Riehl  and  Paltauf,6  whose  studies  were  based 
upon  14  cases  observed  in  Kaposi's  clinic,  and  which  showed  the  analogy 
and  probable  identity  of  this  with  anatomic  tubercle  just  described; 
also  its  resemblance  to  lupus  verrucosus.  It  was  by  them  thought  to 
occur  in  adults  who  had  to  do  with  animals  and  animal  products,  but  we 
know  to-day  that  many  cases  are  also  contracted  from  other  tuberculous 
individuals.  White7  believes  that  this  variety  may  fairly  be  accepted 
as  the  ordinary  form  of  manifestation  in  the  cutaneous  tissues  of  the 
inoculation  of  the  same  with  tuberculous  matter,  whether  derived  from 
the  cadaver  of  man  or  other  animal,  or  by  contact  with  infective  material 
from  living  subjects.  While  it  usually  begins  in  an  insignificant  manner, 
practically  similarly  to  verruca  necrogenica,  it  is  much  more  extensive 
and  may  cover  several  inches  or  more  of  surface.  One,  several,  or  more 

1  Knickenberg,  "Ueber  Tuberculosis  verrucosa  cutis,"  Archiv,  1894,  p.  405. 

2  Guizzetti,  "Ueber  einen  Fall  von  Tuberculum  anatomicum.     Histologisch-bak- 
teriologische  Untersuchungen,"  Monatshefte,  1899,  vol.  xxix,  p.  253. 

3  Hallopeau,  "Sur  les  rapports  de  la  tuberculose  avec  les  maladies  de  la  peau  autres 
que  le  lupus  vulgaris,"  Jour.  mal.  cutan.,  1896,  p.  522. 

4  Riehl  and  Paltauf,  "Tuberculosa  verrucosa  cutis,"  Archiv,  1886,  p.  19. 

5  Finger,  "Ueber  die  sogenannte  Leichenwarze,"  Deutsche  med.  Wochenschr.,  1888, 
p.  85.  6  Loc.  cit. 

7  J.  C.  White,  "Clinical  Aspects  and  Etiologic  Relations  of  Cutaneous  Tubercu- 
losis," Boston  Med.  and  Sttrg.  Jour.,  Nov.  12,  1891,  p.  509. 


714  NEW  GROWTHS 

small  patches  arise,  and  if  the  latter,  generally  near  together,  and  sooner 
or  later  coalesce  and  form  an  irregularly  shaped  or  serpiginous  area. 
The  degree  of  inflammatory  action  present  varies  considerably,  the  area 
or  areas  being  surrounded  by  a  band-like  redness  with  some  infiltration. 
The  whole  patch  is,  as  a  rule,  somewhat  elevated,  infiltrated,  and  beset 
with  wart-like  papillary  hypertrophy,  or  with  dull  or  purplish-red  tuber- 
cles or  nodules,  isolated  or  grouped;  or  with  closely  aggregated  or  discrete, 
usually  minute  pustules,  seated  directly  upon  the  sluggishly  inflamed 


Fig.  158. — Tuberculosis  verrucosa  cutis;  in  a  negro. 

purplish  area,  or  at  the  summits  of  the  tubercles  or  nodules.  Not  in- 
frequently the  interstices  between  the  papillary  or  projecting  vegetations 
contain  some  seropurulent  or  purulent  fluid  which  can  be  pressed  out. 
While  the  disease  spreads  peripherally,  a  slight  tendency  to  thin  scarring 
is  generally  to  be  noted  in  the  earliest  portions.  In  fact,  in  some  cases, 
especially  where  there  are  several  areas  or  one  extensive  plaque,  all  the 
described  features  can  usually  be  seen.  One  of  its  characteristics  is 
that  it  rarely  shows  any  positive  ulceration. 

Its  favorite  region  is  the  back  of  the  hand— sometimes  one,  sometimes 
both.  It  often  spreads  on  to  the  fingers  and  the  interdigital  folds,  up 
the  wrists,  and  less  frequently  on  to  the  palms.  On  this  last-named 
region  it  is,  however,  rare,  and  always  appearing  as  an  extension  from 


TUBERCULOSIS   CUT  IS 


715 


the  dorsum,  as  in  the  2  cases  reported  respectively  by  Cutler1  and  Weber.2 
Inasmuch  as  this  type  is  frequently  seen  in  association  with  pulmonary 
phthisis,  4  examples  of  which  have  been  recently  reported  by  Beclere,3 
it  is  probable,  as  stated  by  this  observer,  following  Vidal,  that  its  presence 
in  this  region  finds  its  explanation  in  the  fact  that  phthisical  patients, 
and  especially  men,  in  whom  this  manifestation  is  most  frequently  en- 
countered, after  coughing  wipe  off  the  mouth  and  mustache  with  the 
back  of  the  hand.  Of  interest  and  suggestive  in  this  connection  is 
Schoull's4  experiment,  who  took  some  hair  from  the  beard  of  a  tuberculous 
patient,  and,  after  soaking  and  agitating  it  in  distilled  water  in  a  test- 
tube,  injected  some  of  the  liquid  into  a  guinea-pig,  the  animal  shortly 
succumbing  to  tuberculosis.  Fabry5  called  attention  to  its  occurrence 
in  coal-miners,  in  whom  the  numerous  and  constant  injuries  and  cuts 
about  the  backs  of  the  hand  incident  to  their  work  play  an  important 


Fig.  1 59. — Tuberculosis  verrucosa  cutis.   Patient  aged  twenty-four  years;  duration  four 
years;  sinuses  of  knee  (courtesy  of  Dr.  F.  C.  Knowles). 

role,  affording  opportunities  for  inoculation,  phthisis  being  not  an  un- 
common, disease  among  such  workmen. 

Like  anatomic  tubercle,  it  is  slow  in  its  course,  often  stationary  for 
periods,  and  in  certain  parts  retrogressive;  it  often  lasts  for  years,  and 
occasionally  disappears  spontaneously.  There  is  usually  left  a  thin, 
atrophic-looking  scar,  sometimes  with  the  sieve-like  aspect  noted  in 
lupus  erythematosus.  It  bears  a  striking  resemblance  to  blastomycetic 

1  Cutler,  Jour.  Cutan.  Dis.,  1898,  p.  535  (case  demonstration)— on  backs  and  palms 
of  both  hands. 

2  Weber,  Brit.  Jour.  Derm.,  1899,  p.  161  (case  demonstration). 

3  B6clere,  Gaz.  hebdom.,  1898,  No.  34;  Annales,  1898,  p.  794. 

4  Schoull,  Jour,  des  prat.,  1899,  p.  347. 

8  Fabry,  "Ueber  das  Vorkommen  der  Tuberculosis  verrucosa  cutis  (Riehl  and 
Paltauf)  bei  Arbeitern  in  Kohlenbergwerken,"  Archiv,  1900,  vol.  li,  p.  69  (7  cases,  most 
of  which  with  associated  pulmonary  tuberculosis,  or  with  the  latter  in  the  family;  2 
cuts  of  cases);  and  Schulze  (Fabry's  clinic),  ibid.,  1904,  vol.  Ixx,  p.  329  (a  synopsis  of 
1 60  cases). 


716 


NEW  GROWTHS 


dermatitis  (q.  ».),  with  which  doubtless  it  has  sometimes  been  con- 
founded. 

Various  other  forms  allied  to  this  in  general  character  have  been 
described,  but  they  are  scarcely  to  be  considered  as  separate  manifesta- 
tions, but  rather  as  aberrant  types,  in  which  one  or  other  clinical  element 
predominates,  and  sometimes  presenting  features  partaking  of  the  nature 
of  both  this  form  and  lupus  vulgaris;  moreover,  it  may  occasionally  be 
upon  other  situations.  Thus,  in  Morrow's1  case  (tuberculosis  papillo- 
matosa  cutis)  the  eruption  was  seated  upon  the  face,  and  consisted  of 
rather  bright-red,  abundant,  and  extremely  prominent  papillomatous 
vegetations;  in  Mracek's2  and  Ravogli's3  cases,  the  leg  was  the  seat  of 
the  manifestation,  which  was  quite  extensive. 

In  some  rare  cases,  described  by  Riehl4  as  tuberculosis  fungosa 
cutis,  the  growths  are  somewhat  fungoidal  or  mushroom-like,  and  re- 


Fig.  1 60. — Tuberculosis  vemicosa  cutis  in  patient  with  pulmonary  tuberculosis.     (Note 
the  close  resemblance  to  blastomycosis.) 

semble  similar  formations  observed  in  granuloma  fungoides;  the  disease 
usually  originates  in  osseous  or  periosteal  lesions;  fistulous  ulcers  are 
formed,  growing  nodular  swellings,  with  fungoidal  aspect,  and  later  the 
ordinary  appearances  of  tuberculous  ulcers.  Other  lesions,  occasionally 
seen  in  the  average  type,  are  tubercles  or  nodules,  small  pustules,  papil- 
lary elevations,  and  crusting.  In  other  instances,  as  described  (fibroma- 
tosis  tuberculosa  cutis)  by  the  same  author,  along  with  papillomatous 
vegetations,  ulcers,  etc.,  there  is  marked  sclerosis  found  on  different 

1  Morrow,  Jour.  Cutan.  Dis.,  1888,  pp.  361  and  401  (with  colored  plate) ;  Shelmire, 
Jour.  Cutan.  Dis.,  1906,  p.  20,  reports  a  case  of  probably  a  mixed  type,  the  verrucose 
element  predominating;  eruption  on  face  and  neck  in  a  negress  (2  good  illustrations). 

2  Mracek,  Hand  Atlas  of  Skin  Diseases,  second  edit.,  plate  86. 

3  Ravogli,  "On  Various  Forms  of  Cutaneous  Tuberculosis,"  Jour.  Amer.  Med. 
Assoc.,  April  16,  1898. 

4  Riehl,  Verhandl.  der  Deutschen  dermatolog.  Gesell.,  iv  Congress,  1894,  p.  354. 


TUBERCULOSIS  CUTIS  717 

parts,  not  infrequently  about  the  nose,  mouth,  and  other  mucous  outlets. 
Wickham  and  Jessner  have  also  described  cases  with  frambesiform 
lesions,  in  that  of  the  latter  the  eruption  being  disseminated.  In  fact, 
almost  all  types  of  nodular,  vegetating,  and  ulcerative  lesions  are  en- 
countered as  the  result  of  tubercle  bacilli  infection,  and  Besnier,  Lejars, 
Jeanselme,  and  others  have  noted  rare  instances  (lymphangitis  tubercu- 
losa  cutanea)1  in  which  the  lymphatics,  usually  of  the  extremities,  were 
the  seat  primarily  or  secondarily  of  infection,  and  the  eruptions  of  various 
characters,  lupoid,  nodular,  and  papillomatous,  corresponding  to  the 
lymphatic  distribution,  and  commonly  with  some  elephantiasic  enlarge- 
ment. To  lymphatic  involvement  is  doubtless  due  also  the  hypertrophic 
character  noted  in  other  types. 

Diagnosis.— The  sluggish  character  of  the  growth,  its  dull  red 
or  purplish-red  color,  its  localization,  history,  and  slow  course,  and  the 
papillomatous  tendency  displayed,  the  absence  of  distinct  ulcerative 
action,  and  usually  of  brownish  or  reddish-yellow  tubercles,  will  serve 
to  distinguish  it  from  both  syphilis  and  other  forms  of  tuberculosis. 
Its  resemblance  to  blastomycetic  dermatitis  is  striking,  and,  in  fact, 
unless  other  symptoms  of  tuberculous  nature  are  present,  a  conclusive 
differentiation  is  possible  only  by  microscopic  and  bacteriologic  means. 

Treatment. — Of  the  various  local  measures  to  be  mentioned  in 
the  section  on  treatment  of  the  tuberculoses,  the  use  of  the  antiseptic 
applications,  such  as  the  mercurial  preparations,  together  with  the  use 
of  strong  salicylic  acid  plasters  and  pyrogallol  salves,  and,  when  neces- 
sary, the  curet,  are  the  most  valuable.  The  #-ray  and  Finsen  treat- 
ments have  also  been  found  serviceable. 

4.  SCROFULODERMA 

Formerly  this  term  was  applied  to  all  those  various  peculiar  and 
suppurative  and  ulcerative  conditions  of  the  skin  occurring  in  strumous 
subjects.  While  this  still  holds  to  a  limited  extent,  it  is  now  chiefly 
restricted  to  the  sluggish  ulceration  or  involvement  of  the  skin  resulting 
by  extension  from  an  underlying  caseating  and  suppurating  lymphatic 
gland.  Occasionally,  however,  it  appears  to  have  its  .origin  as  subcu- 
taneous tubercles  independently  of  these  structures.  Arising  from  the 
former,  the  gland  or  glands,  usually  the  cervical,  are  noted  at  first  to  be 
somewhat  swollen,  sometimes  attaining  many  times  their  normal  size. 
While  they  may  be  hard  at  first,  they  soon  soften,  and  as  the  overlying 
skin  is  distended,  the  latter  becomes  of  a  dull-reddish  or  violaceous  hue. 
In  occasional  instances,  after  reaching  this  stage,  they  gradually  disap- 
pear by  absorption.  Usually,  however,  the  caseation  and  suppurative 
changes  finally  involve  the  skin,  which  may  show  one  or  more  points  of 
softening  and  destruction,  resulting  in  the  formation  of  sinuses  which 
lead  down  to  the  underlying  diseased  glandular  structures.  When  this 
ensues,  more  or  less  flattening  takes  place,  and  when  the  process  is  thus 
advanced,  the  area  is  noticed  to  be  of  a  purplish-red  color,  with  pea-  to 

1  See  Pringle's  remarks  supplementary  to  a  report  of  a  case  by  Cahill,  Brit.  Jour. 
Derm.,  1895,  p.  i,  reviewing  the  models  of  the  malady  in  Baretta  Museum,  Paris. 


718  NEW  GROWTHS 

dime-sized  ulcerated  openings,  and  the  sluggish  inflammatory  infiltration 
extending  slightly  beyond  the  immediate  area  of  disease.  The  skin,  once 
thus  involved,  the  process  extends  superficially,  implicating  the  surround- 
ing integument,  often  to  a  considerable  extent.  The  intervening  islets 
of  purplish-red,  weakened  skin  occupying  the  original  area  often  break 
down  completely,  and  the  scrofulous  ulcer  is  formed.  This  may  also 
result  without  much  invasion  of  the  adjacent  integument.  If  be- 
ginning as  a  subcutaneous  nodule,  independently  of  the  lymphatic 
glands,  the  induration  increases  in  size  in  all  directions,  attaining  the 
dimensions  of  a  large  cherry  or  walnut  (tuberculous  gummata),  then  under- 
going about  the  same  changes  noted  when  the  glandular  structures  are 
primarily  involved;  the  skin  breaks  down  over  almost  the  entire  mass,  or 
first  at  several  points.  Doubtless  some  of  the  cases  of  erythema  indura- 
tum  represent  this  particular  variety.  In  rare  instances,  too,  after  reach- 
ing the  size  of  a  marble  or  pigeon's  egg,  or  larger  the  process  remains 
more  or  less  stationary  with  practically  no  tendency  to  active  destruct- 
ive changes,  sometimes  undergoing  gradual  absorption,  and  disappear- 
ing. Such  growths  may  appear  on  almost  any  part  of  the  body,  their 
nature  at  first  often  being  unsuspected.1 

Instead  of  a  preceding  deep-seated  nodule  or  gland  enlargement, 
there  may  appear  one  or  several  superficial  pin-head-  to  small  pea- 
sized  indurations,  which  soon  become  pustular  and  enlarge  peripherally, 
forming  a  fairly  large,  flat,  often  irregularly  shaped,  yellowish  or  brown- 
ish-yellow, flat,  thin,  crusted  pustule,  with  an  areola  of  a  dull  red  or 
violaceous  color.  The  crusting  is  slow  in  formation,  beginning  centrally, 
and  quite  scanty,  entirely  unlike  that  seen  in  the  large  flat  pustular  syphil- 
oderm,  which  it  slightly  suggests.  As  the  crusting  takes  place  the  lesion 
may  extend  peripheraUy;  or  if  two  or  three  are  in  close  proximity,  coal- 
escence sometimes  ensues.  On  removing  the  crust,  the  superficial, 
irregular  edged,  granular-looking,  scrofulous  ulcer,  with  uneven  base 
covered  with  thin  purulent  secretion,  is  disclosed.  Their  course  is  slow, 
and  they  may  remain  for  months;  healing  is  followed  by  soft  and  super- 
ficial scars.  They  may  appear  upon  any  region,  but  in  the  several  cases 
under  my  care  were  on  the  upper  part  of  the  breast  or  neck.  This  type 
is  that  designated  by  Professor  Duhring  as  the  large  flat  pustular  scrofu- 
loderm. 

The  process  rarely  extends  deeply;  even  when  beginning  in  the  glands, 
the  subsequent  course  after  destruction  of  the  overlying  integument 
is  laterally,  rather  than  deeply,  although  this  latter  can  take  place  when 
the  caseating  and  suppurating  glands  or  nodules  are  quite  large  (scrofu- 
lous gummata,  scrofulogummata,  tuberculous  gummata,  tuberculides 
gommeuses  of  the  French).  Involvement  of  the  lymphatics,  especially 
when  these  tuberculous  gummata  are  on  the  lower  extremities,  occa- 
sionally is  observed,  lymphangitis  resulting,  and  sometimes  elephantiasic 
enlargement. 

The  ulceration  is  usually  superficial,  has  thin,  dull  red  or  purplish, 
undermined  edges,  as  a  rule  irregular  in  outline,  and  has  an  uneven 

1  A  remarkable  case  is  reported  by  G.  W.  Wende  "Nodular  Tuberculosis  of  the 
Hypoderm",  Jour.  Cutan.  Dis.,  1911,  p.  i,  the  growths  appearing  first  on  the  scalp. 


TUBERCULOSIS   CUTIS  719 

base  with  sluggish  granulations  covered  scantily  with  pus.  Its  spread 
is  generally  gradual,  and  there  is  but  moderate,  and  sometimes  extremely 
slight,  outlying  infiltration.  Occasionally  there  is  a  tendency  to  heal 
and  form  here  and  there  weak  cicatricial  tissue;  this  is  observed  some- 
times when  the  overlying  skin  has  suffered  only  irregular  and  incomplete 
destruction.  In  such  cases,  in  some  instances,  there  is  later  developed 
a  tendency  in  the  outlying  skin  to  the  formation  of  lupus  tubercles,  and 
the  disease  may  later  even  assume  the  partial  or  complete  clinical  aspects 
of  lupus.  As  a  rule,  however,  the  practical  absence  of  infiltration,  the 
weak,  sluggishly  red  skin,  with  the  violaceous  hue  and  the  superficial 
ulceration  typifying  this  variety  of  cutaneous  tuberculosis,  are  maintained 
throughout.  Occasionally  temporary  crusting  is  noted.  In  some  in- 
stances, after  the  glandular  structure  softens  and  breaks  down,  the  re- 
parative  process  gradually  sets  in  and  healing  finally  takes  place.  Or  the 
caseating  and  suppurating  glands,  with  the  several  resulting  sinuses, 
may  continue  almost  indefinitely,  the  sinuses  closing  up  now  and  then, 
the  disintegrating  tissue  and  secretion  collecting  beneath  and  again 
finding  exit. 

The  condition  is  usually  one  of  childhood  and  adolescence,  and  is 
commonly  associated  with  other  symptoms  of  a  tuberculous  nature, 
such  as  keratitis  or  its  scars,  chronic  otitis,  bone  or  joint  disease,  etc. 
It  not  infrequently  follows  in  the  wake  of  some  severe  systemic  disease. 
In  old  people,  in  whom  the  manifestation  is  rare,  after  ulceration  results 
a  papillomatous  or  verrucous  tendency  sometimes  develops,  and  the 
picture  of  lupus  verrucosus  or  tuberculosis  cutis  may  be  presented;  or 
later  epithelial  degeneration  may  set  in.  The  course  of  this  form  of  cuta- 
neous tuberculosis  is  slow,  but  it  usually  responds  rapidly  to  appropriate 
treatment,  which  is  practically  the  same  as  in  lupus  and  other  forms. 

5.  LUPUS  VULGARIS 

Synonyms.— Lupus;  Lupus  vorax;  Fr.,  Lupus  vulgaire;  Lupus  tuberculeux;  Scrofu- 
lide  tuberculeuse;  Ger.,  Fressende  Flechte. 

Definition. — A  chronic  cellular  new  growth,  due  to  invasion  of 
the  integument  by  the  tubercle  bacillus,  characterized  by  variously  sized, 
soft,  reddish-brown  tubercles,  tubercular  and  infiltrated  patches,  usually 
terminating  in  ulceration  and  scarring,  sometimes  in  absorption,  exfolia- 
tion, and  atrophy. 

Symptoms. — The  most  common  site  for  the  manifestation  of 
the  malady  is  the  face,  especially  the  region  of  the  nose,  although  other 
parts  of  the  surface  are  not  infrequently  invaded  either  conjointly  with 
the  face  or  independently.  This  will  be  referred  to  again.  The  disease 
begins  by  the  development  of  several  or  more  pin-head-  to  small  pea- 
sized,  deep-seated,  brownish-red  or  yellowish  macules  (lupus  maculosus) 
or  small  discrete  infiltrations  or  tubercles,  having  their  seat  in  the  deeper 
part  of  the  corium,  and  which  are  somewhat  softer  and  looser  in  texture 
than  normal  tissue.  As  the  disease  progresses,  usually,  however,  very 
insidiously  and  slowly,  by  new  lesions  or  infiltration  at  the  bordering 
part,  a  variously  sized  patch,  consisting  of  crowded  or  aggregated  tuber- 


720 


NEW  GROWTHS 


cles,  results.  The  earlier  nodules  or  infiltrated  points,  having  attained 
a  certain  size  or  development,  about  that  of  a  small  pea,  remain  sta- 
tionary, for  a  time  at  least,  and  then,  sooner  or  later,  exhibit  retrogressive 
changes  and  tend  to  break  down  and  disintegrate,  and  destruction 
results,  terminating  in  ulceration.  These  latter  are  rounded,  shallow 
excavations,  with  soft  and  dark-reddish  or  brownish-red  borders,  and 
with  a  variable  amount  of  purulent  secretion,  but  usually  slight  in 
quantity,  which  leads  to  more  or  less  crust-formation.  Later,  as  the 
patch  gradually  increases  in  area,  the  ulcerations  are  disposed,  as  a  rule, 
to  heal,  and  finally  give  place  to  cicatricial  tissue,  generally  of  a  firm 
and  fibrous  character.  The  patch  spreads  by  the  appearance  of  new 
papules  or  infiltrations  at  the  peripheral  portion,  and  not  infrequently 


Fig.  161. — Lupus  vulgaris  in  a  girl  of  fifteen,  of  six  years'  duration. 

new  islets  arise  just  outlying  the  border;  the  intervening  space  is  gradu- 
ally filled  up  by  other  lesions,  and  the  whole  area  becomes  continuous. 

In  a  typically  developed  patch  of  lupus,  in  wrhich,  as  more  commonly 
noted,  ulcerative  tendency  is  observed  (lupus  exedens;  lupus  exulcerans), 
several  conditions  are  to  be  seen,  even  when  the  area  is  scarcely  larger 
than  a  silver  quarter:  the  characteristic  soft,  small,  yellowish-  or  reddish- 
brown  (of  apple-butter  color  and  appearance)  cutaneous  and  subcuta- 
neous points  and  papules ;  similarly  colored  or  yellowish-brown  tubercles 
and  infiltrations;  ulcerations,  usually  small,  rounded,  and  shallow, 
sometimes  confluent  and  irregularly  shaped;  cicatricial  formation,  which, 
as  a  rule,  is  rather  tough  and  keloidal;  and,  in  addition,  outlying  the 
involved  area,  but  close  to  the  border,  can  often  be  seen  a  few  isolated 


TUBERCULOSIS  CUT1S  721 

small  infiltrated  points  or  tubercles.  These  various  lesions  show  the 
several  stages  of  the  process  from  the  beginning  cellular  deposit  to  the 
resulting  necrosis  and  cicatrization.  So  the  disease  continues,  often 
apparently  remaining  stationary  for  months  or  longer,  so  that  in  many 
instances,  and  especially  as  met  with  in  our  country,  several  years  or 
more  may  have  elapsed  before  the  area  involved  is  more  than  i  or  2 
inches  across — usually  irregularly  shaped,  although,  as  a  rule,  somewhat 
rounded  or  ovalish.  In  other  cases,  instead  of  resulting  in  necrosis  and 
ulceration,  the  matured  or  oldest  papules  or  tubercles  or  infiltrated  patch, 
after  long  continuance,  slowly  disappear,  chiefly  by  absorption,  fatty 
degeneration  taking  place,  and  partly  by  exfoliation,  leaving  an  exfoliat- 
ing, atrophic,  or  thin,  cicatricial,  pigmented  tissue,  constituting  the  clin- 


Fig.  162. — Lupus  vulgaris;  chiefly  of  the  exfoliative  type,  with  pigmentation  and 
atrophic  scarring;  showing,  as  a  result,  ectropion;  ulcerative  action  on  other  cheek. 
Patient  aged  thirty-five;  duration  twenty  years. 

ical  variety  known  as  lupus  exfoliativus.  And  in  this  way  the  disease 
continues,  presenting  the  various  stages  and  lesions  noted  in  the  ulcera- 
ting form,  except  the  ulceration  and  tough  fibrous  scar-formation.  It  is 
not  uncommon,  both  in  the  atrophic  and  scar  tissue  resulting  from  the 
earliest  lesions,  for  new  foci  of  disease  to  appear  from  time  to  time,  usually 
isolated,  and  with  very  little  tendency  to  confluence. 

The  disease  may  be  more  or  less  pronounced  in  one  or  more  of  its 
features.  In  exceptional  instances  the  ulcerations  may  be  the  seat 
of  exuberant  granulations,  and  the  underlying  inflammatory  and  cellular 
infiltration  and  edema  be  quite  considerable  or  extreme,  and  with  the 
resulting  cicatricial  formation  giving  rise  to  hypertrophic  disfigurement 
and  distortion — lupus  hypertrophicus.  In  some  cases,  while  in  most 

46 


722 


NEW  GROWTHS 


respects  the  disease  is  as  usually  observed,  the  cicatricial  development 
is  hypertrophic,  tough,  and  thick  (lupus  sclerosus) ;  or  there  may  show 
itself  a  distinct  keloidal  tendency  in  the  resulting  scar  tissue  (lupus 
keloides) .  In  some  instances  the  ulcerations  become  the  seat  of  papillary 
elevations  or  hypertrophy,  and  there  is  then  presented  a  somewhat 
uneven,  papillomatous,  exuding,  and  crusted  surface— lupus  papilloma- 
tosus,  lupus  verrucosus.  As  the  disease  gradually  advances  the  border 
of  tubercles  or  almost  continuous  infiltration  may  be  irregular  or  tor- 
tuous, the  innermost  part  showing  the  usual  scar  or  atrophic  tissue, 
and  the  whole  configuration  and  manner  of  spread  be  of  serpiginous 
character  (lupus  serpiginosus),  somewhat  closely  resembling  the  ser- 
piginous tubercular  syphiloderm;  and  in  cases  with  this  tendency,  as  a 


Fig.  163. — Lupus  vulgaris  in  a  youth  of  sixteen,  of  five  or  six  years'  duration. 

rule,  the  lupus  infiltration  and  ulceration  go  almost  hand  in  hand,  so  that 
sometimes  a  rather  large,  pigmented,  atrophic  or  tough  cicatricial  area, 
with  an  infiltrated,  ulcerating,  irregular,  or  serpiginous  border,  is  pre- 
sented. The  various  other  terms  sometimes  used  in  connection  with  the 
disease,  such  as  lupus  planus,  lupus  nodosus,  lupus  elevatus,  lupus  tumidus, 
lupus  cedematosus,  lupus  elephantiasicus,  etc.,  are  self-explanatory,  signify- 
ing merely  the  accentuation  or  undue  development  of  some  special  feature. 
When  the  nose  and  immediate  region  are  the  parts  involved,  the 
tissue,  except  cartilage,  of  this  organ,  especially  at  and  about  the  end, 
is  gradually  destroyed  and  changed  into  a  firm,  irregular,  and  thin 
cicatrix,  producing  considerable  deformity,  the  resulting  contraction 
often  narrowing  the  nasal  outlets.  In  other  cases  the  atrophic  thinning 
and  cicatricial  tissue  may  tend  to  distend  the  nostrils.  In  occasional 


TUBERCULOSIS   CUTIS 


723 


instances,  however,  of  lupus  involving  the  nose  the  earlier  tubercles  or 
infiltration  give  way  to  ulceration  and  then  become  the  seat  of  papillo- 
matous  vegetations  or  hypertrophic  granulations,  resembling  the  same 
type  of  syphilis  very  closely,  as  in  a  few  instances  under  my  own  care;1 
later  scarring  and  the  usual  disfiguring  changes  result.  Zeisler2  records 
a  somewhat  similar  case.  When  the  spreading  disease  encroaches  toward 
the  eye,  the  cicatricial  formation  which  ensues  frequently  draws  upon 
the  eyelid  and  produces  moderate  or  marked  ectropion.  Involving  or 
spreading  on  the  upper  lip,  often  considerable  edema tous  infiltration  is 


Fig.  164. — Lupus  vulgaris  of  many  years'  duration. 

Hospital  case.) 


(Stelwagon-Gaskill  Jefferson 


noted,  the  part  assuming  large  proportions  (lupus  hypertrophicus). 
Ordinarily,  however,  the  usual  features  are  presented,  and  with  the  con- 
sequent tough,  often  keloidal,  cicatricial  ending,  the  mouth  is  drawn, 
sometimes  slightly  puckered,  and  the  opening  inconveniently  narrowed. 
Both  when  implicating  the  lip  and  the  nose,  the  invasion  of  the  nasal 

1  Stelwagon,  "A  Somewhat  Unusual  Case  of  Lupus  Ulceration  of  the  Nose,"  Jour. 
Cutan.  Dis.,  1892,  p.  428. 

2  Zeisler,  "Remarks  on  Tuberculosis  of  the  Skin,"  North  Amer.  Practitioner,  March, 
1889  (a  clear  and  terse  review,  with  many  references). 


J2A.  NEW  GROWTHS 

mucous  membrane,  and  even  that  of  the  mouth,  is  frequently  observed, 
and,  indeed,  the  disease  often  starts  from  within  the  nasal  orifice. 

In  some  cases  of  lupus  of  the  face,  as  well  as  when  seated  elsewhere, 
not  infrequently  new  foci  appear  one  or  several  inches  or  more  from  the 
original  patch;  or  the  disease  may  develop  at  several  points  simulta- 
neously, or  one  follow  closely  after  the  other.  As  a  rule,  however,  and 
especially  as  observed  in  our  own  country,  there  are  but  one  or  two 
areas,  which  may  be  quite  small  and  scarcely  progressive,  or  exceptionally 
extensive  and  involve  a  greater  part  of  the  face.  In  addition  to  the 
disease  presenting  on  the  face,  foci  sometimes  develop  elsewhere  on  the 
general  surface,  usually  conjointly  or  subsequently  to  the  face  manifesta- 
tion. While,  however,  the  face  is  the  sole  seat  of  the  malady  in  most 
patients,  and  commonly  shares  in  the  disease  in  instances  in  which  the 
eruption  is  rioted  on  other  parts,  still  there  occur  cases,  not  often,  it  is 
true,  where  the  eruption  develops  on  the  leg,  arm,  neck,  trunk,  or  about 
the  genitalia,  and  remains  limited  to  its  original  region,  the  face  remain- 
ing free  throughout.  Bender,1  in  an  analysis  of  374  cases,  found  that  the 
face  was  the  seat  of  the  disease  in  287,  of  which,  in  115,  it  was  more  or 
less  of  the  entire  face;  in  70,  it  was  in  the  nose;  35,  on  the  cheek;  25,  nose 
and  other  parts  of  face;  16,  on  lips;  15,  nose  and  lips;  6,  temple  and  fore- 
head; 3,  chin;  and  2,  eyelids;  40,  upper  extremities;  15,  lower  extremities; 
12,  face  and  neck;  6,  face  and  extremities;  3,  face  and  arm;  3,  ear;  2, 
general;  2,  scalp;  i,  hand  and  foot;  i,  nape  of  neck;  i,  back,  and  i,  palate. 
It  presents  no  special  peculiarities  in  the  various  unusual  localities,  ex- 
hibiting primarily  the  beginning  maculopapular,  yellowish-browTn  papules 
or  tubercles,  closely  aggregated  or  contiguous  and  confluent,  and 
progresses  in  the  ordinary  manner  and  with  the  same  changes.  There 
seems  to  be  a  greater  tendency  shown  on  these  regions  for  the  malady 
to  be  serpiginous  in  character,  often  exhibiting  a  close  resemblance  to 
the  serpiginous  tubercular  syphilid.  In  these  cases,  too,  the  exfoliative 
feature  is  often  more  pronounced  than  it  is  usually  upon  the  face.  In 
most  the  disease  is  limited  to  one  region,  although  it  often  involves  a 
great  extent  of  surface.  The  ulcerative  tendency,  when  present,  is 
often  quite  pronounced,  and  if  the  disease  is  about  a  joint,  may  result 
in  serious  deformity  and  materially  restrict  the  mobility  of  the  part. 
When  on  the  lower  part  of  the  leg  and  also  about  the  genitalia  and  anal 
region,  the  ulcerations  are  often  the  seat  of  papillomatous  vegetations 
(lupus  papillomatosus,  lupus  verrucosus),  with  crusting  and  offensive 
discharge;  considerable  thickening  and  edematous  infiltration  with 
lymphangitis  are  also  frequently  noted  with  the  disease  when  on  the 
extremities. 

Lupus  of  the  mucous  membranes  has  been  incidentally  mentioned 
in  connection  with  that  of  the  lip  and  nose,  but  the  involvement  may 
also  be  conjointly  with  the  disease  some  distance  from  these  parts. 
In  fact,  it  is  not  improbable  that  in  many  cases  of  cutaneous  lupus  the 
primary  infection  is  within  the  nose.  And  cases  of  lupus  invading  the 
throat  are  also  recorded  from  time  to  time,  though  few  in  number,  in 

1  Max  Bender  (Ueber  des  Beziehungen  des  Lupus  vulgaris  zur  Tuberkulose), 
Deutsche  med.  Wochenschr.,  1886,  p.  413. 


TUBERCULOSIS  CUTIS 


725 


which  there  is  no  evidence  of  the  eruption  upon  the  integument.  It 
may  consist  of  an  insignificant  or  moderate  diffused  infiltration,  with 
slight  papular  or  tubercular  elevations,  or  more  the  nature  of  papillary 
excrescences;  or  the  area  is  studded  with  whitish  epithelial  opacities. 
Superficial  ulceration  is  not  uncommon,  and  may  assume  a  serpiginous 
configuration;  or  it  presents  the  aspects  of  a  raw  granulating  patch. 
The  most  commonly  involved  site  is  that  of  the  nares,  near  the  outlets, 
and  the  mucous  membrane  of  the  inside  of  the  lips,  contiguous  to  the 
adjacent  skin.  In  most  of  these  cases  the  disease  has  progressed  from 
the  skin,  although,  as  already  stated,  the  primary  involvement  may 
doubtless  not  infrequently  be  on  the  mucous  membrane.  Other  parts, 
such  as  soft  palate,  velum,  hard  palate,  etc.,  may  also  be  the  seat  of  the 
malady.  According  to  Finsen,1  in  the  cases  of  lupus  treated  at  his  light- 
institute,  in  70  to  80  per  cent,  the  mucous  membrane  of  the  nose  or  mouth 
was  also  involved,  a  surprisingly  large  proportion  when  compared  to 
average  American  experience,  and  much,  I  feel  sure,  above  that  generally 
observed.  Bender,2  in  380  cases,  found  in  about  45  per  cent.  (173  cases) 
mucous  membrane  involvement  conjointly  with  the  skin;  in  6  cases  only 
was  the  disease  limited  to  the  mucous  membranes.  In  147  of  these  173 
cases  in  which  inquiry  was  made  as  to  place  of  beginning  it  was  elicited 
that  in  46  cases,  or  31.2  per  cent.,  the  mucous  membrane  was  the  part 
originally  attacked.  While  in  a  number  of  instances  but  one  mucous 
surface  was  invaded  (nose,  75;  tear-duct,  9;  conjunctiva,  8;  lips,  12; 
palate,  n),  in  many  several  regions  were  the  seat  of  the  disease,  so  that 
in  tabulating,  the  mucous  membrane  of  the  nose  was  found  implicated 
in  115  cases,  conjunctiva  in  21;  tear-duct  in  24;  lips  in  43;  palate  in  31; 
tongue  in  i ;  larynx  in  13;  rectum  and  vulva  in  i. 

While  in  the  very  large  majority  of  lupus  patients  the  usual  char- 
acters and  location  are  observed,  occasionally  atypical  cases3  especially 
as  regards  distribution,  configuration,  extent  of  eruption,  and  association 
with  other  forms  of  integumentary  tuberculosis  present.  A  rare  form, 
usually  on  the  face,  but  sometimes  on  other  parts,  is  that  described  by 
Leloir4  as  lupus  vulgaris  sclerosus  erythematoides,  which  resembles 
closely  and  simulates  lupus  erythematosus  (also  referred  to  under  this 
latter  disease).  It  is  very  slow  in  its  course,  tending  to  spread  in  a  cen- 
trifugal manner,  and  never  ulcerates.  It  is  of  a  bright  or  dusky  red  color, 
disappearing  partly  under  pressure,  and  here  and  there,  especially  periph- 
erally, covered  with  fine  scales  or  small  lamellated  crusts;  somewhat 
raised  at  the  border,  and  slightly  depressed  centrally  in  consequence  of 
the  tendency  to  atrophic  cicatrization  or  interstitial  resorption.  If  the 

1  Stelwagon  "An  Account  of  a  Visit  to  Professor  Finsen's  Light-Institute  at  Copen- 
hagen,"  University  Med.  Mag.,  Philada.,  Dec.,  1900. 

2  Max  Bender,  "Ueber  Lupus  der  Schleimhaute"  (a  review  of  the  literature  with 
references),  Archiv,  1886,  vol.  xx,  p.  892.     See  also  valuable  paper  by  Doutrelepont, 
"Ueber  Haut-  und  Schleimhauttuberculose,"  Deutsche  nted.  Wochenshr.,  1892,  p.  1033. 

3  Howard  Fox,  "Three  Unusual  Forms  of  Cutaneous  Tuberculosis,"  Jour.  Cutan. 
Dis.,  Feb..  1912  (with  illustrations) ;  extensive  case  of  lupus  serpiginosum  of  somewhat 
rapid  development,  strongly  suggestive  clinically  of  syphilis;  case  lichen-planus-like 
inner  aspect  of  thigh  and  knee;  and  a  case  with  two  tuberculous  ulcerations,  upon  the 
central  portion  of  the  mucous  membrane  of  the  lower  lip. 

4  Leloir,  Jour.  mat.  cutan.,  1891,  p.  241;  good  abstract  in  Brocq's  letter,  Jour. 
Cutan.  Dis.,  1892,  p.  27. 


726 


NEW  GROWTHS 


involved  skin  is  put  upon  the  stretch,  as  a  rule  small  miliary  tubercles  of 
a  yellowish  color  become  visible;  there  is  a  good  deal  of  underlying  infil- 
tration, which  also  distinguishes  it  from  lupus  erythematosus.  Histo- 
logic  and  bacteriologic  findings  and  experimental  inoculations  proved 
its  tuberculous  nature,  although  it  presents  clinically  a  meeting-ground 
between  these  two  affections.  Hardaway1  believes  this  form  much  more 
common  than  generally  thought,  but  that  it  is  usually  confounded  with 
lupus  erythematosus,  a  view  which  I  am  inclined  to  share.  Very  excep- 
tionally lupus  patches  from  the  start  display  a  tendency  to  circinate 
shape,  with  clearing,  usually  atrophic  or  cicatricial  center,  in  some  re- 
spects resembling,  in  shape  more  especially,  the  lupus  vulgaris  erythema- 


Fig.  165. — Lupus  vulgaris  involving  the  entire  face,  scalp  anteriorly,  and  the  ears; 
there  is  also  a  tubercular  patch  on  the  upper  part  of  the  arm;  many  years'  duration, 
slowly  progressive  (courtesy  of  Dr.  L.  A.  Duhring). 

toides  of  Leloir,  except  that  the  borders  are  distinctly  nodular.  It  begins 
as  a  nodule,  and  this  sinks  centrally  as  it  spreads.  A  rare  instance  of  this 
form — of  added  interest  on  account  of  the  large  number  of  such  areas, 
all  of  the  same  characters,  varying  in  size  from  a  pea  to  a  dime  or  slightly 
larger,  and  chiefly  about  face — is  recorded  by  Elliot,2  which  could  be  well 
described  by  the  name  lupus  annularis.  In  other  cases,  somewhat  rare, 
the  eruption,  instead  of  being  limited  to  one  or  two  regions  or  areas,  is 
quite  generally  distributed  (lupus  disseminatus).  Crocker  refers  to  a 
case,  a  boy  aged  ten,  in  whom  there  were  47  variously  sized  patches 

1  Hardaway,  Manual  of  Skin  Diseases. 

2  Elliot,  Jour.  Cutan.  Dis.,  1896,  p.  476;  Ransom,  ibid.,  1895,  p.  269,  and  Sutton, 
ibid.,  1910,  p.  391,  have  each  also  reported  an  example;  in  each  case  but  a  single  patch. 


TUBERCULOSIS   CUTIS  J2J 

scattered  over  the  whole  body;  and  Morrow,1  a  case,  a  woman  of  twenty- 
two,  in  whom  the  disease  developed  some  years  previously,  exhibiting, 
with  some  caseating  glands,  various  plaques  of  extensive  distribution; 
and  Fordyce,2  in  a  man  aged  twenty-eight,  in  whom  it  had  first  appeared 
at  the  age  of  four,  and  involved  the  whole  face  and  neck,  with  numerous 
patches  over  the  arms,  chest,  back,  etc.  Some  years  ago,  when  associated 
with  Professor  Duhring,  I  saw  in  his  clinic  a  case  of  a  Hungarian  woman 
of  twenty-one  in  whom  a  large  part  of  the  entire  surface  was  involved, 
on  the  legs  the  disease  forming  one  continuous  covering,  with,  however, 
but  little  tendency  to  ulceration;  and  also  recall  several  instances  of 
almost  universal  distribution  in  the  clinics  of  Hebra,  Neumann,  and 
Kaposi  during  my  student  days  in  Vienna.  Such  cases  are,  however, 
extremely  rare  in  our  own  country;  less  so  in  the  European  capitals. 
In  rare  instances  a  verrucous  or  papillomatous  tendency  is  noted  in  cases 


Fig.  1 66. — Lupus  (tuberculosis  cutis)  of  papillomatous  type;  in  a  negro  youth  of 
eleven;  duration  two  to  three  years;  yielded  almost  completely  to  *-rays.;  later 
relapsing  and  spreading,  patient  finally,  after  several  years,  dying  of  pulmonary  tuber- 
culosis. 

showing  scattered  patches,  with  but  few  or  no  typical  lupus  nodules, 
closely  allied  to  or  identical  with  tuberculosis  verrucosa  cutis. 

In  other  instances  lupus  vulgaris  areas  are  found  associated  with 
various  other  tuberculous  integumentary  lesions  and  other  signs  of 
tuberculosis.  White3  briefly  details  10  such  cases,  which  had  been 
under  his  direct  care,  in  which  one  or  more  clinical  forms  of  tuber- 
culosis were  present  in  association  with  lupus  vulgaris,  such  as  case- 
ating and  ulcerating  glands,  tuberculosis  verrucosa,  tuberculous  dac- 
tylitis,  etc.  Wickham4  relates  a  case  in  which  three  forms  were 

1  Morrow  (case  demonstration),  ibid.,  1895,  p.  259. 

2  Fordyce  (case  demonstration),  ibid.,  IQOO,  p.  119. 

3  J.  C.  White,  "  Clinical  Aspects  and  Etiologic  Relations  of  Cutaneous  Tubercu- 
losus,"  Boston  Med.  and  Surg.  Jour.,  Nov.  12,  1891,  p.  5°9  (an  excellent  presentation 
and  review  of  the  subject). 

4  Wickham,  Paris  letter,  Brit.  Jour.  Derm.,  1890,  p.  337. 


728 


NEW  GROWTHS 


present:  lupus  vulgaris  on  face,  tuberculosis  verrucosa  cutis  on  hands 

and  feet,  and  these  two  forms 


Fig.  167. — Lupus  vulgaris  of  extensive 
development;  areas  on  nose,  ears,  trunk,  and 
thighs  (courtesy  of  Dr.  M.  B.  Hartzell). 


about  one  knee,  and  tuber- 
cular abscesses — tuberculosis 
gummata — on  face  and  hands; 
and  Brousse  and  Ardin-Delteil1 
had  under  observation  a  some- 
what similar  case,  a  girl  aged 
sixteen,  in  whom  the  cutaneous 
lesions,  following  a  disease  of 
the  bone  of  the  right  toe 
when  aged  four,  consisted  of 
a  tuberculosis  verrucosa  cutis 
of  the  right  foot  and  leg,  an 
area  of  lupus  vulgaris  on  the 
left  cheek,  and  a  tuberculous 
gumma  of  the  side  of  the  face. 
W.  G.  Smith2  describes  an  un- 
usual case  in  which  lupus  of 
the  ordinary  type  was  seated 
about  the  nose,  symmetric 
exostoses  on  nose  and  fingers, 
and  on  the  latter  also  pulpy 
nodosities,  and  a  psoriasis-like 
eruption  on  the  body  and 
limbs,  apparently  leaving 
scars;  the  true  nature  of  this 
last  was  obscure.  In  rare  in- 
stances, however,  the  lupus 
lesions  do  present  a  psoriatic 
aspect,  designated  by  Hutch- 
inson  lupus-psoriasis.  Colcott 
Fox3  recently  recorded  an  ex- 
ample of  this  variety  in  a  girl 
under  three  years  in  whom 
there  were  two  patches  on  the 
left  knee  and  three  on  the 
right;  three  on  each  buttock, 
very  closely  symmetric;  one 
on  the  point  of  left  elbow; 
one  on  the  back  of  right  heel; 
three  on  dorsum  of  left  hand 
and  fingers;  and  one  on  the 
back  and  on  the  flexor  aspect 
of  the  right  wrist,  and  one  on 


right  thumb;  the  bilateral,  and  to  some  extent  symmetric  localization,  and 

1  Brousse  and  Ardin-Delteil,  La  presse  med.,  1898,  No.  32,  p.  i! 

2  W.  G.  Smith,  Brit.  Jour.  Derm.,  1897,  p.  187. 

3  Colcott  Fox,  ibid.,  1898,  p.  329  (case  demonstration). 


TUBERCULOSIS  CUTIS  729 

the  size  and  character  of  the  patches  simulating  psoriasis.  In  these  rare 
cases,  however,  there  is  usually  greater  and  denser  infiltration,  with  well- 
defined  and  infiltrated  edges,  than  observed  in  this  latter  disease.  Sooner 
or  later,  as  a  rule,  there  is  atrophy  or  scarring,  and  sometimes  ulcerative 
tendencies  develop,  as  in  a  patient  under  my  own  observation,  a  young 
girl  aged  eight,  in  whom  the  lesions,  seated  about  the  neighborhood  of 
both  knees,  were  scaly  and  psoriatic  in  general  appearance,  although 
tending  to  crowd  together ;  several  years  later  these  gave  place  to  ulcera- 
tions  of  scrofulous  aspect,  and  also  simulating  those  observed  in  erythema 
induratum  and  in  syphilis. 

The  neighboring  lymphatic  glands  in  lupus  cases,  if  of  any  extent, 
sometimes,  although  not  frequently,  show  inflammatory  swelling  and 
enlargement,  and  tend  to  break  down  and  suppurate,  but,  as  a  rule,  this 
is  observed  only  in  those  instances  in  which  ulceration  is  a  feature,  and 
often  due,  doubtless,  to  the  added  pyogenic  factor  in  the  case.  It  has 
been  shown  by  Leloir,1  however,  that  in  addition  to  adenitis  due  to  in- 
flammatory products  there  is  gland  involvement  due  to  direct  tubercu- 
lous infection  or  transference  from  the  lupus  area;  in  7  cases  examined 
by  him  this  was  established  both  by  microscope  and  inoculation  ex- 
periments. 

There  are  no  constitutional  symptoms  in  lupus,  unless  from  an  asso- 
ciated internal  tuberculosis;  the  occasional  and  probably,  one  might  say, 
frequent  occurrence  of  other  tuberculous  processes,  usually  of  the  lungs, 
noted  will,  as  is  to  be  expected,  give  rise  to  some  general  symptoms. 
Lespinne2  has  observed  infective  intoxication  occur  at  times,  with  rise 
of  temperature,  etc.,  and  some  suspicious  pulmonary  signs,  due,  he  con- 
siders, to  the  absorption  of  the  products  of  the  bacilli;  from  which, 
however,  as  a  rule,  no  organic  disease  results;  during  such  attacks  he  has 
further  noted  that  the  lupus  patch  shows  some  reactionary  symptoms 
similar  to  those  observed  after  tuberculin  injection.3 

The  course  of  lupus  has  already  been  inferentially  stated.  It  is 
almost  invariably  a  slow  disease,  appearing  insidiously  and  from  week 
to  week  or  month  to  month  with  scarcely  perceptible  progress.  Fre- 
quently it  develops  gradually,  but  often  with  periods  of  apparent  quies- 
cence, into  a  variously  sized  patch  of  a  dime  to  that  of  one  several  inches 
in  diameter,  and  then  remains  stationary  for  a  time;  from  occasional 
partial  subsidence  of  the  inflammatory  element  retrogression  some- 
times seemingly,  and  possibly  with  certainty,  is  observed  now  and  then, 
but,  upon  the  whole,  the  malady  gradually  extends,  showing  no  tendency 
to  disappear.  Its  presence,  as  a  rule,  gives  rise  to  but  little  trouble 
beyond  its  disfigurement,  subjective  symptoms  being  practically  absent, 
or  not  sufficiently  annoying  to  give  rise  to  complaint;  the  ulcerations, 
especially  when  a  decided  pyogenic  character  is  added,  sometimes  are 

1  Leloir,  abs,  of  paper,  ibid.,  1890,  p.  55. 

2  Lespinne,  Jour.  mat.  cutan.,  Oct.,  1891,  p.  531. 

3  Gaskill,  "Extensive  Tuberculoses  Cutis  with  Death  from  Pyemia,"  Jour.  Cutan. 
Dis.,  May,  1913,  records  an  interesting  case  of  wide  distribution — chiefly  face,  lower 
lumbar  region,  buttocks,  and  legs — of  lupus  vulgaris  type,  in  which  at  intervals  of 
weeks  or  several  months,  there  developed  diffused,  somewhat  superficial  and  flat,  un- 
dermining abscess-like  formations;  death  finally  resulted  from  pyemia. 


730 


NEW  GROWTHS 


painful  and  sensitive.  Enlarged,  swollen,  and  inflamed  and  caseating 
glands  may  result  in  some  cases,  and  general  tuberculous  infection  may 
eventually  ensue.  As  we  see  the  disease  here,  however,  and  for  the  most 
part  elsewhere,  the  patients  are  but  little  disturbed  in  a  general  way  by 
the  presence  of  the  local  tuberculous  process.  Occasionally,  it  is  true, 
the  open  lesions  seem  to  favor  the  development  of  erysipelas;  and  later 
in  life,  in  some  instances,  an  epitheliomatous  degeneration  sets  in,  and 
the  malady  then  acquires  a  more  serious  character,  especially  as  lupus 
tissue  seems  to  permit  of  rapid  epithelial  involvement  and  destruction, 
often  of  a  malignant  type.  Dubois-Havenith1  in  118  cases  noted  this 
latter  development  5  times.  This  is  above  the  average  proportion, 
as  it  is  generally  believed  to  be  between  1.50  and  2  per  cent. 

Etiology  of  Cutaneous  Tuberculosis.— The  disease,  more 
especially  the  ordinary  type — lupus  vulgaris — to  which  most  of  these 
remarks  apply,  is  common  in  some  parts  of  the  world — as,  for  example, 
in  Austria — and  somewhat  infrequent  in  others — as,  for  instance,  in 
our  own  country.  The  reasons  for  this  are  not  perfectly  clear,  although 
doubtless  it  is  mainly  to  be  found  in  the  different  methods  of  living, 
the  character  of  the  food-supply,  and  other  causes  not  known.  Great 
Britain  also  furnishes  a  large  number  of  cases  compared  to  this  country. 
The  worst  cases  in  this  country,  moreover,  are  usually  found  among  the 
foreign-born  population.  It  is  much  more  common  in  females  than 
males — at  least  two  or  three  to  one.  It  usually  has  its  beginning  in  the 
first  periods  of  life,  as  in  childhood  and  early  adolescence;  to  this,  how- 
ever, there  are  exceptions,  although  it  is  rare  to  see  it  beginning  after 
middle  age.  In  Colcott  Fox's2  analysis  of  96  hospital  cases  under  his 
observation,  more  than  half  began  before  the  age  of  ten,  and  30  of  these 
under  five,  and  of  the  latter,  5  in  the  first  year;  10  began  after  the  thirtieth 
year,  and  of  these,  4  after  the  fortieth.  Of  the  96  cases,  64  were  females. 
Tuberculosis  verrucosa  and  tuberculosis  ulcerosa  are  often  first  seen  later 
in  life,  and  exceptionally  lupus  may  begin  at  that  period.3 

The  direct  cause  of  the  disease,  as  first  demonstrated  by  the  find- 
ings of  Demme,  Doutrelepont,  Pfeiffer,  and  Koch,  and  since  by  many 

1  Dubois-Havenith,  Du  lupus  vulgaire,  Brussels,  1890  (an  exceedingly  valuable 
monograph  with  a  good  review  of  etiology,  pathology,  and  treatment) . 

See  also  the  excellent  monograph,  Epitheliome  et  Lupus,  by  Desbonnets,  Paris, 
1894  (contains  a  review  of  reported  cases);  also  Hutchinson's  paper,  "Notes  on  Cancers 
and  Cancerous  Processes,"  Archives  of  Surgery,  1890-91,  vol.  ii,  p.  138  (details  several 
cases  of  his  own  and  refers  to  6  cases  observed  by  others);  Sequeira,  "Lupus  Car- 
cinoma," Brit.  Jour.  Derm.,  1908,  p.  40,  besides  giving  his  experience  (1.5  per  cent.) 
in  the  London  Hospital,  reviews  the  subject  (with  bibliography) ;  he  is  of  the  belief 
that  x-ray  treatment,  especially  when  the  exposures  are  frequent  and  carried  out  over 
long  periods,  tends  to  increase  the  proportion  of  instances  in  which  epithelioma  develops 
on  lupus  vulgaris  or  its  scars;  Bargues,  "Pe  1'  epitheliome  sur  lupus  vulgaire,"  Annales, 
IQIO,  p.  3,  reports  6  new  cases  of  epithelioma  and  lupus  vulgaris  from  Dubreuilh's 
clinic,  and  gives  an  analysis  of  164  published  cases,  and  a  tabulated  review  of  these 
cases,  with  full  bibliography;  Zweig,  Archiv,  1910,  cii,  p.  83,  adds  6  cases. 

2  Colcott  Fox,  "On  the  Nature  of  Lupus  Vulgaris  from  a  Clinical  Standpoint," 
Westminster  Hospital  Reports,  1893,  p.  23. 

3  See  papers  by  Colcott  Fox,  "  Four  Cases  of  Senile  Tuberculosis  of  the  Skin," 
Brit.  Jour.  Derm.,  1892,  p.  160,  and  by  Travers  Smith  "Lupus  and  Senile  Struma," 
ibid.,  p.  163.     Colcott  Fox  refers  to  several  contributions  on  the  subject. 


TUBERCULOSIS  CUTIS  731 

others,  is  the  tubercle  bacillus,  a  view  which  already  had  much  support 
in  the  clinical  association  with  other  tuberculous  processes.  In  fact, 
the  clinical  evidence  of  its  tuberculous  nature  is  to-day  sufficiently  large 
to  be  in  itself  convincing.  Bender1  found  in  159  cases  in  which  inquiry 
was  made,  there  were  99  (62.3  per  cent.)  patients  in  whom  present  or 
past  evidences  of  tuberculosis  existed;  hereditary  predisposition  was 
noted  in  33.3  per  cent.;  and  at  the  time  of  examination  in  77  cases  other 
signs  of  tuberculosis  were  present;  2  of  his  cases,  while  under  observation, 
died  of  other  forms  of  the  disease — i  of  laryngeal  and  pulmonary  tubercu- 
losis, and  the  other  of  tuberculous  meningitis  combined  with  caries  of 
the  petrous  bone.  Colcott  Fox  in  his  series  also  noted  the  frequency  of 
family  history  of  consumption,  and  in  33  of  the  96  cases  there  were 
evidences  of  the  existence  of  glandular  disease  of  some  kind;  16  per  cent, 
of  the  patients  suffered  at  some  time  from  scrofulous  gummata.  In 
Block's2  144  cases  114  were  affected  with  some  form  of  tuberculous  dis- 
ease, either  prior  to  the  attack  (about  28  cases)  or  following  it.  In  the 
series  reported  by  Sachs,3  out  of  115  patients  there  were  only  15  in  whom 
no  past  or  present  or  hereditary  tuberculosis  could  be  found.4  Single 
reported  examples  suggestive  of  its  tuberculous  origin  are  innumerable. 
A  striking  one  is  that  referred  to  by  Walsh,5  of  a  young  woman  with 
lupus  upon  the  face  and  other  tuberculous  symptoms,  whose  father  died 
of  phthisis,  her  mother  of  bronchitis,  and  eight  or  nine  brothers  of  pul- 
monary tuberculosis.  Winfield6  records  a  case  of  a  subject  with  pul- 
monary tuberculosis,  in  whose  wife  and  daughter  lupus  developed. 
Howe7  has  also  reported  some  suggestive  examples.  Such  instances, 
often  less  striking,  it  is  true,  are  common  in  the  experience  of  all  ob- 
servers, and  dermatologists  of  the  present  day  are  in  accord  as  to  their 
significance. 

Further  evidence  is  to  be  found  in  examples  of  contagion  or  acci- 
dental inoculation  and  also  in  the  success  of  experimental  inoculation. 
Several  of  the  former  may  be  referred  to.  White8  has  observed  a  number 
of  cases  in  which  lupus  was  presumably  due  to  the  inoculation  of  tuber- 
culous matter,  12  cases  within  a  period  of  three  years.  Corlett9  also 
met  with  such  an  instance ;  Jadassohn10  records  2  cases,  i  from  a  tubercu- 
lous ulcer  and  the  other  from  a  phthisical  tattooer;  Dent11  observed  3 
cases  of  the  disease  develop  in  three  sisters  who  slept  in  the  same  room, 

1  Max  Bender,  Deutsche  med.  Wochenschr.,  June  17,  1886. 

2  Felix  Block,  Archiv,  1886,  vol.  xiii,  p.  201  (also  gives  the  age  at  which  disease 
began,  as  well  as  regions  affected,  practically  similar  to  the  observations  made  by  Ben- 
der and  Colcott  Fox). 

3  Sachs,  ibid.,  p.  241. 

4  See  interesting  paper  by  J.  C.  McGuire  ("Lupus  Vulgaris:  Its  Relations  to  Tuber- 
culosis"), Jour.  Cutan.  Dis.,  1891,  p.  264,  with  review  of  this  question,  and  interesting 
replies  concerning  it  from  various  authorities;  also  Payne's  address  on  Lupus,  full  abs. 
in  Brit.  Jour.  Derm.,  1891,  p.  369. 

5  D.  Walsh,  Brit.  Jour.  Derm.,  1898,  p.  19  (case  demonstration). 

6  Winfield,  Jour.  Amer.  Med.  Assoc.,  Dec.  12,  1896,  p.  1220  (with  illustrations). 

7  Howe,  "Thirteen  Cases  of  Tuberculosis  of  the  Skin,"  Jour.  Cutan.  Dis.,  1892,  p. 

3°3- 

8  J.  C.  White,  loc  cit.,  cites  other  cases  from  literature. 

9  Corlett,  ibid.,  1893,  p.  146. 

10  Jadassohn,  Virchow's  Archiv,  1890,  vol.  cxxi,  p.  210. 

11  C.  J.  Dent,  Brit.  Jour.  Derm.,  1891,  p.  156. 


732  NEW  GROWTHS 

while  the  other  eight  children  of  the  family  were  free — the  malady  appar- 
ently originally  arising  from  a  pre-existing  tuberculous  ostitis  in  one  of 
the  patients.  Wild1  has  recently  called  attention  to  suggestive  exam- 
ples: 4  of  lupus  of  the  lobule  of  the  ear  following  ear-piercing;  3  cases  of 
tuberculosis  verrucosa  cutis  of  the  hands  in  laundresses  who  had  washed 
linen  from  tuberculous  individuals;  several  cases  of  the  same  type,  and 
i  of  lupus  vulgaris,  which  apparently  originated  from  tuberculous  pa- 
tients in  the  same  households.  Elliot's2  case  of  tuberculosis  verrucosa 
in  a  woman  aged  seventy  is  also  an  example  of  contagion;  the  disease, 
which  was  on  the  back  of  the  hands,  developing  after  nursing  and  washing 
the  linen  of  a  phthisical  son.  I  have  had  as  patients  several  young  chil- 
dren with  beginning  face  lupus,  in  families  in  which  tuberculous  indi- 
viduals lived  and  by  whom  they  had  been  frequently  nursed  and  caressed. 
Ware3  reported  an  additional  instance  of  tuberculous  inoculation  follow- 
ing ritual  circumcision,  and  states  that  there  is  a  record  in  literature  of 
21  such  cases — and  I  believe  probably  even  a  greater  number — as  Dub- 
reuilh4  collected  17  cases  of  tuberculosis  of  the  penis  consequent  upon 
this  religious  rite  by  consumptive  operators.  Ernst5  has  collected  8 
recorded  cases  (i  of  his  own)  of  cutaneous  tuberculosis  from  tattooing. 
That  lupus  and  other  cutaneous  tuberculoses  occasionally,  although  not 
frequently,  arise  at  the  point  of  vaccination  has  been  shown  by  Besnier6 
and  others,  and  quite  recently  another  probable  case  came  under  Perry's7 
observation,  and  i  also  under  Little's8  notice,  to  which  I  can  add  i  of  my 
own  (the  sister  of  a  physician),  the  disease  making  its  appearance 
shortly  after  that  procedure  in  early  childhood,  and  when  coming  under 
my  care,  ten  or  twelve  years  later,  it  had  reached  the  size  of  a  palm. 
To  this  overwhelming  evidence  of  the  tuberculous  character  of  these 
various  cutaneous  processes  and  the  communicability  of  the  disease  must 
be  added  the  success  of  experimental  animal  inoculation,  notably  by 
Leloir,9  Eve,10  and  Gougerot  and  Laroche,11  and  the  reactionary  symp- 
toms brought  about  by  tuberculin  injections. 

Pathology  of  Tuberculosis  Cutis.— The  tubercle  bacillus, 
being  the  accepted  cause  of  the  disease,  its  mode  of  entrance  into  the 
cutaneous  tissues  other  than  by  direct  inoculation  already  referred  to 
remains  to  be  solved.  Sticker12  believes  that  in  lupus,  as  well  as  in  lep- 

1  Wild,  "Some  Sources  of  Infection  in  Cutaneous  Tuberculosis,"  Brit.  Med.  Jour., 
Nov.  n,  1899,  p.  1353. 

2  Elliot,  Jour.  Amer.  Med.  Assoc.,  Jan.  12,  1889,  also  quotes  statistics  showing  fre- 
quency of  pulmonary  tuberculosis  in  association  with  the  cutaneous  lesions. 

3  Ware,  New  York  Med.  Jour.,  Feb.  26,  1898. 

4DubreuiIh  and  Auche,  Archives  de  med.exper.  et  d'anat.  patholog.,  Sept.,  1890,  p. 
601;  abs.  in  Annales,  1891,  p.  95  (in  all,  60  collated  cases  of  integumentary  inoculation). 
'  Ernst,  Dermatolog.  Centralbl.,  Dec.,  1907,  p.  66. 
'Besnier,  "Lupus  Vaccinal."  Annales,  1889,  p.  576. 
'Perry,  Brit.  Jour.  Derm.,  1898,  p.  196  (case  demonstration). 

8  Graham  Little,  ibid.,  1900.  p.  60  (case  demonstration). 

9  Leloir,  Comp.-Rend.  et  Memoire  de  la  Soc.  de  Bio!..  1882  p  84? 

10  Eve,  Brit.  Med.  Jour.  1888,  i,  p.  644. 

11  Gougerot  and  Laroche,  Archiv  de  Med.  Exper.  et  d'Anat.  Path.,  Sept.,  1908,  No.  5, 
p.  581;  abs.  in  Brit.  Jour.  Derm.,  1909,  p.  125,  claim  to  have  produced  lesions  clinically 
and  histologically  identical  with  several  of  the  varieties  of  tuberculides  that  occur  in 
human  beings;  their  method  was  not  by  inoculation,  but  to  rub  into  an  epilated  surface 
of  guinea-pigs  a  virulent  culture  of  tubercle  bacillus. 

12  Sticker,  Dermatolog.Zeitschrift,  1898,  vol.  v,  H.  6. 


TLBERCULOSIS   CUTIS  733 

f 

rosy,  the  primary  lesion  or  infection  is  in  the  nose,  and  through  the 
lymphatics  to  the  skin,  and  this,  in  face  cases,  which  constitute  the  over- 
whelming majority  of  cases,  seems,  as  also  suggested  by  Leredde,1  Me- 
neau  and  Freche,2  and  others,  not  improbable.3  Leloir4  believed  the 
bacillus  gains  access  to  the  integument  in  one  of  the  following  ways: 

(1)  By  direct  inoculation  from  without;  (2)  indirect  inoculation  by  con- 
tinuity from  deep  tuberculous  foci;  (3)  inoculation  by  way  of  the  lym- 
phatics or  the  veins  passing  through  a  tuberculous  focus  more  or  less 
remote;  (4)  infection  of  hematic  origin;  (5)  infection  by  inheritance ;  the 
first  two  being  probably,  as  I  believe  myself,  the  usual  methods.     Bes- 
nier,  quoted  by  Leloir,  holds  the  view  that  the  tuberculous  ulcer  of 
phthisical  patients  is  secondary  to  general  infection,  while  lupus  and 
tuberculosis  verrucosa  cutis  are  the  result  of  external  inoculation.  ' 

It  is  doubtless  probable  that  weakened  tissue  and  regions  disposed 
to  circulatory  disturbance  show  less  resistance  to  invasion.  As  in  lupus 
erythematosus,  the  "flushing"  parts,  as  the  cheeks,  nose,  ears,  etc., 
and  dependent  situations,  where  the  circulation  is  sluggish,  as  the  ex- 
tremities, and  regions  weakened  by  chilblains,  are  most  vulnerable. 
These  are,  it  is  true,  the  parts  which  are  most  exposed  to  injury  and  to 
inoculation.  Its  tendency  to  appear  primarily  at  the  site  of  injuries 
or  in  scar  (weakened)  tissue  has  also  been  noted,  both  by  Crocker  and 
Malcolm  Morris;  in  their  treatises  they  refer  to  this,  and  an  example  has 
been  lately  reported  by  Walsh,5  the  disease  making  its  appearance  some 
years  after  the  scars  had  been  produced.  Hutchinson6  is  disposed  to 
believe,  in  view  of  its  frequently  beginning  after  slight  injuries,  that  a 
stage  of  congestion  and  cell  effusion,  indistinguishable  from  common 
inflammation,  usually  precedes  for  a  short  period  the  characteristic 
growth.  The  arising  of  new  points  or  foci  beyond  the  main  patch  is 
doubtless  due,  as  suggested  by  this  writer,  to  the  bacilli  or  their  products 
spreading  either  in  the  perivascular  spaces  or  along  the  lymphatic  chan- 
nels. It  is  difficult,  however,  to  explain  the  varying  clinical  conditions 

1  Leredde  (Hallopeau  et  Leredde,  Traite  pratique  de  Dermatologie,  p.  468). 

2  Meneau  and  Freche,  "Origine^nasale  du  lupus  de  la  face,"  Annales,  1897,  p.  516. 

3  H.  E.  Jones,  in  an  analysis,  bearing  upon  this  point,  of  923  cases  of  lupus  vulgaris 
(Sequeira's  service,  Skin  and  Light  Department  of  London  Hospital),  Brit.  Jour. 
Derm.,  1907,  p.  305,  was  able  to  divide  them  into  the  following  six  groups:    (i)  47.3  per 
cent.,  arising  as  a  small  spot  on  face,  cheek,  or  neck,  including  a  few  arising  around  the 
margin  of  the  eyelids  and  on  the  auricle,  but  not  those  springing  from  tuberculous 
glands,  or  in  scars  of  gland  abscesses,  or  in  scars  left  from  the  removal  of  old  glands; 

(2)  28.9  per  cent.,  arising  on  the  nose  or  in  the  nostril;  (3)  11.4  per  cent.,  arising  sec- 
ondary to  tuberculous  glands,  either  in  the  scar  or  gland  abscesses;  (4)  1.8  per  cent., 
arising  from  mucous  membranes,  other  than  the  nasal,  chiefly  the  margins  of  the  lips; 
(5)  1.8  per  cent.,  arising  secondary  to  tuberculous  disease  of  the  bones;  (6)  8.5  per  cent., 
arising  in  miscellaneous  ways  and  on  various  parts  of  the  body,  and  not,  as  far  as 
ascertained,  secondary  to  tuberculous  diseases  of  bone;  also  some,  presumably  a  general 
infection,  in  these  cases,  arising  after  the  exanthemata  or  lowering  illnesses,  with  mul- 
tiple lesions  on  various  parts  of  the  body.     Philippson,  in  his  recent  valuable  little  book 
on  lupus  ("Der  Lupus,  Seine  Pathologic,  Therapie,  Prophylaxe,  Julius  Springer,"  Ber- 
lin, 1911 — translated  from  Italian  MSS.  by  Juliusberg),  states  that  in  135  cases  the  in- 
fection was  primary  in  the  skin  in  42  cases,  secondary  to  surgical  tuberculosis  in  53 
cases,  secondary  to  nasal  tuberculosis  in  26  cases,  and  haematogenous  in  14  cases. 

4  Leloir,  Brit.  Jour.  Derm.,  1894,  p.  298. 

5  Walsh,  "A  Case  of  Lupus  in  Symmetrical  Seton  Scars,"  Brit.  Jour.  Derm.,  1894, 

P-  365- 

*  Hutchinson,  Brit.  Med.  Jour.,  Jan.  7,  14,  and  21,  1888. 


734 


NEW  GROWTHS 


found  in  cutaneous  tuberculosis,  but  the  individual  nutrition,  resisting 
power,  and  possibly  virulence  of  the  bacillus  may  be  of  some  importance. 
A  striking  fact,  however,  is  that  in  most  instances  there  is  but  a  single 
type  in  the  individual  case,  distinct  and  clean-cut  throughout,  only 
occasional  cases  being  observed  in  which  several  of  the  manifestations 
are  present  in  the  same  patient;  and  according  to  my  own  observations, 
this  latter  seldom  occurs  so  primarily.1  So  distinctive  are  these  types 
usually  that  the  possibility  has  often  suggested  itself  that,  after  all, 
we  may  be  dealing  with  several  varieties  of  bacillus,  apparently  mor- 
phologically and  biologically  the  same,  according  to  our  present  methods, 
but  which  future  investigations  may  lead  to  differentiation. 

Leloir  and  Tavernier's2  opinion  as  to  the  forms  or  certain  phases  of 
lupus  seems  to  me  to  offer  a  partial  explanation  of  these  cases — that 
it  is  due  to  the  combined  action  of  the  bacillus  of  Koch  and  suppurative 
agents.  They  believe  that  there  are  two  microbic  processes — (i)  neo- 
plastic,  due  to  the  irritation  of  tubercle  bacillus,  and  (2)  suppurative, 
due  to  the  staphylococcus  aureus,  the  latter,  determining  the  presence 
or  absence  of  the  ulcerative  feature,  not  being  found  in  the  non-ulcerative 
form.  It  is  not  improbable  that  the  latter,  and  doubtless  other  infective 
factors,  added  to  an  area  of  tuberculosis  cutis  in  a  subject  in  tropical 
countries,  may  lead  to  destructive  and  persistent  ulcerations,  and  furnish 
some  examples  of  the  so-called  "tropical  ulcer." 

In  lupus  the  bacilli  are  seen  in  extremely  scant  numbers,  sometimes 
scarcely  to  be  found,  in  others  not  more  than  a  single  bacillus  in  a  cell 
(Cornil  and  Leloir).  It  is  possible  that  the  bacilli  may  undergo  rapid 
destruction,  or  that  the  morbid  action  results  from  their  products  or 
toxins.  It  may  be  also,  as  Much's  investigations3  indicate,  that  there 
may  be  other  elements  of  tubercle  organisms  besides  the  ordinary  bacil- 
lus, which  so  far  have  escaped  the  observation  of  investigators.  In  other 
forms  of  cutaneous  tuberculosis  the  bacilli  are  often  found  in  greater 
abundance,  and  this  is  especially  so  in  the  more  acute  lesions — as,  for 
instance,  in  the  type  described  as  tuberculosis  ulcerosa. 

The  pathologic  histology  of  cutaneous  tuberculosis,  more  especially 
lupus  vulgaris,  has  been  studied  by  numerous  investigators  (Virchow, 
Auspitz,  Lang,  Kaposi,  Friedlander,  Thin,  Jarisch,  Leloir,  Unna,  Bowen, 
and  others) ,  whose  findings  and  interpretations  in  the  main  and  essential 
points  coincide.  Bowen,4  a  careful  and  well-known  dermatologist,  has 
given  us  an  admirable  and  terse  review  and  summary,  based  upon  the 
work  of  others  and  his  own  observations,  and  from  which  I  shall  largely 
quote  verbatim. 

The  disease  has  its  starting-point  in  the  corium,  affecting  primarily 

1  Hoffman  reports  (Miinchener  Med.  Wochenschr.,  1909,  No.  35)  an  interesting  case 
of  associated  types — multiple  verrucous  cutaneous  tuberculosis  with  generalized  "fol- 
liclis"  and  transition  forms. 

2  Leloir  and  Tavernier,  Jour.  mat.  cutan.,  Oct.,  1891,  p.  543. 

3  The  interesting  investigations  by  Zieler,  Much,  Kriiger,  Friedlander  and  others 
concerning  the  toxins  and  other  forms  of  organisms  (Much's  organisms),  while  not 
conclusive,  may  tend  to  clear  up  some  of  the  obscurity  surrounding  the  etiology  of  the 
tuberculides — see  under  "tuberculosis  cutis"  for  brief  notice  and  references. 

4  Bowen,  "  The  Pathology  of   Cutaneous  Tuberculosis,"  Boston  Med.  and  Surg. 
Jour..  Nov.  12,  1891,  p.  516;  and  Morrow's  System,  vol.  iii  (Dermatology),  p.  535. 


TUBERCULOSIS  CUTIS 


735 


the  lower  portions,  progressing  upward  by  extension  of  the  foci  of  disease, 
and  causing,  in  most  instances,  secondary  and  non-specific  alterations 
of  the  epithelial  elements.  The  first  appearance  of  the  lupus  tissue  is 
found  to  be  an  accumulation  of  cells,  situated  about  the  capillaries  and 
lymph-channels,  in  many  cases  representing  a  growth  of  the  adventitia 
of  these  vessels,  and  constituting  the  primary  nodule  or  point  of  infiltra- 
tion— of  so-called  granulation  tissue — made  up  of  the  peculiar  cell- 
formations  more  or  less  characteristic  of  tuberculous  processes:  small 
round  cells,  found  abundantly  at  the  periphery  of  the  nodule;  larger, 
epithelioid  cells,  with  clear  nucleus,  and  the  so-called  giant-cells,  with 
homogeneous  center  and  peripherally  arranged  nuclei.  The  epithelioid 
cells  are  fewer  in  number,  and  the  giant-cells  in  larger  representation 
than  is  observed  in  the  classic  tubercle  of  tuberculosis;  there  are,  more- 
over, more  vascularity  and  a  greater  formation  of  connective  tissue. 
Unna  believes  that  many  of  the  small  round  cells  at  the  periphery  of  the 


Fig.  168. — Lupus  vulgaris  section  (low  power):  e,  Epidermis;  c,  c,  c,  corium,  infil- 
trated with  the  tuberculous  neoplasm;  g,  g,  Langhans'  giant-cells  (courtesy  of  Dr.  J.  T. 
Bowen). 

lupus  nodule  are  not  leukocytes,  but  early  derivatives  of  the  connective- 
tissue  cells;  he  regards  these  as  identical  with  the  "plasma  cells"  of  Wal- 
deyer,  and  distinct  from  Ehrlich's  mast-cells.  He  has  named  these  cells 
plasma  cells,  and  holds  that  they  are  the  first  appearances  in  various 
chronic  inflammatory  and  infectious  processes.  This  view  is  not,  how- 
ever, generally  accepted.  It  would  seem  probable,  as  Bowen  states, 
that  the  fixed  tissue-cells  are,  at  least  in  the  main,  the  parents  of  the 
epithelioid  and  giant-cell  formations.  This  giant-cell,  when  discovered 
in  lupus  nodules  by  Friedlander,  was,  with  cheesy  degeneration  of  the 
nodule,  thought  to  be  characteristic  of  tuberculous  lesions,  but  it  is  now 
known  to  be  present  in  other  pathologic  processes,  notably  in  the  gum- 
matous  and  small  papular  syphilitic  lesions;  still  its  presence,  especially 
when  considered  in  connection  with  the  other  histologic  features,  and 
with  their  formation  and  development,  is  of  special  significance.  The 
feature  that  is  absolutely  pathognomonic,  however,  is  the  bacillus,  which 
is  constantly  present,  though  sometimes  sparingly. 


736 


NEW   GROWTHS 


The  next  stage  in  the  history  of  the  lupus  nodule  Is  the  degeneration 
of  the  newly  formed  cells  and  of  the  fibrillary  tissue.  The  cells  lying 
in  the  center  of  the  nodule  are  the  first  to  be  affected,  their  protoplasm 
becomes  homogeneous,  while  the  nuclei  lose  to  a  certain  extent  their 
susceptibility  to  staining.  Following  Weigert,  the  cells  in  lupus,  as  in 
internal  tuberculosis,  are  regarded  as  undergoing  a  coagulation  necrosis, 
although  this  view  is  opposed  by  Unna.  At  all  events  the  tuberculous 
elements  undergo  necrotic  degeneration  in  consequence  of  the  toxic 
influence  of  the  bacilli;  owing  to  the  small  numbers  of  the  latter  it  is 
of  slow  progress.  Together  with  this  degeneration  in  the  epithelioid 
cells  there  is  also  a  regenerative  process — the  cells  are  capable  of  prolifera- 


Fig.  169.— Lupus  vulgaris  section  (high  power):  g,  g,  g,  Langhans'  giant-cells;  e,  e,  e, 
epithelioid  cells;  r,  r,  small  round  cells  (courtesy  of  Dr.  J.  T.  Bowen). 

tion  when  not  affected  by  the  virus  to  the  extent  of  advanced  degenera- 
tion, and  may  finally  become  converted  into  connective  tissue.  In  this 
manner  is  produced  the  lupoid  scar  tissue,  which,  however,  Unna  con- 
siders distinct  from  ordinary  scar  tissue;  inasmuch  as  there  is  never  a 
reproduction  of  elastic  fibers,  the  connective  tissue  is  never  arranged 
in  intersecting  bundles,  but  placed  horizontally  to  the  surface,  and  it 
contains  numerous  large  "cell  spindles"  rich  in  protoplasm.  If  this 
regenerative  connective-tissue  process  is  excessive,  the  hypertrophic  or 
elephantiasic  feature  of  the  disease  sometimes  observed  results.  Pro- 
liferation of  the  epithelial  elements  is  also  at  times  noted,  which  Bowen 
considers  an  accidental  and  secondary  process;  the  interpapillary  down- 
growths  deep  into  the  corium,  with  the  outgrowth  of  the  papillae,  explain 


TUBERCULOSIS  CUTIS 


737 


the  papillomatous  forms.  Lang  also  pointed  out  the  occasional  prolifera- 
tion of  the  glandulat  elements. 

When  the  tuberculous  infiltration  of  the  corium  reaches  a  certain 
grade  of  intensity  and  the  overlying  epidermis  is  stretched  and  thinned, 
a  fracture  of  the  latter  frequently  ensues,  and  the  disease  foci  are  exposed 
and  ulcerations  result.  In  such  instances,  as  noted  by  Leloir  and  Taver- 
nier,  there  is  probably,  frequently  at  least,  an  added  septic  process,  due 
to  the  presence  of  pus-cocci. 

In  the  lesions  of  tuberculosis  ulcerosa  (miliary  tuberculosis  of  the 
skin),  as  Bowen  states,  the  cutis  is  found  to  be  filled  to  a  considerable 
depth  with  foci  of  small  round  cells,  with  occasional  epithelioid  and  giant- 
cells.  In  the  center  of  these  foci  the  necrosis  has  progressed  rapidly, 


Fig.  170. — Tuberculosis  verrucosa  section:  h,  Hypertrophied  horny  layer,  dipping 
down  into  the  corium;  p,  epithelial  downgrowths,  with  enlarged  papillae  between  them; 
g,  giant-cells;  e,  enlarged  papillae  (courtesy  of  Dr.  J.  T.  Bowen). 

so  that  upon  macroscopic  examination  the  appearances  of  softening  and 
cheesy  degeneration  are  apparent.  The  tubercles  often,  by  their  coali- 
tion, form  masses  of  softened  and  necrotic  tissue,  in  which  the  evidences 
of  unaltered  granulation  tissue  can  be  found  only  in  the  outlying  parts. 
In  the  cases  examined  by  Bowen  the  bacilli  were  present  in  large  numbers, 
in  one  instance  every  field  containing  enormous  masses,  according,  as  he 
states,  with  the  observations  of  Riehl,  Doutrelepont,  and  others. 

In  scrofuloderma,  according  to  Bowen,  the  anatomic  characters 
differ  in  no  essential  way  from  tuberculosis  of  the  internal  organs;  granu- 
lation tissue  of  small  round  and  epithelioid  cells,  with  a  moderate  quan- 
tity of  giant-cells,  has  its  seat  in  the  subcutaneous  tissue,  undergoes 
degeneration,  and  may  break  through  the  thinned  and  tense  layers  of 
the  epidermis  above,  giving  rise  to  the  characteristic  ulcer  of  this  type. 

47 


738  NEW  GROWTHS 

The  degeneration  is,  as  a  rule,  much  farther  advanced  than  in  lupus, 
large  areas  of  necrotic,  softened  tissue  being  usually  visible  under  the 
microscope.  The  bacilli  in  some  instances  are  scanty,  in  others  numer- 
ous, and  generally  much  more  so  than  in  lupus,  and  in  less  abundance 
than  in  tuberculosis  ulcerosa. 

In  tuberculosis  verrucosa  the  findings  of  Riehl,  Paltauf,  Bowen, 
and  others  practically  agree.  Bowen  states  that  the  chief  anatomic 
characteristic  of  this  form,  in  distinction  from  the  papillary  growths 
of  lupus,  is  the  situation  of  the  tuberculous  neoplasm;  while  in  the  latter 
the  foci  of  granulation  tissue  lie  in  the  lower  and  middle  portions  of  the 
corium,  in  tuberculosis  verrucosa  they  are  quite  constantly  found  in  the 
upper  papillary  layers,  usually  in  the  papillae  themselves,  and  this  cor- 
responds to  the  observations  of  Riehl  and  Paltauf.  Moreover,  the 
papillary  outgrowth  is  an  early  feature  of  the  process,  appearing  at  the 
very  beginning:  in  lupus,  on  the  other  hand,  it  is  met  with  at  a  later 
period,  and,  as  a  rule,  only  when  ulceration  has  taken  place.  As  Bowen 
adds,  many  transitional  forms  occur,  and  it  may  be  difficult,  in  some  in- 
stances, from  microscopic  examinations  alone,  to  determine  which  of 
these  two  clinical  varieties  is  represented.  A  characteristic  of  the  typical 
process,  however,  in  most  cases  distinguishing  it  from  other  forms,  is 
the  occurrence  of  foci  of  acute  inflammation  immediately  below  the  rete, 
and  the  formation  of  miliary  abscesses,  a  secondary  phenomenon  due  to 
the  invasion  of  micrococci;  in  some  cases,  however,  Bowen  has  noted 
this  secondary  inflammation  to  be  very  slight  or  entirely  wanting. 
Bacilli  are  found  readily  in  some  instances;  in  others  a  good  deal  of 
careful  search  is  necessary;  and  in  this  respect,  while  some  observers 
have  noted  the  contrary,  Bowen,  in  his  examinations,  was  not  able  to 
demonstrate  a  striking  divergence  from  lupus. 

Diagnosis  of  Tuberculosis  Cutis.— The  diagnosis  of  the  types 
of  tuberculosis  cutis  other  than  lupus  vulgaris  has  been  sufficiently 
touched  upon;  these  remarks,  therefore,  concern  the  latter,  the  form 
with  which  practitioners  are  most  likely  to  come  in  contact.  The 
peculiar  yellowish-red  infiltrated  macule,  point,  or  tubercle  of  soft  con- 
sistence, readily  disturbed  by  slight  pressure  with  a  probe  or  blunt 
instrument,  is  an  important  characteristic  of  this  type,  and  in  itself 
often  sufficient  for  the  diagnosis.  The  diseases  of  the  skin  with  which 
lupus  vulgaris  is  sometimes  confounded  are  epithelioma,  more  espe- 
cially of  the  superficial  or  rodent  ulcer  type,  and  syphilis;  its  confusion 
with  lupus  erythematosus,  acne  rosacea,  and  eczema  is  much  less  prob- 
able. The  difference  between  this  disease  and  blastomycosis  will  be 
referred  to  under  the  latter. 

As  to  epithelioma,  it  differs  from  lupus  in  the  following  particulars: 
it  is  usually  single,  begins  commonly  late  in  life,  has  a  peculiar  pearly, 
roll-like,  or  markedly  infiltrated  border;  it  frequently  arises  from  a  pre- 
existing mole  or  wart,  or  from  a  circumscribed,  long-continued,  scurfy 
or  crusted  spot;  the  ulceration  begins  almost  invariably  at  one  point, 
and  is  often  somewhat  deep,  with  frequently,  and  always  sooner  or  later, 
considerable  loss  of  substance;  its  course  in  some  cases  is  slow,  but  in 
others,  after  the  disease  is  once  established,  is  frequently  quite  rapid. 


TUBERCULOSIS  CUTIS 


739 


The  tubercular  syphiloderm  in  many  cases  bears  considerable  re- 
semblance to  lupus— in  fact,  these  two  diseases  are  often  strikingly 
similar  in  their  symptomatology,  and  occasionally  even  the  trained 
specialist  may  for  a  time  be  puzzled.1  I  find  that  with  general  prac- 
titioners the  admitted  respectability  of  a  patient,  especially  if  a  woman, 
is  permitted  to  have  too  much  weight,  and  leads  often  to  an  erroneous 
diagnosis  of  lupus.  It  is  not  to  be  lost  sight  of,  however,  that  syphilis 
is  often  innocently  contracted— as,  for  example,  through  the  marital 
relation.  An  important  clinical  fact  bearing  upon  the  diagnosis  between 
these  two  diseases  is  that  lupus  vulgaris  is  in  this  country  comparatively 
rare,  and  that  the  physician  is  much  safer  and  almost  always  right  in 
considering  a  tubercular  eruption  with  atrophic  or  ulcerative  tendency 
appearing  in  adult  life  to  be  syphilitic  rather  than  that  of  lupus,  unless 
there  are  conclusive  reasons  for  considering  the  contrary;  and  in  a  sur- 
prisingly large  number  appropriate  treatment  will  confirm  the  tentative 
diagnosis  by  the  extremely  rapid  improvement  which  ensues.  Generally 
speaking,  however,  a  careful  study  of  the  symptoms  presenting  will 
render  a  purely  arbitrary  and  unscientific  method  unnecessary,  for  in 
almost  all  cases  there  are  sufficient  differences  which  will  serve  to  prevent 
mistakes.  The  common  site  of  lupus  is  the  face,  and  while  it  may  appear 
elsewhere  independently,  as  a  rule,  when  occurring  upon  other  parts,  it 
is  in  conjunction  with  the  .disease  upon  the  former  region.  The  tuber- 
cular syphiloderm,  on  the  other  hand,  occurs  upon  almost  any  part  in- 
dependently, although  it  cannot  be  denied  that  the  face  is  quite  a  fre- 
quent seat.  This  manifestation  of  syphilis  being  usually  a  late  one,  is, 
for  obvious  reasons,  more  commonly  observed  toward  middle  or  late 
life;  lupus,  in  most  instances,  has  its  start  in  childhood  and  early  adoles- 
cence, and  is  somewhat  rare  in  beginning  after  thirty  or  forty.  The  color 
of  the  syphilitic  eruption  is  a  darker  red,  more  of  a  coppery-red,  while 
that  of  lupus  is  more  of  a  yellowish-red  or  brownish-red  color.  The 
former  is  relatively  more  rapid  in  its  course,  and  in  a  few  years'  time  may 
cover  several  square  inches,  whereas  in  lupus  several  years  often  elapse 
before  more  than  a  silver-dollar-sized  area  is  covered.  In  syphilis  cres- 
centic  and  serpiginous  groupings,  crescentic  and  horse-shoe-shaped 
ulcerations  are  almost  invariable :  in  lupus  such  conditions  or  configura- 
tion are  uncommon.  The  ulcerations  of  syphilis  may  be  superficial 
or  deep,  those  of  lupus  almost  uniformly  shallow;  there  is  usually  a 
moderately  or  profusely  abundant  purulent  discharge  in  the  ulcerations 
of  the  former,  whereas  in  lupus  destruction  it  is,  as  a  rule,  scanty — some- 
times extremely  so.  In  the  former  disease  bone  may  become  involved 
in  the  destructive  process;  in  lupus  such  destructive  action  is  rarely  seen. 
In  lupus  the  cicatricial  formation  is  often  thick,  dense,  and  tough, 
whereas  in  syphilis  it  is  usually  soft  and,  when  compared  to  the  some- 
times preceding  extensive  ulceration,  insignificant. 

In  the  non-ulcerating  forms  of  lupus  and  tubercular  syphiloderm 
the  differentiation  is  often  fraught  with  greater  difficulty  than  in  the 
more  common  or  ulcerating  types.  Most  of  the  facts  pointed  out, 

1  Stelwagon,  "Remarks  on  the  Destructive  Skin  Diseases:  Epithelioma,  Lupus 
Vulgaris,  and  Syphilis,"  Amer.  Medicine,  1905,  vol.  ix,  p.  643. 


740  NEW  GROWTHS 

however,  are  also  of  service  here.  The  history  of  the  case  is  sometimes 
valuable:  in  lupus  not  infrequently  the  patient  comes  of  a  tuberculous 
family,  with  a  history  of  consumption  in  the  immediate  or  collateral 
branches;  sometimes  an  examination  of  the  patient  will  disclose  other 
evidences  of  a  scrofulous  character,  such  as  scars  of  a  cervical  adenitis, 
marks  of  a  keratitis,  or  even  tuberculous  involvement  of  the  lungs.  On 
the  other  hand,  in  syphilis,  upon  careful  inquiry  or  inspection,  evidences 
or  history  of  preceding  characteristic  phenomena  of  that  disease  may 
usually,  but  by  no  means  always,  be  elicited.  As  already  stated,  how- 
ever, it  must  be  admitted  that  in  rare  instances  the  several  differences 
mentioned  as  distinguishing  these  two  cutaneous  diseases  are  practically 
lacking,  or  sufficiently  so  as  to  make  a  positive  diagnosis  without  further 
observation  of  the  case  almost  impossible.  Nor  are  the  differences  as 
given  absolute,  as  exceptions  as  to  character,  course,  etc.,  are  encountered 
in  both  affections.  In  such  instances,  and,  in  fact,  in  all  except  those 
cases  in  which  the  diagnosis  can  be  made  without  difficulty  and  with 
certainty,  the  general  physician  is  much  safer  in  withholding  an  opinion 
or  expressing  himself  guardedly,  and  in  the  meantime  treating  the  patient 
as  if  the  disease  were  of  syphilitic  origin.  When,  in  obscure  cases,  a 
positive  conclusion  is  urgent,  resort  may  be  had  to  the  tuberculin  and 
Wassermann  tests,  but  such  would  scarcely  be  necessary  if  a  skilled 
opinion  was  within  reach. 

Lupus  vulgaris  differs  from  lupUs  erythematosus  chiefly  in  the  pres- 
ence of  papules,  tubercles,  and  often  ulceration  and  tough  fibrous  scarring, 
all  of  which  are  wanting  in  this  latter  disease;  moreover,  the  former  is 
lacking  in  the  patulous  or  stuffed-up  gland-ducts  and  the  firm  yellowish- 
gray  adherent  scales,  so  commonly  noted  in  lupus  erythematosus.  Lupus 
vulgaris  is  almost  always  deeper  seated.  Lupus  vulgaris  erythematoides 
of  Leloir  bears  a  close  resemblance,  but  here  also  the  deeper  infiltra- 
tion and  the  lupus-infiltrated  points  or  nodules  which  can  generally  be 
recognized  when  the  skin  is  put  upon  the  stretch  serve  to  distinguish  it 
from  lupus  erythematosus. 

Acne  rosacea  merely  exhibits  an  apparent  similarity,  but  the  dilated 
vessels,  acne  lesions,  and  history  and  course,  with  absence  of  any  tendency 
to  destructive  action,  are  sufficient  to  prevent  error.  Both  scaly  eczema, 
when  rather  sharply  circumscribed,  and  psoriasis  patches  bear  some  like- 
ness to  non-ulcerative  or  exfoliative  lupus,  but  the  infiltration  of  the 
latter  and  its  scant  scaliness,  its  slow,  sluggish  course,  and  persistence 
in  the  same  spots  will  usually  prevent  all  possibility  of  such  a  mistake. 
Moreover,  the  itchiness  of  eczema  and  its  occasionally  frequently  pre- 
senting a  disposition  to  gummy  exudation,  and  the  more  or  less  general 
distribution  of  psoriasis,  are  further  points. 

In  addition  to  the  objective  clinical  characters,  histologic  features, 
and  history,  the  usual  determining  diagnostic  factors  in  lupus  vulgaris 
and  the  other  types  of  tuberculosis  of  the  skin,  in  obscure  cases  recourse 
may  be  had  to  a  trial  injection  of  tuberculin  (combined  systemic  and 
local  reaction  test),  or  to  the  so-called  local  reaction  tuberculin  tests,1 

|  These  are  the  ophthalmic  (Calmette,  Wolf- Eisner)  instillation  test,  consisting  of 
the  instillation  of  i  drop  of  a  £  to  i  per  cent,  tuberculin  solution  in  the  eye,  and  the 


TUBERCULOSIS  CUTIS  741 

and  lastly,  in  extremely  obscure  cases,  to  experimental  animal  inocula- 
tion. A  positive  result  with  these  tests  is  a  fairly  reliable  indication 
of  the  tuberculous  character  of  the  disease,  but  is  not  absolutely  so.1 
Fortunately,  in  almost  all  cases,  a  study  of  the  local  conditions  alone  will 
usually  be  found  sufficient  to  reach  a  positive  diagnosis. 

Prognosis  of  Tuberculosis  Cutis.— As  to  the  prognosis  of 
lupus  vulgaris,  much  depends  upon  the  age  of  the  subject,  duration 
of  the  disease,  extent  of  the  territory  involved,  and  the  thorough  co- 
operation of  the  patient.  It  is  always  a  chronic  disease,  usually  ex- 
ceedingly rebellious  to  treatment,  and  one  that  calls  for  a  guarded 
opinion ;  moreover,  relapses,  sometimes  due  to  inefficient  or  insufficiently 
radical  treatment,  are  not  uncommon.  According  to  my  experience, 
however,  small  beginning  areas  of  the  disease,  especially  in  the  young, 
are  usually  readily  curable,  and,  as  a  rule,  show  no  tendency  to  relapse 
if  treatment  has  been  sufficiently  thorough.  The  same  holds  true  with 
small  areas  in  the  adult;  and  in  areas  of  moderate  size,  more  especially 
in  American  born,  permanent  results  are  not  unusual,  although  not  infre- 
quently one  or  two  relapses  may  occur  before  this  favorable  termination 
is  reached.  In  cases  of  considerable  extent,  if  treatment  is  persisted  in, 
the  final  result  is  often  satisfactory,  even  though  outcroppings  of  tuber- 
cles in  the  scar  tissue,  or  at  the  edge  of  the  patch,  as  generally  observed, 
recur  several  times  and  call  for  further  measures.  One  might  feel  hopeful 
of  more  extensive  cases  if  the  patient's  continued  co-operation  were  given, 
but  in  many  such  instances  the  repeated  disappointments  experienced 
from  the  recurrent  evidences  of  the  disease  often  lead  to  a  total  aban- 
donment of  medical  aid.  It  is  true  that  in  such  cases  the  prognosis 
must  be  guarded,  for  even  with  well-directed  and  persistent  treatment 
the  malady  is  frequently  rebellious  and  recurrent;  and  occasionally, 
too,  when  the  area  involved  is  comparatively  small,  it  is  likewise  noted 
to  be  extremely  obstinate.  Fortunately,  lupus  does  not  thrive  as  well 

von  Pirquet,  Lignieres,  and  Moro  tests.  The  von  Pirquet  test  consists  of  scarifying 
into  the  skin,  as  in  vaccination,  a  drop  or  so  of  the  tuberculin  solution;  the  Lignieres 
test,  rubbing  in  the  solution  on  a  closely  shaved  skin  area;  and  the  Moro  test,  rubbing 
into  a  small  area  of  thoroughly  cleansed,  thin  and  unbrcken  skin  i  or  2  grains  of  a 
tuberculin  ointment,  made  up  of  equal  parts  of  Koch's  old  tuberculin  and  anhydrous 
lanolin.  If  in  the  eye  test  a  limited  or  general  conjunctival  redness  or  inflammatory 
reaction  of  from  mild  to  severe  grade  ensues  in  from  a  few  hours  to  eight  or  ten  hours, 
abating  in  twenty-four  to  seventy-two  hours,  it  is  considered  a  positive  indication; 
this  test  should  not  be  made  if  there  is  any  disease  of  the  eye  or  conjunctiva;  the  litera- 
ture contains  some  recorded  accidents  with  it.  On  this  account,  in  fact,  the  eye  test 
has  been  largely  given  up. 

In  the  true  skin  tests  (Lignieres,  Moro)  a  positive  reaction,  erythematous  and  papu- 
lar, in  the  area  of  application,  following  within  thirty-six  hours,  and  then  disappearing 
slowly  in  from  five  to  ten  days  or  so,  is  also  considered  strongly  suggestive.  (Trimble, 
N.  Y.  Med.  Jour.,  May  22,  1909,  gives  an  account  of  some  experimental  trials  with  the 
Moro  inunction  test,  and  Wilson,  Jour.  Amer.  Med.  Assoc.,  1908,  vol.  li,  p.  1836,  gives 
brief  review  (with  references)  and  experimental  trials  of  the  eye  instillation  method.) 
Kingsbury,  Jour.  Cutan.  Dis.,  1909,  p.  78,  reports  favorable  observations  with  the 
latter  method. 

1  Indeed,  far  from  it  if  the  observations  by  Augagneur  (These  de  Lyon,  1910,  p. 
103 — abs.  by  Fernet,  Brit.  Jour.  Derm.,  1911,  p.  87)  are  correct — that  syphilitics,  clin- 
ically non-tuberculous,  react  to  the  tuberculin  tests  in  as  great  a  percentage  of  cases 
as  tuberculous  subjects.  This  seems  to  be  corroborative  of  the  earlier  similar  con- 
clusions reached  by  Nicolas,  Favre,  and  Charlet  that  these  tests  did  not  seem  to  differ- 
entiate between  syphilis  and  tuberculosis. 


742 


NEW  GROWTHS 


with  us  as  elsewhere,  and  when  it  does  occur,  it  is  noted  to  be,  as  a  rule, 
less  virulent  and  progressive,  and  generally  yields  much  more  readily 
to  therapeutic  measures  than  is  observed  in  those  countries  where  the 
disease  is  more  common. 

The  danger  of  general  infection  is  not  to  be  forgotten,  although  in 
most  cases  the  health  usually  remains  good  and  uninvolved;  on  the  other 
hand,  death  from  tuberculosis  of  the  lungs  or  general  tuberculosis  has 
been,  as  already  stated,  noted  in  some  instances,  probably  more  fre- 
quently than  is  commonly  believed.  The  statements  under  etiology  as 
to  the  frequency  of  the  systemic  tuberculous  association  are  convincing 
on  this  point,  and  to  these  may  be  added  the  observations  of  Besnier 
and  Leloir;1  the  former  noted  that  21  per  cent,  of  his  lupus  patients  died 
of  consumption,  and  the  latter  refers  to  a  number  of  instances  in  his  own 
experience  in  which  pulmonary  tuberculosis  followed  lupus  through  the 
medium  of  the  lymphatic  system;  Forchhammer's  record  is  likewise 
startling.2 

The  prognosis  as  to  the  other  forms  of  cutaneous  tuberculosis  has 
been  already  incidentally  touched  upon.  As  a  rule,  they  are,  except- 
ing the  disseminated  type,  more  amenable  to  treatment,  unless  very 
extensive.  The  same  possibility,  however,  to  general  infection  exists. 
The  prognosis  of  miliary  tuberculosis  of  the  skin  is,  as  stated  in  its  con- 
sideration, always  grave. 

Treatment  of  Tuberculosis  Cutis — While  the  remarks  as  to 
treatment  are  more  especially  directed  to  that  of  lupus  vulgaris,  they 
apply  also  to  the  other  forms,  modified,  of  course,  to  suit  the  different 
conditions  presenting.  The  most  expedient  methods  for  the  latter  have 
been  briefly  referred  to  in  connection  with  the  description  of  these  other 
varieties. 

The  rational  management  of  lupus  keeps  in  view  the  supervision  of 
the  patient's  general  health,  together  with  the  employment  of  local 
measures  having  as  an  object  destruction  or  removal  of  the  diseased 
tissue.  As  a  rule,  but  little  stress  is  placed  by  most  writers  upon  con- 
stitutional treatment,  but  in  accepting  the  tubercle  bacillus  as  the  essen- 
tial factor  of  the  disease,  with  the  frequent  association  of  allied  and 
systemic  tuberculous  affections  observed,  the  importance  of  general 
measures  (not  necessarily  medicinal)  cannot,  in  my  judgment,  be  ignored 
if  the  best  results  are  to  be  attained.  In  short,  the  patient,  as  well  as 
his  cutaneous  disease,  must  receive  attention:  good,  nutritious  food, 
fresh  air,  outdoor  exercise,  and  plenty  of  sunshine,  with,  in  many  cases, 
the  administration  of  such  remedies  as  cod-liver  oil,  hypophosphites, 
iron,  quinin,  and  other  alterative  tonics.  Judged  by  my  own  experi- 
ence, cod-liver  oil  in  small  or  moderate  doses  long  continued  is  the  most 
valuable  of  the  internal  remedies,  and  has  in  some  cases  a  material  in- 
fluence in  limiting  the  spreading  or  active  tendency  of  the  disease,  and 

1  Besnier,  "Le  lupus et  son  traitement,"  Annales,  1883,  p.  377;  Leloir,  "Les  rapports 
du  lupus  avec  tuberculose,"  ibid.,  1886,  p.  328. 

2  Forchhammer,  Archiv,  1908,  vol.  xcii,  p.  3  (with  review  of  subject),  states  that  of 
IIQO  lupus  patients  treated  at  the  Finsen  Institute  during  ten  years,  whose  history 
could  be  followed,  143  had  died,  and  of  these  81  died  of  tuberculous  diseases;  58  of  these 
of  tuberculosis  of  the  lungs. 


TUBERCULOSIS   CUTIS  743 

in  aiding  toward  making  the  results  from  local  treatment  more  perma- 
nently favorable;  in  other  words,  rendering  the  soil  a  less  favorable  hab- 
itat for  the  bacillus.  The  hypophosphites  have  also  proved  of  service. 

Other  remedies  have  likewise  been  credited  with  favorable  effect. 
The  syrup  of  the  iodid  of  iron  is  one  which  has  had  some  support, 
and  Liveing  commended  3  to  5  minims  (0.18-0.3)  of  tincture  of  iodin, 
sometimes  associated  with  a  few  drops  of  Fowler's  solution.  Duhring1 
believes  that  potassium  iodid  favorably  influences  some  cases,  and  also 
speaks  well  of  iodin  and  phosphorus,  in  combination  with  cod-liver  oil. 
Lately  Philippson2  stated  that  the  internal  use  of  parafluorbenzoate  of 
sodium,  in  7-  or  8-grain  doses  (0.465-0.533)  three  times  daily,  acts 
favorably;  and  Stepp3  commends  fluoroform  (CHF13),  a  gaseous  sub- 
stance taken  up  by  water  to  the  extent  of  2.8  of  its  volume,  and  of  this 
solution  the  dose  is  i  to  4  drams  (4.-! 6.),  four  or  five  times  daily.  Sev- 
eral observers — Bramwell  and  Taylor4  and  a  few  others — have  seen  a 
favorable  influence  exerted  by  thyroid  feeding  or  thyroidin.  Taylor 
does  not  consider  it  safe  for  outpatients,  inasmuch  as  to  obtain  satis- 
factory influence  acute  thyroidism  must  be  produced;  and  he  further 
adds  that  it  is  only  likely  to  benefit  those  in  which  there  is  much  chronic 
inflammation  marking  the  disease,  or  where  ulceration  is  taking  place. 
According  to  Pringle,5  in  cases  of  lupus  in  which  the  hyperemic  or  in- 
flammatory element  is  marked,  thyroid  feeding  had  given  results  little 
short  of  marvelous  in  many  instances  under  his  observation  and  without 
necessarily  producing  the  disagreeable  phenomena  of  thyroidism. 

Tuberculin  injections,  which  at  one  time  aroused  the  hopes  of  the 
dermatologic  world,  have  been,  undeservedly  I  believe,  almost  wholly 
abandoned,  but  a  careful  review  of  the  earlier  experiences  and  recent 
observations  with  the  new  tuberculin  show  the  remedy  to  be  of  distinct 
value  in  many  cases,  although  its  use  requires  caution  and  care.  Many 
of  the  earlier  experiments  proved,  upon  the  whole,  of  distinct  benefit, 
but  the  unfavorable  reports  of  its  trial,  more  especially  in  St.  Louis 
Hospital,  Paris,  by  Besnier  and  Hallopeau,6  and  the  deaths  reported  as 
following  its  use  in  lupus, — i  by  Hallopeau  and  i  each  by  Jarisch,  Burck- 
hardt,  and  Blanc,7 — brought  it  rapidly  into  disrepute.  In  the  past  few 
years,  however,  there  has  been  a  slight  rebound,  the  new  tuberculin 
being  employed,  and  apparently  without  injurious  results,  and  with 
alleged  favorable  influence  upon  the  disease  (Bukovsky,  Napp  and 
Grouven,  Krzysztalowicz,  Ravogli,  G.  H.  Fox,  Lustgarten,  Wright,  and 
others).8  An  impartial  judgment  of  the  facts  at  hand  would  seem  to  me 

1  Duhring,  Diseases  of  the  Skin,  third  edit.,  1882,  p.  481. 

2  Philippson,  Dermatolog.  Zeitschr.,  1899,  No.  3. 

3  Stepp,  abs.  in  Monatshefte,  1899,  vol.  xxix,  p.  551. 

4  Bramwell,  Brit.  Jour.  Derm.,  1894,  p.  345;  Stopford  Taylor,  ibid.,  p.  345. 
6  Pringle,  ibid.,  1899,  p.  433. 

6  Full  abs.  in  Brocq's  Paris  letter,  Jour.  Cutan.  Dis.,  1891,  p.  191. 

7  These  3  cases  are  cited  by  Piffard  (with  brief  abstracts  and  references),  ibid., 
1891,  p.  172. 

8  It  has  recently  been  tried  by  the  following  observers,  and  in  the  number  and  vari- 
ety of  cases  stated,  usually  with  favorable,  but  variable,  influence:  Bukovsky  (Jan- 
ovsky's  clinic),  Archiv,  1898,  vol.  xlvi,  p.  223  (15  cases  lupus,  2  of  scrofuloderm,  and 
2  of  tuberculosa  verrucosa  cutis);  Napp  and  Grouven  (Doutrelepont's  clinic),  ibid., 
p.  399,  with  bibliography  (39  cases,  of  which  36  were  of  lupus,  2  tuberculosis  cutis, 


744  NEW  GROWTHS 

to  justify,  in  recurrent  cases  which  had  proved  rebellious  to  other  means, 
the  use  of  the  new  tuberculin  (tuberculin  R. — TR.),  not  with  the  belief 
of  its  being  curative  in  itself,  but  as  a  substantial  aid  in  rendering  the 
local  measures  more  effectual.  Most  observers,  among  whom  those  above 
named,  who  have  largely  employed  it,  do  not  claim  that  it  cures,  but 
accord  it  value  as  an  adjuvant.  The  first  dose  should  be  small  and  subse- 
quent dosage  and  frequency  regulated  by  its  action  or  by  the  opsonic 
index  (Wright)  of  the  blood;  overdosage  and  too  great  frequency,  it  is 
to  be  noted,  would  lessen  the  opsonic  power,  or  phagocytosis,  and 
probably  do  damage,  and  are  therefore  to  be  guarded  against.1 

Injections  of  thiosinamin  have  been  recommended  by  Hebra,  Jr., 
using  a  15  per  cent,  alcoholic  solution,  of  which  the  beginning  dose  is 
about  TTUv  (0.265)  increasing  to  Tfl.xv  (i.);  an  injection  is  administered 
every  two  or  three  days.  As  with  tuberculin,  it  is  to  be  looked  upon 
as  an  adjuvant  only,  and  should  be  combined  with  suitable  local  meas- 
ures. Calomel  injections  have  also  recently  had  some  support  as  aux- 
iliary treatment  of  value  (Asselbergs,  Du  Castel,  Brousse,  and  Tschle- 
now),2  an  injection  of  about  f  of  a  grain  (0.05)  in  i  c.c.  of  sterilized  oil 
being  administered,  usually  in  the  buttocks,  every  week  or  ten  days. 
Fournier3  is  inclined  to  consider  such  cases  of  syphilitic  nature,  and  that 
the  favorable  effect  are  explainable  upon  an  error  of  diagnosis. 

Local  Treatment. — The  Finsen  method  and  the  x-ra,y  are  playing 
an  important  part  in  certain  centers  in  the  local  treatment  of  this  disease, 
but  these  are,  for  various  reasons,  often  inconvenient  or  impracticable, 
and,  before  referring  to  them  specifically,  the  plans  long  in  vogue  and  still 
quite  generally  employed  will  be  described.  These  measures  can  be 
roughly  divided  into:  (i)  mild  and  stimulating;  (2)  destructive.  In 
almost  all  cases  the  area  of  apparent  disease  can  be  materially  reduced 

i  tuberculosis  of  tongue;  in  2,  serious  symptoms  of  collapse  without  recognizable 
reason);  Krzysztalowicz,  Wien.  med.  Wochenschr.,  1898,  pp.  59  and  108  (13  cases); 
G.  H.  Fox,  Jour.  Cutcm.  Dis.,  May,  1898,  p.  232;  Lustgarten,  ibid.:  Bussenius  and  Coss- 
mann,  Das  Tuberkulin  R. — seine  Wirkung  und  seine  Stellung  in  der  Therapieder  inneren 
und  dusseren  Tuberkulose,  Hirschwald,  Berlin,  1898;  Adrian,  Archiv,  1898,  vol.  xlv,  H. 
i  (in  one  of  his  cases,  lupus  of  the  face  complicated  with  chronic  nephritis,  dangerous 
symptoms  arose);  Van  Hoorn,  Deutsche  med.  Wochenschr.,  1898,  No.  27  (greatest 
improvement  between  the  first  dose  and  maximum  dose  (20  mg.) — above  that  failed  to 
influence  and  sometimes  was  damaging);  Forges,  Wien.  klin.  Wochenschr.,  1898,  p.  366 
(improvement  at  first);  Heron,  Brit.  Med.  Jour.,  July  9,  1898  (refers  to  5  successful 
cases  with  old  tuberculin,  and  i  case  with  new  tuberculin);  Starck,  Munchen.  med. 
Wochenschr.,  April  26,  1898  (3  cases— 2  cured,  i  unfavorable);  Taylor,  Brit.  Med.  Jour., 
July  9,  1898  (first  weeks  improvement,  later  stationary,  and  then  a  recrudescence); 
Ravogli  ("Tuberculin  in  Dermatology"),  Chicago  Clinic,  1897,  p.  143  (favorable  influ- 
ence; with  brief  review  of  the  subject  and  some  references).  See  also  recent  interesting 
paper  by  McCall  Anderson,  "A  Plea  for  the  More  General  Use  of  Tuberculin  by  the 
Profession,"  Brit.  Jour.  Derm.,  1905,  p.  317  (with  illustrations),  and  same  paper  in 
French  in  Revue  pratique,  1906,  p.  175;  R.  C.  Low,  "Tuberculin  in  Diagnosis  and  Treat- 
ment," Scottish  Med.  and  Surg.  Jour.,  May,  1905,  and  in  French  in  Revue  pratique, 
1906,  p.  100. 

1  For  further  remarks  on  this  method  and  literature  references,  see  "Opsonins," 
p.  108. 

2  Asselbergs,  Annales,  1898,  p.  10  (25  cases;  in  some  cases  slight  amelioration  only, 
in  others  marked  improvement,  and  in  others  complete  disappearance) ;  Du  Castel,  ibid., 
1898,  p.  674,  and  1899,  p.  527  (3  cases;  2  cases  improvement,  i  uninfluenced);  Brousse, 
Jour.  mal.  cutan.,  April,  1899,  p.  235  (i  case;   favorable  effect);  Tschlenow,  abs.-ref. 
in  Monatshefte,  1899,  vol.  xxix,  p.  549  (2  cases;  favorably  influenced). 

3  Fournier  ("Pseudo-lupus  syphilitique"),  Annales,  1896,  p.  854. 


TUBERCULOSIS  CUTIS 


745 


by  the  former,  partly  by  controlling  the  inflammatory  element  of  the 
malady,  and  in  some  by  a  possible  effect  upon  the  bacilli  and  their  prod- 
ucts or  upon  the  added  pyogenic  organisms.  The  mildly  antiseptic 
plans  are,  especially  in  the  crusted  and  ulcerative  forms,  in  accord  with 
the  well-based  views  of  Leloir  and  Tavernier,1  referred  to.  Leloir  was, 
therefore,  accustomed  to  direct  his  whole  treatment  primarily  against 
the  staphylococcus  aureus  as  a  preliminary  to  a  final  more  active  plan 
against  the  neoplastic  growth  due  to  the  bacillus.  If  the  disease  is  at  all 
extensive  or  attended  with  destructive  changes,  the  use  primarily  of  the 
mild  or  non-destructive  applications  is  to  be  advised.  When  the 
hyperemic  element  is  pronounced  and  there  is  any  irritability,  the  fre- 
quent or  constant  application  of  the  calamin-zinc-oxid  lotion  can  often 
be  used  temporarily  with  considerable  apparent  benefit.  The  continu- 
ous application  of  a  good  diachylon  ointment  is  also  found  valuable  at 
this  time.  One  of  the  best  of  the  milder  preparations,  however,  is  an 
ointment  of  oleate  of  mercury,  which,  in  a  few  instances,  proved  useful 
in  my  hands.2  Brooke's3  formula  is  the  most  satisfactory:  1$.  Oleate  of 
mercury,  5  per  cent.,  oj  (32.);  powdered  zinc  oxid  and  powdered  starch, 
aa  5ij  (8.);  white  vaselin,  3iv  (16.);  salicylic  acid,  gr.  xx  (1.35);  ichthyol, 
ttlxx  (1.35).  This  can  be  colored  the  skin  tint  by  adding  10  to  30  grains 
(0.65-2.)  of  calamin  or  some  Armenian  bole.  If  the  surface  of  the  in- 
volved area  is  unbroken,  this  is  to  be  rubbed  in  for  several  minutes 
night  and  morning,  and,  when  possible,  also  spread  upon  lint  and  kept 
continuously  applied  as  a  plaster;  if  ulcerated,  the  latter  method  is  the 
only  feasible  one.  The  constant  application  of  mercurial  plaster  is  also 
of  value  in  many  cases.  It  is  possible  the  mercurial  preparation  has  a 
bactericidal  action,  as  Doutrelepont,4  and  later  White,5  had  already, 
from  clinical  results,  pointed  out  in  their  use  of  corrosive  sublimate 
applications.  White  employed  lotions  of  i  to  2  grains  (0.065-0.135)  to 
the  ounce  (32.),  and  an  ointment  of  the  same  strength;  the  former  he 
found  more  satisfactory  in  the  tubercular  and  all  closed  forms,  and  the 
latter  on  open  ulcerated  and  crusted  surfaces.  The  application  is  to  be 
made  twice  daily.  Other  remedies  of  allied  action  to  that  of  the  mercu- 
rials are  sulphurous  acid,  advised  by  Hutchinson;6  salicylic  acid  (salicylic 
acid,  5j-iss  (4--6.);  vaselin,  5j  (32.)),  or  2  to  10  per  cent,  strength,  as 
recommended  by  Marshall;7  guaiacol,  as  recently  extolled  by  Funk 
and  Alivisatos,8  with  occasional  applications  of  a  10  per  cent,  lactic  acid 
solution.  Sulphurous  acid  is .  also  esteemed  by  Harrison.9  Guaiacol 
was  variously  used — pure,  with  equal  parts  glycerin  or  with  equal  parts 

1  Leloir  and  Tavernier,  loc.  cit. 

2  Stelwagon  (Clinical  Lecture  on  Lupus,  with  illustrations),  International  Clinics, 
July,  1896,  p.  341. 

3  Brooke,  "A  Preliminary  Treatment  of  Lupus  Vulgaris,"  Brit.  Jour.  Derm.,  1890, 
p.  145;  "On  the  Treatment  of  Scrofuloderma  and  Lupus,"  ibid.,  1891,  p.  383. 

4  Doutrelepont,  Monatskefle,  1884,  p.  i. 

5  J.  C.  White  ("On  the  Treatment  of  Lupus  by  Parasiticides"),  Boston  Med.  and 
Surg.  Jour.,  Oct.  25,  1885. 

6  Hutchinson,  Med.  Times  and  Gazette,  April  26, 1884. 

7  Marshall,  Brit.  Med.  Jour.,  June  25,  1884,  p.  1253. 

8  Funk,  Monatshefte,  1899,  vol.  xxix,  p.  216;  Alivisatos,  La  semaine  medicale,  1900, 
p.  10  (guaiacol  and  olive  oil,  each,  4  parts;  alcohol  (60  per  cent.),  i  part). 

9  Harrison,  Brit.  Med.  Jour.,  Aug.  6,  1892. 


746  NEW  GROWTHS 

sterilized  olive  oil,  and  applied  frequently;  and  with,  occasionally,  other 
more  active  measures.  The  compound  lotion  of  zinc  sulphate  and  potas- 
sium sulphuret  advised  in  acne  and  lupus  erythematosus  is  also  often 
useful  as  a  preliminary  application.  lodoform,  usually  as  an  ointment, 
5  to  15  per  cent,  strength,  has  had  some  praise,  but  it  is  not  superior  to 
other  remedies  already  mentioned,  and  which  are  free  from  the  all-per- 
vading odor  of  this  drug.  The  mild  preparations,  which,  however,  have 
been  most  employed  by  myself,  are  the  calamin-zinc-oxid  lotion  and 
the  oleate  of  mercury  ointment,  generally  as  in  the  formula  prescribed 
by  Brooke. 

One  soon  finds,  however,  in  the  great  majority  of  instances,  that 
if  much  advance  is  to  be  made,  recourse  to  stronger  remedies  is  neces- 
sary; and  if  the  area  of  disease  is  small,  and  in  cases  in  which  time  is  a 
consideration,  it  is  best  to  adopt  such  measures  from  the  start.  First, 
as  to  those  of  moderate  activity,  which  are  not  usually  actively  destruct- 
ive. The  best  of  these  are  salicylic  acid,  resorcin,  and  pyrogallic  acid. 
The  first — salicylic  acid — may  be  prescribed  in  several  ways — in  collo- 
dion, 30  to  60  grains  (2. -4.)  to  the  ounce  (32.);  in  plaster  mass,  made 
up  with  petrolatum  and  resin  plaster,  i  to  2  drams  (4--8.)  to  the  ounce 
(32.);  mixed  with  sufficient  glycerin  to  make  a  paste,  as  recommended 
by  Treves;  and  as  Unna's  plaster-mull.  This  last  is  made  in  several 
strengths;  the  weakest  can  be  placed  among  the  mild  remedies  already 
mentioned,  the  strongest,  which  are  here  referred  to,  containing  respect- 
ively about  i  ounce  (32.)  and  \\  ounces  (50.)  to  the  spread  meter,  and 
with  about  the  same  quantity  of  creasote,  which  lessens  the  pain  of  the 
application.  Unna,1  Jamieson,  and  others  have  warmly  commended  this 
plaster-mull,  more  especially  in  the  superficial  and  non-ulcerative  types, 
and  from  its  use  in  several  cases  I  can  subscribe  to  its  value.  It  is  kept 
continuously  applied,  changing  daily;  the  tubercles  undergo  destruc- 
tion, and  are,  so  to  speak,  shelled  out.  A  10  to  20  per  cent,  salicylated 
collodion  is  also  satisfactory.  In  ointment  form,  used  2  or  3  drams 
(8.-I2.)  to  the  ounce  (32.),  and  kept  constantly  in  contact,  it  is  also  quite 
active.  I  have  had  no  experience  with  the  salicylic  acid  glycerin  paste. 
Resorcin  can  be  employed  in  the  same  manner  and  strength  as  salicylic 
acid,  most  commonly  as  a  strong  ointment.  As  a  rule,  it  is  not 
painful. 

Of  the  several  remedies  just  named,  however,  pyrogallol,  originally 
recommended  by  Jarisch,  is  in  my  experience  the  most  certain  in  action. 
Upon  the  whole,  it  is  best  employed  as  a  stiff  ointment,  made  up  with 
resin  cerate  and  vaselin,  or  with  some  resin  plaster  added  during  the  warm 
season.  I  have  not  had  much  success,  however,  with  the  10  per  cent, 
strength  as  commonly  advised,  nor  secured  action  in  several  days,  as 
Jarisch  and  others  reported;  on  the  contrary,  I  can  agree  with  G.  H. 
Fox2  that  to  secure  effective  result  a  strength  of  at  least  25  per  cent, 
should  be  employed,  generally  in  about  one-third  proportion.  During 

1  Unna,  Aerztliches  Vereinsblalt  fur  Deutschland,  No.  166,  1886;  Lancet,  Sept.  25, 
1886. 

2  G.  H.  Fox,  "The  Therapeutics  of  Cutaneous  Tuberculosis,"  Boston  Med.  and 
Surg.  Jour.,  Nov.  12,  1891. 


TUBERCULOSIS   CUTIS 


747 


the  cooler  season  an  ointment  made  up  as  follows  can  be  used:  1$.  Pyro- 
gallol,  5ij-iij  (8.-I2.) ;  vaselin  and  resin  cerate,  aa  q.  s.  ad  3j  (32.). 

This  is  spread  thickly  upon  patent  lint  or  any  other  suitable  material, 
and  kept  closely  applied,  changing  to  a  fresh  plaster  twice  daily.  At 
each  renewal  the  parts  are  wiped  off  gently  with  a  piece  of  soft  linen  or 
cotton,  and  any  loose  skin,  crust,  scale,  or  slough  thus  removed.  At  the 
end  of  five  to  eight  days  it  is  usually  noted  that  a  superficial  slough  or  a 
slough  of  variable  thickness  has  formed,  which  may  be  more  or  less  ad- 
herent. This,  if  but  slightly  adherent,  may  be  rubbed  off  or  picked  off; 
if  firmly  adherent, — and  this  is  more  commonly  the  case, — poultices  are 
to  be  applied  until  it  softens  and  comes  away,  which  may  require  several 
hours  or  a  day  or  more.  The  parts  are  then  gently  washed  with  soap  and 
water,  rinsed,  and  wiped  dry,  and  the  pyrogallol  ointment  reapplied; 
and  so  on  until  the  destructive  action  has  been  deemed  sufficient.  A 
course  of  such  treatment  usually  requires  from  ten  days  to  two  or  three 
weeks.  After  removing  the  final  slough  a  carbolized  resin  cerate  or  an 
ointment  of  pyrogallol  of  i  or  2  per  cent,  strength  may  be  used,  and 
healing  allowed  to  take  place.  Others  follow  this  treatment,  as  I  have 
also  done  in  some  instances,  with  an  ointment  made  up  of  equal  parts  of 
mercurial  plaster  and  petrolatum  or  with  pure  mercurial  plaster.  After 
thorough  healing  it  is  often  seen  that  in  places  the  disease  is  still  persist- 
ent, or  soon  afterward  new  foci  reappear  in  the  scarred  tissue;  the  same 
method  is  to  be  resumed,  usually  for  a  shorter  period. 

Belonging  in  this  same  class,  or  occupying  a  middle  position  between 
these  and  the  more  destructive  caustics,  is  arsenic,  in  the  form  of  an 
ointment  or  paste.  It  is  one  of  the  older  methods,  but,  in  my  opinion, 
is  far  superior  and  more  effectual  than  many  of  the  newer  remedies.  For 
application  to  areas  of  2  or  3  square  inches  to  that  of  a  palm  an  oint- 
ment used  by  Hebra,  consisting  of  arsenious  acid,  gr.  xx  (1.35) ;  cinnabar, 
5j  (4.);  cold  cream,  oj  (32.),  is  to  be  commended.  In  order  to  diminish 
the  pain  of  the  application — its  greatest  drawback — 5  to  10  grains 
(0.35-0.65)  of  cocain  muriate  can  be  added.  This  is  spread,  somewhat 
thickly,  upon  lint  and  covered  with  wax  tissue  and  bound  on;  it  is  changed 
twice  daily,  and  continued  from  two  to  four  days.  Considerable  edema 
and  inflammatory  swelling  result,  which,  however,  soon  subside  after 
the  arsenical  application  has  been  discontinued.  Its  action  is,  unless 
too  long  continued,  only  on  the  diseased  tissue;  the  nodules  and  other 
lupus  infiltration  are  converted  into  a  grayish,  necrotic  mass.  The 
after-treatment  for  several  days  should,  when  possible,  consist  of  poul- 
ticing until  the  sloughs  come  away,  and  then  subsequently  a  i  or  2  per 
cent,  pyrogallol  salve,  or  an  ointment  of  equal  parts  of  mercurial 
plaster  and  vaselin.  As  with  all  other  methods,  the  arsenical  applica- 
tion may  have  to  be  repeated  one  or  more  times  before  a  permanent 
result  is  reached.  If  the  area  of  disease  is  quite  small,  the  arsenical 
application  can  be  made  in  the  form  of  a  strong  paste  with  acacia,  as 
advised  in  epithelioma. 

Among  other  remedies  of  this  same  class  may  be  mentioned  lactic 
acid,  strongly  commended  by  Mosetig.  It  is  chiefly  prescribed  in  the 
ulcerative  types,  and  applied  on  a  wad  of  cotton  for  ten  to  thirty  minutes, 


748  HEW  GROWTHS 

once  or  twice  daily  at  first,  and  during  the  interim  using  a  mild  salve, 
such  as  boric  acid  ointment  or  a  5  to  10  per  cent,  aristol  ointment. 

Various  caustics,  in  addition  to  the  safer  preparations  mentioned, 
have  been  advocated  from  time  to  time,  such  as  Vienna  paste,  fuming 
nitric  acid,  chlorid  of  zinc  (see  Epithelioma) ,  but  these  are  rarely  resorted 
to  at  the  present  day.  The  galvanocautery,  however,  has  been  strongly 
urged  by  Besnier1  and  others,  using  variously  shaped  knives  and  points, 
practically  combining  cauterization  with  scarification.  The  Paquelin 
cautery  has  also  been  variously  advocated,  and  Unna  often  employs  this 
in  conjunction  with  the  plaster-mulls.  Somewhat  similar  is  the  Hoi- 


Fig.  171. — Galvanocautery  needle,  knife,  and  spiral  points  (Besnier). 

lander  hot-air  treatment,  or  hot-air  cauterization2  by  means  of  a  suitable 
apparatus,  by  which  air  heated  up  to  several  hundred  degrees  is  projected 
on  the  surface.  It  requires  anesthesia  and  some  skill  and  care  not  to 
go  beyond  the  safety  limit.  Properly  managed,  however,  according  to 
reports,  its  effects  are  excellent.  Plonski3  saw  i  case  practically  cured 
in  one  sitting.  Like  all  heat-cautery  methods,  however,  it  is  potent  for 
evil  if  poorly  handled. 

Liquid  air  and  carbon-dioxid  snow  (q.  v.)  have  both  been  tried  in 
a  few  instances  in  lupus  vulgaris  for  their  cauterant  action.  They  are 
less  violent  and  less  destructive,  but  more  manageable,  than  thermo- 
caustics,  and  may  have  a  field  of  usefulness  in  superficial  areas  of  disease. 


Fig.  172. — Multiple  scarifier  (as  modified  by  Van  Harlingen). 

Of  the  operative  methods  which  have  been  practised  from  time  to 
time,  is  to  be  especially  mentioned  that  by  curetting.  Volkmann 
originally  suggested  it,  and  since  then  it  has  figured  largely  in  the  treat- 
ment of  this  disease.  It  can  be  employed  when  patients  do  not  object 
to  operative  measures,  in  conjunction  with  caustic  applications;  and  the 
two  together  constitute  a  plan  of  treatment  to  be  warmly  commended. 

1  Besnier,  "Le  lupus  et  son  traitement,"  Annales,  1880,  p.  687,  and  1883,  p.  377  (a 
review  of  the  various  methods,  and  especially  descriptive  (1883)  of  his  own  favorite 
method,  with  cuts  of  instruments). 

2  Hollander,  Deutsche  med.  Wochenschr.,  1897,  p.  688;  Berlin,  klin.  Wochenschr., 
July  12,  1899. 

3  Plonski,  Monatshefte,  1899,  vol.  xxix,  p.  562  (case  demonstration). 


TUBERCULOSIS   CUTIS  749 

Etherization  is  usually  necessary.  The  parts  are  thoroughly  curetted, 
the  edges  being  well  looked  after.  Inasmuch  as  some  morbid  cells  or 
tissue  are  left,  a  supplementary  cauterization  is  an  essential  part  of  this 
method.  One  of  two  plans  can  be  used:  either  momentary  cauteriza- 
tion with  caustic  potash  in  stick  or  strong  solution,  or  several  days' 
use  of  a  25  per  cent,  pyrogallol  salve.  The  latter,  I  believe,  assures  less 
chance  of  recurrence.  The  subsequent  treatment  is  the  same  as  follow- 
ing the  caustic  methods.  Linear  scarification,  warmly  advocated  by 
Vidal,  and  which  had  the  strong  support  of  Morrow,  Brocq,  Squire, 
Malcolm  Morris,  Stopford  Taylor,  and  others,1  has  practically  given  place 
to  other  methods. 

Excision  has  from  time  to  time  had  support,  but  rarely  employed 
until  Lang2  gave  it  the  weight  of  his  advocacy,  although  Clark,3  Bid- 
well,4  and  a  few  others5  previously  or  since  have  reported  favorable 
results.  It  has  not  been  looked  upon  with  favor  in  England  or  this 
country,  except  for  circumscribed  areas.  The  method  consists  in  com- 
plete excision,  going  well  beyond  the  borders  of  the  disease,  and  then 
supplementing  with  Thiersch  grafts  usually  immediately  after  the  opera- 
tion. Lang's  great  success  with  this  method,  which  he  now  combines 

1  Morrow,  "The  Mechanico-surgical  Treatment  of  Skin  Diseases,"  Jour.  Cutan. 
Dis.,  1888,  p.  132;  Stopford  Taylor,  "A  Comparison  of  the  Various  Methods  of  Treat- 
ing Lupus  Vulgaris  During  the  Past  Twenty  Years,"  Brit.  Jour.  Derm.,  1894,  p.  345. 
Both  papers  give  reviews  of  the  subject  and  more  or  less  details  of  the  principal  methods 
in  vogue.     Brocq,  Paris  letter,  Jour.  Cutan.  Dis.,  1888,  p.  103,  gives  Vidal's  method  of 
quadrilateral  linear  scarification  in  minute  detail. 

The  method  of  procedure  in  linear  scarification  is  as  follows:  the  parts  are  thoroughly 
gone  over  with  close  parallel  incisions,  |  to  5  inch  part,  reaching  down  through  the  dis- 
eased tissue,  and  then  the  area  is  cross-tracked  in  the  same  manner.  Taylor  finds  it 
unnecessary,  as  a  rule,  to  cross-track  the  incisions,  as  in  so  doing  the  epidermis  is  likely 
to  be  torn  off,  the  papillae  exposed,  and  suppuration  ensue,  healing  being  thus  delayed. 
The  hemorrhage  is  rarely  troublesome,  and  is,  as  a  rule,  readily  controlled  by  a  wad  of 
cotton.  There  is  no  question  about  the  excellent  cosmetic  effect  of  this  method,  and 
in  nose  cases,  where  there  has  been  a  good  deal  of  destructive  deformity,  it  saves  tissue 
and  even  seems  to  create  new  tissue,  so  that  the  deformity  is  much  diminished.  On 
operating  on  the  nose  the  nares  are  firmly  supported  by  plugging  with  cotton  or  lint, 
so  as  to  have  a  good  foundation.  The  objection  raised  against  the  operation  by  Unna 
and  others — that  it  makes  auto-infection  possible — is  not  supported  by  the  observa- 
tions of  those  who  have  most  frequently  performed  it.  Multiple  puncture  (Dubini, 
Volkmann,  Veiel)  is  a  somewhat  similar  operation,  with  which  Volkmann  was  accus- 
tomed to  supplement  erosion  with  the  curet,  and  it  has  been  employed  independently, 
but  is  less  satisfactory  than  linear  scarification. 

2  E.  Lang,  "Der  Lupus  und  dessen  operative  Behandlung,"  Vienna,  1808;  also 
(later  communication  on  the  results,  with  illustrations)  Wien.  med.  Wochenschr.,  No. 
38,  1900,  and  (later  paper)  Deutsche  Med.  Wochenschr.,  Oct.  7, 1909.    Lang's  experience 
has  been  large — 412  cases  since  1892;  in  262  cases  out  of  291  reexamined,  at  least  six 
months  after  the  conclusion  of  treatment,  good  results  still  remained.     He  now  com- 
bines excision  and  the  Finsen  method;  und  Deutsche  Med.  Wochensckr.,]une  23, 1910. 
In  this  number  of  the  Wochensckrift  other  methods  of  treatment  are  also  reviewed: 

Finsen  treatment  by  Zinsser,  Radium  treatment  by  Wichmann,  and  other  methods 
by  Gottschalk. 

3  Bruce  Clark,  Lancet,  Mar.  18,  1893  (7  cases). 

4  Bidwell,  Brit.  Jour.  Derm.,  1893,  p.  288  (4  cases — i  relapse). 

BM.  B.  Hutchins  (2  cases),  Jour.  Amer.  Med.  Assoc.,  Dec.  12,  1896,  p.  1223; 
Popper,  Dermatolog.  Zeitschrift,  1897,  vol.  iv,  H.  i  (Lang's  method — 34  cases,  onry  3 
recurrences;  gives  minute  details  of  cases  and  operation);  Buschke,  Archiv,  1899,  vol. 
xlvii,  p.  23  (18  cases);  Urban,  Monatshefle,  1898,  vol.  xxvi,  p.  429;  Tavastsjerna,  abs,- 
ref.  in  Jour.  Cutan.  Dis.,  1899,  p.  148  (18  cases — a  large  number  involving  nose  and 
mouth;  cure  held  in  5  cases  two  years  after  operation);  N61aton's,  Jour.  mal.  eutan., 
Jan.,  1900. 


750  NEW  GROWTHS 

with  the  Finsen  treatment,  is  well  worthy  of  more  general  adoption. 
The  chief  objection  is  the  disfigurement. 

For  destroying  lupus  tubercles  which  are  isolated,  more  especially 
those  that  spring  up  in  the  scar  tissue,  and  often  irrespective  of  what 
the  active  plan  of  treatment  has  been,  a  sort  of  a  double  burr  (Mal- 
colm Morris)  or  ordinary  dental  burr  (G.  H.  Fox)1  has  been  warmly 
commended.  For  the  same  purpose,  as  well  as  for  the  systematic  treat- 
ment of  cases,  the  pointed  silver  nitrate  stick  has  been  used,  particularly 
in  Vienna;  it  is  easily  bored  into  the  discrete  tubercles,  and  while  it  thus 
disturbs  and  destroys  the  body  of  the  lesion,  its  mild  cauterizing  action 
is  damaging  to  the  morbid  cells  with  which  it  comes  in  contact.  It  is 
rarely  resorted  to  to-day,  scooping  out  with  the  curet,  the  burr,  or  the 
electric  needle  being  far  preferable  if  an  operative  method  is  elected. 

Electrolysis  may  likewise  be  used  for  circumscribed  patches,  in  a 
manner  originally  proposed  by  Gartner  and  Lustgarten2  and  since  com- 
mended by  Jackson.3  The  former  used  a  silver  metal  plate,  and  the 
latter  one  of  zinc,  with  a  rim  of  hard  rubber  projecting  about  a  milli- 
meter beyond  the  metal,  to  protect  the  healthy  skin  or  to  prevent  too 
severe  action  at  the  edge,  the  diameter  of  the  plate  being  from  \  to  f 
inch;  this  is  attached  to  the  negative  pole,  the  anode  sponge  elec- 
trode being  placed  at  any  convenient  point.  The  current  strength 
required  is  from  5  to  10  milliamperes.  The  plate  electrode  is  pressed 
gently  upon  the  patch  to  be  treated,  and  the  current  passed  for  about 
seven  or  eight  minutes.  The  area  is  gone  over  at  intervals  of  a  week 
for  a  few  times,  and  then  the  isolated  tubercles  which  are  left  are  treated 
with  the  electric  needle,  using  a  current  of  3  milliamperes.  In  this 
same  class  of  cases  liquid  air  or  carbon-dioxid  snow  can  be  used  as  a 
cauterant. 

(Two  other  methods  of  increasing  importance,  and  which  in  coun- 
tries or  centers  where  lupus  is  more  common  have  to  some  extent  sup- 
planted the  plans  of  treatment  formerly  in  use,  are  the  Finsen-light 
treatment  and  the  Rontgen-ray  treatment.) 

First  as  to  the  Finsen  treatment.4  Finsen  and  his  capable  assist- 
ants, Bang  and  Forchhammer,  have  been  practising  the  method  devised 
by  him,  at  his  institute  at  Copenhagen,  for  some  years,  and  with  final 
results  eminently  satisfactory.  As  referred  to  in  the  introductory 
chapter  the  method  is  thought  to  hinge  upon  the  bactericidal  properties 
of  concentrated  chemical  rays,  using  the  arc  light,  and  controlling  or 
preventing  the  action  of  the  heat  rays.  Others,  among  whom  Lereddle, 
Sequeira,  Malcolm  Morris,  Hyde  and  Montgomery,  and  Lesser,  have 
also  reported  favorable  results,  so  that  the  method  is  now  regarded  as 
one  of  the  most  important  in  the  therapeutics  of  this  disease. 

During  a  visit  to  Copenhagen,  some  years  ago,  I  had  the  pleasure 
of  observing  this  method  as  practised  by  Finsen  himself.  The  favorable 

1  G.  H.  Fox,  "On  Various  Methods  of  Treating  Lupus  Vulgaris,  Including  the  Use 
of  Burr  and  Hook,"  Jour.  Cutan.  Dis.,  1885,  p.  70. 

2  Gartner  and  Lustgarten,  Wien.  med.  Presse,  1886,  p.  776. 

3  G.  T.  Jackson,  Jour.  Cutan.  Dis.,  1890,  p.  416. 

4  See  under  General  Remarks  on  Treatment  regarding  apparatus  and  other  points 
not  here  considered. 


TUBERCULOSIS  CUTIS  751 

results  and  the  excellent  cosmetic  effects  were  well  in  evidence.1  I  am 
not  able  to  escape  the  conviction  however,  that,  with  some  of  the  other 
methods  mentioned,  as  thoroughly  and  persistently  carried  out,  the  same 
end  could  be  attained,  but  probably  with  not  as  good  cosmetic  results. 
Where  lupus  is  at  all  common — or,  say,  not  rare  or  uncommon,  as  it  is 
with  us — the  Finsen-light  treatment  can  be  efficiently  and  easily  con- 
ducted, owing  to  proper  training  of  the  attendants  in  the  technic. 
On  the  other  hand,  where  only  an  occasional  case  of  the  disease  is  met 
with,  it  will,  owing  to  the  lack  of  proper  training  in  its  application, 
scarcely  supplant  the  other  known  methods — unless  there  are  still 
further  improvements  in  the  apparatus  and  a  considerable  shortening 
of  the  time  of  exposure. 

The  duration  of  an  exposure  with  the  Finsen  or  Finsen-Reyn  lamp 
varies  from  three-quarters  to  one-and-a-half  hours,  depending  upon 
whether  the  disease  is  superficial  or  deep.  It  is  usually  necessary  to 
repeat  the  treatment  on  the  same  area  at  least  once  or  twice,  but  before 
a  new  exposure  is  made  the  reaction  from  the  preceding  one  should  have 
been  allowed  to  subside;  this  ordinarily  requires,  on  an  average,  about 
ten  days.  The  reaction  comes  on  from  a  few  hours  to  a  day  after  the 
exposure,  and  varies  from  an  erythematous  to  a  vesico-bullous  character; 
there  is  no  necrosis.  When  the  disease  is  extensive,  one  area  after 
another  can  be  treated,  so  that  it  often  is  necessary  to  give  a  daily  seance, 
and  then  several  months,  or  much  longer,  may  be  required  before  the 
entire  involved  surface  has  been  sufficiently  covered.  Patients  should 
report  a  few  months  after  an  apparent  cure  for  examination,  and  the 
exposures  resumed  should  there  be  any  evidence  of  lupus  tubercles  or 
infiltration.  For  superficial  types,  the  first  part  of  the  treatment  can 
be  done  with  the  lamp  of  the  Lortet  and  Genoud  model,  or  with  the  iron- 
electrode  lamp;  this  will  often  act  satisfactorily  and  relatively  more 
rapidly  in  removing  a  great  part  of  the  disease,  and  then  the  Finsen  or 
Finsen-Reyn  lamp  can  be  subsequently  used  for  the  remaining  deeper 
lupus  deposits.  The  same  combined  plan  can  in  many  cases  be  satis- 
factorily adopted  with  the  Rb'ntgen-ray  and  Finsen  treatments;  the  for- 
mer being  employed  first,  and  when  the  disease  area  has  been  reduced 
to  one  or  several  obstinate  patches  the  Finsen  treatment  can  be  resorted 
to.  In  Copenhagen,  in  some  instances,  in  order  to  shorten  the  period 
of  treatment,  there  is  a  preliminary  treatment  of  the  deeper-seated  areas 
with  pyrogallol  applications,  as  already  outlined.  In  ulcerated  areas,  a 
preliminary  treatment  by  any  appropriate  plan  is  necessary  before  the 
Finsen  treatment  is  resorted  to,  as  this  cannot  be  used  satisfactorily  upon 
ulcerated  surfaces.  Its  special  field  is  in  the  dry  non-ulcerative  cases. 
When  the  mucous  membranes,  as  in  the  nose,  etc.,  are  affected,  the 

1  Forchhammer,  Finsen's  able  associate  and  successor  (abs.  in  Brit.  Jour.  Derm., 
1911,  p.  338)  reports  that  in  the  fifteen  years  of  its  use  at  Finsen  Institute  2000  patients 
had  been  under  treatment,  1200  of  whom  had  been  followed  up: — cured  721,  or  60 
per  cent.;  under  treatment  217,  or  18  per  cent.;  treatment  discontinued  131,  or  n  per 
cent.;  dead  131  or  n  per  cent.  More  than  one-half  of  the  cured  patients  have  been 
free  from  recurrences  for  from  two  to  ten  years.  About  80  per  cent,  of  the  "initial" 
(somewhat  recent  and  more  or  less  limited)  cases  are  cured;  and  about  50  per  cent,  of 
the  inveterate  cases  (extensive  and  of  long  duration). 


752 


NEW  GROWTHS 


disease  cannot  be  satisfactorily  treated  with  the  light.  Such  regions 
are  to  be  handled  as  described  later. 

The  favorable  reports  of  the  curative  action  of  the  x-rays1  in  lupus 
made  by  the  pioneers  in  this  method  (Schiff,  Freund,  Neisser,  Pusey, 
Kummel,  and  others)  have  been  corroborated  by  many  other  observers, 
and  it  has  now  become,  along  with  the  Finsen  plan,  one  of  the  accepted 
methods.  I  can  fully  endorse  its  great  value  in  some  cases.  One  cannot 
say,  however,  in  a  given  case  how  much  good  it  will  do,  and  in  some 
instances  it  seems  to  have  but  little  influence;  in  others,  only  after  con- 
siderable reaction  has  been  produced;  and  in  others  again,  not  till  the 
danger-point  of  Rontgen-ray  reaction  has  been  passed.  Nevertheless, 
it  shares  the  honors  at  present  with  the  Finsen  light,  and  to  some  extent 
has  supplanted  it.  Its  great  advantage  is  that  a  large  part  or  the  entire 
diseased  surface  can  be  treated  at  the  one  time,  and  in  cases  which  show 
response  to  its  influence  a  good  result  is  comparatively  quickly  obtained. 
In  a  few  instances  a  favorable  action  is  noted  without  the  production  of 
x-ray  erythema,  but  ordinarily  it  is  necessary,  for  the  best  and  most 
rapid  effect,  to  bring  about  a  moderate  and  continuous  reaction;  some- 
times it  is  necessary  to  push  it  to  the  point  of  x-ray  dermatitis  of  the 
second  degree — vesiculation  or  serous  exudation — before  an  impression 
is  made  upon  the  disease,  but  caution  should  be  exercised  and  such  action 
kept  within  the  bounds  of  safety,  intermitting  when  necessary.  As  in 
the  use  of  this  active  agent  in  any  disease,  the  first  exposures  should  be 
cautiously  given,  with  a  tube  of  low  to  medium  vacuum,  at  10  inches 
distance,  and  for  five  minutes'  duration,  and  at  intervals  of  three  to 
four  days.  After  a  period  of  ten  days  to  two  weeks,  if  no  susceptibility 
has  been  shown,  the  distance  can  be  gradually  reduced  to  3  or  4 
inches,  and  the  time  lengthened  to  ten  or  fifteen  minutes,  and  the  ex- 
posures made  at  more  frequent  intervals.  The  inexperienced,  however, 
cannot  be  too  cautious  in  the  bolder  use  of  this  method,  as  its  effects 
when  carelessly  pushed  are  sometimes  unpleasant,  not  to  say  disastrous. 
In  those  instances  where  moderate  reaction  has  been  purposely  provoked 
and  kept  up,  after  a  few  weeks'  treatment  it  should  be  discontinued  till 
this  subsides;  in  some  cases  improvement  sets  in  and  continues.  The 
method  should  again  be  resumed  as  soon  as  improvement  begins  to  flag. 
Wickham,  an  expert  in  the  use  of  radium,  has  had  remarkable  results 
from  its  use  in  this  disease. 

Of  the  various  methods  mentioned,  I  personally  give  preference 
to  pyrogallol  and  arsenical  ointments  or  pastes,  to  curetting  with  sup- 
plementary cauterization,  and  to  x-ray  and  Finsen  phototherapy — the 
last  only  in  rare  instances  and  selected  cases,  owing  to  the  difficulties  of 
its  proper  employment. 

Treatment  of  lupus  of  the  mucous  membranes  must  be  more  or  less 
limited  in  its  methods,  owing  to  the  difficulty  of  application.  Curetting 
can  be  made  use  of,  especially  when  the  disease  is  readily  reached  and 
within  easy  view,  and  supplementary  cauterization  with  silver  nitrate 
stick  or  strong  solution.  The  best  method,  however,  here  consists  in 

1  See  under  General  Remarks  on  Treatment  regarding  apparatus,  protection  of 
patient,  and  other  points. 


LUPUS  ERYTHEMATOSUS  753 

cauterization  by  means  of  the  galvanocautery,  repeating  at  intervals 
of  a  few  weeks  until  the  morbid  tissue  is  all  destroyed.  The  Paquelin 
cautery  may  also  be  employed  for  this  purpose,  but  is  not  so  valuable 
or  generally  useful  as  the  galvanocautery.  At  Finsen's  institute  they 
make  a  daily  application  of  a  compound  solution  of  iodin  and  potassium 
iodid,  and  twice  weekly  galvanocauterization.  The  Pfannenstiel1  method 
of  treatment  of  intranasal  cavities  has  been  commended— consisting  of 
daily  packing  with  tampons  which  are  kept  constantly  moistened  with 
hydrogen  peroxid  solution,  and  at  the  same  time  the  patient  taking 
sodium  iodid  internally.  Lactic  acid  is  a  valuable  remedy  in  these 
cases,  and  can  be  applied  pure,  or  with  one  to  several  parts  water,  ac- 
cording to  whether  it  is  used  alone  or  with  preceding  curetting,  and  also 
upon  the  character  and  infiltration  of  the  area  to  be  treated.  Various 
other  remedies  have  been  advocated  from  time  to  tune,  but  the  most 
valuable,  in  my  judgment,  are  curetting,  galvanocauterization,  and 
lactic  acid.  The  use  of  cocain  solution  as  a  preliminary  in  those  who  bear 
pain  poorly,  carefully  employed,  reduces  the  pain  of  treatment  and  avoids 
the  necessity  of  a  general  anesthetic.  The  x-ray  has  a  value  in  these 
cases  also. 

LUPUS  ERYTHEMATOSUS 

Synonyms. — Seborrhoea  congestiva  (Hebra);  Lupus  erythematodes;  Lupus  seba- 
ceus;  Ulerythema  centrifugum  (Unna);  Fr.,  Lupus  erythemateux;  Scrofulide  erythe- 
mateuse. 

Definition. — Lupus  erythematosus  is  a  chronic,  mildly  or  moder- 
ately inflammatory,  small-celled  superficial  new  growth  formation,  char- 
acterized by  one,  several,  or  more  circumscribed,  variously  sized,  usually 
oval  or  rounded,  discrete  or  confluent,  pinkish  to  dark-red  patches, 
covered  slightly  and  more  or  less  irregularly  with  adherent  grayish  or 
yellowish  scales,  and  seated  most  commonly  upon  the  face,  less  frequently 
upon  the  scalp  also,  and  very  exceptionally  upon  other  parts. 

Symptoms. — Two  varieties  are  encountered,  the  circumscribed 
or  discoid  (lupus  erythematosus  discoides)  and  the  more  or  less  diffuse, 
scattered,  or  disseminated  (lupus  erythematosus  disseminatus) .  The 
former  is  the  common  clinical  type,  and  is  usually  seen  about  the  nose, 
cheeks,  and  ears,  and  less  frequently  the  scalp,  and  when  on  the  last, 
generally  conjointly  with  the  disease  on  the  face.  It  may,  however, 
be  limited  to  the  scalp,  for  a  time  at  least,  and  very  exceptionally  it  may 
exist  on  this  part  for  some  years  without  appearing  elsewhere2  In  rarer 

1  Pfannenstiel,  Hygeia,  May  and  June,  1910,  Straudberg,  Berlin,  klin,  Wochenschr., 
1911,  No.  4,  and  Sequeira,  Brit.  Jour.  Derm.,  1911,  p.  327,  have  all  seen  excellent  results, 
as  has  also  Forchhammer  (cited  by  Sequeira).   The  procedure,  quoting  from  Sequeira's 
paper,  is  as  follows:  The  patient  is  given  45  grains  of  sodium  iodid  internally  daily, 
divided  into  six  doses.    Every  morning  the  nasal  cavity  is  thoroughly  cleansed  by  the 
nasal  douche  containing    sodium  chlorid    and  boric  acid  or  other  mild  antiseptic; 
after  which  it  is  dried,  and  tampons  of  sterilized  gauze  moistened  with  a  2  per  cent, 
solution  of  hydrogen  peroxid  are  inserted;  the  patient  is  provided  with  the  solution 
and  with  a  pipet,  with  which  he  keeps  the  tampon  well  moistened;  a  result  is  usually 
attained  with  two  to  three  weeks'  treatment.     The  action  results  from  the  free  iodin 
liberated  in  the  presence  of  ozone. 

2  Stowers,  Brit.  Jour.  Derm.,  1898,  p.   144,  exhibited  before  the  Dermatologic 
Society  of  Great  Britain  and  Ireland,  a  woman  with  the  disease  upon  the  scalp  of 
eleven  years'  duration,  without  any  manifestation  on  other  parts. 

48 


754 


NEW  GROWTHS 


instances  the  hands  also  show  the  eruption,  but,  as  a  rule,  in  conjunc- 
tion with  the  patches  elsewhere.  In  most  cases,  however,  coming  under 
observation  the  face  is  the  sole  seat  of  the  disease,  and  the  flush  areas 
—nose,  cheeks,  and  ear-lobes—are  its  most  usual  sites. 

There  are  no  constitutional  symptoms  except  in  the  disseminated 
type,  to  be  referred  to  later,  nor  are  subjective  symptoms  present  to  a 
troublesome  degree;  there  may  be  slight  burning  or  itching,  but  usually 
no  local  discomfort  is  complained  of.  In  the  discoid  type— the  common 
clinical  type— the  disease  begins  as  one  or  several  rounded,  circumscribed, 
pin-head-  to  pea-sized  pinkish  or  reddish  spots,  upon  which,  if  undis- 
turbed by  frequent  washing,  slight  adherent  scaliness  is  observed.  They 
are  somewhat  elevated,  at  times  scarcely  perceptibly,  in  others  quite 
noticeably,  and  this  is  most  pronounced  at  the  border.  They  slowly,  or 
exceptionally  somewhat  rapidly,  increase  in  area  by  peripheral  growth, 
and,  after  attaining  variable  size,— a  fractional  part  of  an  inch  to  an  inch 


Fig.  173. — Lupus  erythema tosus;  a  not  uncommon  situation  and  configuration  (courtesy 

of  Dr.  J.  A.  Fordyce). 

or  more  in  diameter, — they  are  apt  to  remain  stationary;  or  they  may 
increase  still  further  and  several  contiguous  areas  coalesce,  or  a  disposi- 
tion to  retrogression  may  show  itself  in  some  patches,  and  a  tendency 
to  atrophic  change  centrally.  If  coalescence  ensues,  this,  with  often 
the  appearance  of  new  patches  nearby,  covers  considerable  area.  When 
at  all  developed,  the  clinical  picture  is  quite  peculiar  and  characteristic: 
the  patches  are  noted  to  be  sharply  denned  against  the  sound  skin  by 
a  slightly  or  pronouncedly  elevated  border,  while  the  innermost  central 
part  is  somewhat  depressed  and  usually  atrophic;  the  glandular  ducts 
are  generally  enlarged  and  patulous,  and  often  more  or  less  plugged  with 
sebaceous  and  epithelial  debris;  and  the  entire  surface  is  very  thinly  and 
irregularly  covered  with  grayish  or  grayish-yellow  scaliness,  although 
this  is,  as  a  rule,  scanty  in  quantity.  In  some  cases,  however,  it  forms  a 
coating  with  projection  into  the  follicular  openings.  These  cases  of 
marked  follicular  involvement  represent  Besnier's  follicular  type.  There 
is  some  infiltration  or  thickening,  variable  as  to  degree,  but  generally 
it  is  slight  or  moderate.  The  patch  is  pinkish  or  reddish  in  color, 
with  frequently  a  violaceous  tinge,  the  color  being  most  noticeable  at 


LUPUS  ERYTHEMATOSUS 


755 


the  border,  at  the  central  part  often  partly  hidden  or  lessened  by  the 
scales. 

Not  infrequently  the  disease  is  observed  to  present  itself  as  one 
or  several  patches  on  the  nose  and  neighboring  cheeks,  and  by  growth, 
and  often  by  the  appearance  of  new  spots  in  the  intervening  spaces, 
gradually  fuse  together  and  form  a  large  area  with  the  narrowed  part 
over  the  bridge  of  the  nose,  and  the  outer  portion  stretching  and  widen- 
ing out  on  each  side  more  or  less  symmetrically,  like,  as  Hebra  expressed 
it,  the  outstretched  wings  of  a  butterfly;  this  distribution  and  shape  have 
given  rise  to  the  name  "bat's-wing  disease."  The  whole  area,  with  the 
elevated  outline  border,  may  be  of  uniform  appearance  and  thickness, 
or  thinning  and  atrophy  are  noted  centrally  or  here  and  there  in  points 
corresponding  to  the  centers  of  the  several  original  constituent  patches; 
the  former  is  more  usual.  Other  small  characteristic  patches  are  fre- 


Fig.  174. — Lupus  erythematosus. 

quently  to  be  seen  on  outlying  regions.  Cases  of  the  malady  are  not  un- 
common in  which  but  a  few  fairly  large  areas  present,  of  a  markedly  in- 
filtrated character,  with  a  prominent  border,  and  which  are  persistent 
and  show  but  little  progression  or  retrogression  (lupus  erythemateux 
fixe  of  Brocq).  In  some  instances  or  patches  retrogressive  changes  are 
not  infrequently  noted  without  atrophic  tendency,  and  the  skin,  if  the 
patch  disappears,  is  found  to  be  normal.  In  other  patients,  and  occa- 
sionally in  one  or  two  patches,  there  is  very  distinct  atrophy,  so  that 
the  surface  presents  the  appearance  of  a  thin,  flat,  superficial  scar,  some- 
what sieve-like,  showing  the  previously  enlarged  duct-openings.  On  the 
ears,  lobe  and  tip,  and  less  frequently  in  the  concha,  and  the  outermost 
portion  of  the  canal,  it  is  not  uncommon  to  find  patches  of  the  disease, 
but  not,  as  a  rule,  so  sharply  defined;  in  patches  just  inside  of  the  concha, 
however,  the  duct-openings  are  often  quite  noticeable  and  plugged  up, 
and  occasionally  dark  colored,  suggesting  an  aggregation  of  comedones. 


756  NEW  GROWTHS 

In  some  cases  the  patches  are  observed  to  be  exceedingly  superficial, 
almost  wholly  devoid  of  thickening  or  infiltration,  the  duct-openings 
not  conspicuous,  scantily  covered  with  branny  scaliness,  having,  how- 
ever, the  sharply  defined  border.  In  these  instances  the  areas  are 
suggestive  of  mild  dermatitis  seborrhoica,  but  do  not  shade  off  into  the 
sound  skin,  as  the  latter  commonly  does.  They  resemble  slightly,  too, 
when  the  scaliness  is  extremely  trifling,  erythematous  patches  of  erythe- 
ma multiforme  or  chilblains.  This  represents  one  form  of  Besnier's 
vascular  or  erythematous  type.  In  other  cases  the  patches  may  be  some- 
what puffy  in  appearance,  quite  a  lively  red,  with  often  a  violaceous  tone, 
and  but  little  tendency  to  scaliness,  without  noticeable  duct  involvement, 
and  some  appreciable  dilatation  of  the  cutaneous  capillary  vessels; 
retrogressive  changes  are  usually  more  decidedly  atrophic  than  in  the 
usual  clinical  types — constituting  the  so-called  telangiectatic  type. 

In  lesions  on  the  hands,  concerning  which  valuable  papers  have  been 
contributed  by  Hyde,1  Klotz,2  Ohmann-Dumesnil,3  and  others,  the  form 
of  the  disease  is  more  usually  superficial,  not  very  scaly,  and  the  color 
is  frequently  a  violaceous  red,  sometimes  rosy  red;  they  are  fairly  well 
defined  against  the  sound  skin,  although  not  so  clear-cut  in  this  respect 
as  generally  observed  in  patches  on  the  face.  The  dorsal  surface  is  the 
usual  seat,  either  of  the  body  of  the  hand  or  the  fingers,  but  the  palm 
and  anterior  aspects  of  the  fingers  may  also  be  affected.  Occurring  on 
fingers,  toes,  and  pinnacle  of  ear,  it  sometimes  begins  as  chilblain  or  a 
simulation  of  it  (lupus  pernio) .  The  hands,  as  already  stated,  are  usually 
conjointly  affected  with  the  face,  although  it  may  occur  on  this  region 
primarily  or  even  independently.  From  the  literature  review  furnished 
by  the  gentlemen  named,  it  would  seem  that  the  disease  on  this  region, 
although  relatively  rare,  is  more  common  in  England  than  elsewhere. 

On  the  scalp  the  disease  is,  while  not  frequent,  not  uncommon, 
and  presents  some  features  different  or  in  a  more  aggravated  degree 
than  observed  ordinarily  on  the  face.  Although,  according  to  Besnier, 
Brocq,  Meneau,4  and  others,  the  varying  characters  of  the  disease,  as 
regards  discoid,  disseminated,  superficial,  and  infiltrated  types,  may 
occur  upon  the  scalp,  as  elsewhere,  the  somewhat  thick  discoid  form  is 
that  generally  observed.  There  is  not  so  much  redness,  as  a  rule,  as  on 
the  face,  but  usually  more  thickening,  with  partial  and  generally  complete 
hair  loss  of  the  affected  area,  and  rather  hard,  thick,  fibrous,  depressed 
scar-tissue  formation;  although  here,  as  elsewhere  in  the  disease,  there  is 
no  suppurative  action,  no  ulcer ative  destruction.  The  atrophic  degen- 
erative change  is  generally  so  marked  that  it  simulates  true  scar  tissue, 

1  Hyde,  "Lupus  Erythematosus  as  it  Affects  the  Hands,"  Jour.  Cutan.  Dis.,  1884, 
p.  321  (4  cases). 

2  Klotz,  "On  the  Clinical  Diagnosis  of  Lupus  Erythematosus  of  the  Hand  and 
Foot,"  ibid.,  1888,  pp.  50  and  qo  (2  cases). 

3  Ohmann-Dumesnil,  "Erythematous  Lupus  of  the  Hand,"  Amer.  Jour.  Med.  Sci., 
Dec.,  1888  (i  case).   These  several  papers  go  into  the  subject  at  length,  with  good  sur- 
veys of  the  literature,  with  references;  in  the  last  an  analysis  of  46  collated  cases  is  given. 

4  Meneau  ("Lupus  erythemateux  de  cuir  cheveleu"),  Annales,  1896,  p.  579,  reports 
4  cases  and  reviews  the  literature,  quoting  from  various  authorities;  Dubois-Havenith 
records  a  case,  Jour.  mal.  cutan.,  1899,  p.  239,  limited  to  the  scalp;  Galloway,  Brit. 
Jour.  Derm.,  1897,  p.  329  (case  demonstration),  exhibited  a  patient  in  whom  blebs 
of  some  size  developed  on  the  scalp  areas — a  case  apparently  unique  in  this  respect. 


PLATE   XX. 


Lupus  erythematosus. 


LUPUS  ERYTHEMATOSUS  757 

and  is  essentially  scar-like  in  character;  it  is  not  usually  sieve-like,  as  ob- 
served upon  the  face.  It  is  somewhat  depressed  below  the  skin  level. 
The  hair-follicles  are  permanently  destroyed.  The  patches  commonly 
begin  insidiously,  with  a  slightly  or  moderately  elevated  red  border,  and 
with  patulous  and  frequently  stuffed  duct-openings,  but  there  is  not,  as 
a  rule,  much  scaliness.  While  ordinarily  not  presenting  here  more  than 
one  to  several  variously  sized  patches,  it  may  be  exceptionally  quite 
extensive  and  coalesce,  and  involve  a  greater  part  of  the  scalp.  The 
disease  rarely  occurs  primarily  upon  the  hairy  region,  but  usually  sec- 
ondarily, and  commonly  associated  with  patches  upon  the  face  or  else- 
where. According  to  my  own  observations,  the  malady  here  is  always 
attended  with  atrophic  or  scar-like  changes,  rarely  disappears  sponta- 
neously, and  always  leaves  permanent  traces — hair  loss  and  cicatricial 
tissue. 

Lupus  erythematosus  disseminatus,  the  exanthematic,  or  dissemi- 
nated type  of  the  malady,  first  described  by  Kaposi1  and  since  observed 
by  others  (Besnier,  Hallopeau,  Hardaway,  Koch,  Cavafy,  Fernet,  and 
others)  ,2  is,  as  a  rule,  a  much  more  serious  phase  of  the  disease.  It  may 
develop  from  the  ordinary  chronic  discoid  form,  but  more  frequently 
acutely  (acute  lupus  erythematosus)  and  independently.  It  is  charac- 
terized by  small,  usually  numerous,  pin-head-  to  bean-sized  spots  or 
patches,  appearing  primarily  on  the  face,  where  it  may  remain  and  cover 
considerable  surface  by  the  slight  enlargement  of  the  original  plaques, 
but  commonly  by  the  appearance  of  others  in  the  clear  interspaces. 
They  are  hyperemic,  show,  for  the  most  part,  but  little  infiltration  and 
scaliness,  and  rarely  any  marked  glandular  involvement.  The  center 
may  be  somewhat  depressed,  and  with  or  without  atrophic  tendency. 
A  certain  capriciousness  is  sometimes  noted,  old  spots  disappearing  and 
new  ones  presenting.  Not  infrequently  the  hands  exhibit  lesions,  and 
other  parts  of  the  body,  as  the  limbs  and  trunk,  also  become  invaded. 
In  some'  instances  there  is  a  resemblance  to  the  lesions  of  erythema 
multiforme,3  and  in  one  instance  to  the  early  eruptive  patches  of  granu- 

1  Kaposi,  Archiv,  1872,  p.  36. 

2  Hallopeau.  Wickham's  Paris  letter,  Brit.  Jour.  Derm.,  1892,  p.  123;  Hardaway, 
Jour.  Cutan.  Dis.,  i88q,  p.  448,  and  1892,  p.  268;  Koch,  Archiv,  1896,  vol.  xxxyn, 
p.  39  (illustrated);  Cavafy,  Brit.  Jour.  Derm.,  1897,  p.  328;  Bulkley,  Jour.  Cutan.  Dis., 
1897,  p.  178;  Brooke,  Brit.  Jour.  Derm.,  1895,  p.  73;  Jamieson,  ibid.,  1893,  p.  115, 
records  2  cases  of  more  or  less  general  distribution,  but  not  acute  in  development; 
Fernet,  "Le  Lupus  Erythemateux  Aigu  d'emb!6e,"  Etude  Clinique,  Paris,  1908,  records 
a  case  of  his  own  of  acute  development;  gives  details  of  9  similar  cases  recorded  by  others 
(Kaposi,  3;  Boeck,  i;  Koch,  i;  Judersohn,  2;  Short,  i;  Heath,  i  (unpublished);  Leslie 
Roberts,  "Acute  Lupus  Erythematous"  (aign  d'emblee),  Brit.  Jour.  Derm.,  iQ".  P- 
167,  reports  another  acute  and  fatal  case  of  this  type  in  a  woman,  aged  21;  father  died 
of  tuberculosis  of  throat,  and  his  six  brothers  were  said  to  have  died  of  tuberculosis; 
review  of  these  acute  cases  with  observations;  Morris  and  Dore,  Brit.  Jour.  Derm., 
1911,  p.  187  (case  demonstration;  special  point  of  interest  the  polymorphic  character 
of  the  lesions  on  the  hands;  when  first  seen  some  were  like  lichen  planus,  some  like 
psoriasis,  and  some  like  erythema  multiforme). 

3  Crocker,  Jour.  Cutan.  Dis.,  January,  1894  ("Lupus  Erythematosus  as  an  Imitator 
of  Various  Forms  of  Dermatitis"),  also  describes  cases  of  the  ordinary  benign  types 
of  the  disease,  in  which  resemblance  was  shown  to  several  other  eruptions,  more  par- 
ticularly papular  and  nodular  erythema  and  lichen  planus;   Engman  and  Mopk, 
Interstate  Med.  Jour.,  April,  1909,  have  recently  reported  several  cases  in  association 
with  other  skin  diseases. 


758  NEW  GROWTHS 

loma  fungoides  (Hallopeau).1  Very  exceptionally  vesicular  and  bullous 
lesions  have  been  noted,  more  especially  in  the  central  area  of  the  atro- 
phic  spots;  but  in  a  few  instances  as  beginning  lesions.  An  eczematous 
aspect  with  slight  crusting  has  also  been  observed.  In  rare  cases  there 
are  attacks,  sometimes  persistent,  of  an  erysipelatoid  condition  of  the 
face  associated  with  the  eruption,  to  which  Kaposi  especially  refers,  and 
denominated  by  him  "erysipelas  faciei  perstans."  New  lesions  often 
come  out  in  distinct  crops,  with  symptoms  of  general  disturbance  and 
febrile  action.  The  eruptive  phenomena  persist,  the  disease  advances 
and  often  retrogresses,  and  in  many  of  these  patients  sooner  or  later 
signs  of  more  or  less  acute  tuberculosis  supervene,  and  death  results, 
probably  more  than  a  majority  of  the  recorded  cases  ending  fatally. 
In  one  under  my  own  observation  the  eruption  was  quite  profuse  and  more 
or  less  generalized,  partaking  of  the  appearance  of  erythema  multiforme 
and  lupus  erythematosus,  with  atrophic  tendencies  in  some  of  the  spots; 
but  as  regards  the  course  and  patient's  general  condition  was  relatively 
benign,  although  persistent.  As  in  most  of  these  cases,  there  was  a 
good  deal  of  burning  and  some  itching. 

Lupus  Erythematosus  of  the  Mucous  Membrane. — In  lupus  ery- 
thematosus the  disease  is  almost  invariably  one  of  the  integument,  but 
it  occasionally  is,  conjointly  with  cutaneous  lesions,2  met  with  on  the 
vermilion  of  the  lip,  in  the  mouth,  and  on  the  conjunctiva,  usually 
extending  from  the  skin  of  the  lower  eyelid.  On  the  vermilion  of  the 
lip  there  may  be  slight  thickening,  with  scaliness,  commonly  of  a  branny 
or  shred-like  character,  or  there  may  simply  be  a  rounded,  abraded- 
looking,  rather  sharply  defined  area,  with  minute  sieve-like  puncta. 
The  area  is  closely  similar  in  color  to  the  lip,  but  may  have  a  violaceous 
tinge.  Extending  into  the  inside  of  the  lip  on  to  the  true  mucous  mem- 
branes, it  has  the  appearance  of  a  superficial  abrasion,  but,  as  a  rule, 
well  defined.  The  color  of  the  patch  when  within  the  mouth — and  it 
has  been  observed  on  various  parts — is  somewhat  variable — some  bright 
red,  and  sometimes  punctate,  others  a  pale  red,  the  latter  often  with  an 
atrophic  thinning.  On  the  conjunctiva  the  surface  is  congested,  usually 
sharply  defined,  and  there  may  be  slight  thickening,  but  this  is  more 
likely  to  be  on  the  ciliary  border.  In  a  case  under  my  observation,  in 
which  a  patch  extended  from  the  nose  on  to  the  nasal  mucous  membrane, 
there  was  considerable  infiltration  of  the  latter. 

1  Hallopeau,  loc.  «'/.,  exhibited  a  patient  before  the  French  Dermatologic  Society 
in  whom  the  eruptive  phenomena  appeared  to  those  present  to  represent  the  beginning 
stage  of  granuloma  fungoides— a  year  later  the  case  was  again  exhibited,  and  the  lupus 
erythematosus  character  of  the  manifestation  was  evident. 

2  Some  cases  in  which  the  mucous  membrane  was  involved  have  been  in  the  dissemi- 
nated type  of  the  disease,  an  example  of  which  (Petrini's  case)  is  referred  to  by  Leslie 
Roberts,  Brit.  Jour.  Derm.,  1897,  D.  177.     See  also  paper  by  G.  H.  Fox  (case  of  lupus 
erythematosus  of  the  face  and  oral  cavity),  Jour.  Cutan.  Dis.,  1890,  p.  24;  also  case 
demonstration  by  Lustgarten,  ibid.,  1897,  p.  529;  Rille,  Wien.  klin.  Wochenschr.,  1898, 
p.  1164;  Hassler  (case  demonstration),  Jour.  mal.  cutan.,  Jan.,  1900;  Bowen,  Twentieth 
Century  Practice,  vol.  v  ("Diseases  of  the  Skin"),  p.  698;  Dubreuilh,  Annales,  1901,  p. 
231  (on  mucous  membrane  lesions);  T.  Smith,  Brit.  Jour.  Derm.,  1906  p  59  (on  mucous 
membrane  lesions);  Kren,  "Ueber  Lupus  erythematodes  der  Lippenrotes  und  der 
5chleimhaute,    Arckiv,  1907,  vol.  Ixxxiii,  p.  13  (4  cases,  with  review  and  partial  bibli- 
ography). 


LUPUS  ERYTHEMATOSUS  759 

The  course  of  lupus  erythematosus  is  essentially  chronic  and  per- 
sistent. Although  in  some  cases  there  occur  retrogression  and  disappear- 
ance of  old  patches,  and  sometimes  without  trace,  there  is  almost  always 
a  new  cropping-out  to  take  their  place,  and  thus  the  disease  is  continued. 
In  the  large  majority  of  the  cases,  however,  the  patches  are  persistent 
and  progressive,  but  after  reaching  a  variable  size  remain  more  or  less 
stationary  indefinitely.  In  extremely  rare  instances,  primarily  or  as  a 
subsequent  development,  some  slight  tendency  to  the  appearance  of 
flattened,  lupus-like  tubercles  is  observed,  and  the  condition  is  suggestive 
of  both  lupus  erythematosus  and  lupus  vulgaris.  I  have  met  with  two 
or  three  such  instances  in  which  the  acceptance  of  a  mixed  type  seemed 
the  only  solution,  corresponding  clinically  to  the  lupus  erythemato- 
tuberculeux  of  Besnier  and  the  lupus  erythematoi'de  of  Leloir.1 


Fig.  175. — Lupus  erythematosus — nose  and  lip. 

Fortunately,  in  lupus  erythematosus,  the  disease  areas,  however 
long  continued,  do  not  show  any  tendency,  as  sometimes  observed  in 
old  cases  of  lupus  vulgaris  to  malignant  (epitheliomatous)  change, 
although  Pringle2  has  recorded  such  an  instance  and  also  refers  to  a  few 
cases  recorded  by  Dyer,3  Stopford  Taylor,  and  Kreibich;  and  quite  re- 
cently Dubreuilh  and  Petges4  have  added  2  others. 

1  SpStzer  (E.  Lang's  Clinic)  reports  (Annales,  1907,  p.  189)  a  case  in  which  there  was 
an  association  of  the  two  diseases  (histologically  demonstrated) ;  and  Kyrle  also  records 
(Archiv,  1909,  vol.  xciv,  p.  309.  histologic  cuts)  a  case  of  lupus  erythematosus  in  which 
one  of  the  patches  showed  histologically  the  typical  picture  of  lupus  vulgaris. 

2  Pringle,  Brit.  Jour.  Derm.,  1900,  p.  i;  Reyn,  Nord.  Med.  Arkiv.,  1911,  abt.  ii,  p. 
49 — abs.  in  Brit.  Jour.  Derm.,  1912,  p.  375,  reports  an  additional  instance,  on  the  nose. 

3  Dyer,  Daniel's  Texas  Med.  Jour.,  1892-93,  vol.  viii,  p.  178. 

4  Dubreuilh  and  Petges,  "De  1'epithelioma  consecutif  un  lupus  erythemateux," 
Annales,  1909,  p.  106  (2  cases,  with  review  and  references). 


760  NEW  GROWTHS 


.  —  Lupus  erythematosus  is  not  common,  and  is  essen- 
tially a  malady  of  early  and  middle  adult  life.  Kaposi1  has,  however, 
seen  the  disease  in  a  child  of  three  years,  and  Jamieson2  in  one  of  eight, 
and  exceptionally  it  has  been  observed  to  begin  late  in  life.  My  own 
cases  have  mostly  been  between  the  ages  of  eighteen  and  forty.3  While 
both  sexes  are  its  subjects,  more  than  two-  thirds  are  in  women;  and 
in  the  acute  more  or  less  generalized  cases  almost  all  women.  Local 
congestive  conditions  and  flushings  from  any  cause  favor  its  production, 
such  as  seborrhea,  dermatitis  seborrhoica,  acne  rosacea,  exposure  to  the 
sun,  chilblains,  and  it  has  appeared  after  variola,  erysipelas,  and  similar 
disorders.  The  influence  of  systemic  conditions  is  not  known,  but  I  am 
convinced  that  cases  always  tend  to  get  worse  during  times  when  the 
general  health  is  below  the  standard  and  when  active  digestive  disturb- 
ances and  nervous  excitement  or  depression  occur.  That  general  sys- 
temic states  have  a  material  influence  is  shown  by  Fordyce's  case,4  in 
which  an  extensive  eruption  appeared  early  in  pregnancy  and  disappeared 
toward  its  termination;  and  a  second  case,  disappearing  during  preg- 
nancy and  appearing  after  confinement.  Galloway  and  Macleod  and 
many  others  rather  favor  the  view  of  an  underlying  toxaemia  being  an 
important  etiologic  factor. 

The  main  question,  however,  is  the  possible  relationship  to  tubercu- 
losis. In  recent  years  there  has  been  a  growing  belief  that  the  eruption 
is  an  expression  of  this  disease,  and  the  evidence  accumulating  and  re- 
cently set  forth,  notably  by  Boeck,5  following  that  already  formulated  by 
Hutchinson,  Besnier,  Hallopeau,6  Darier7  and  others,  has  materially 
strengthened  this  view,  with  which  my  own  clinical  observations  coincide. 
In  more  than  a  majority  of  the  cases  of  the  disseminated  type  reported 
tuberculosis  or  some  suggestive  pulmonary  disease  developed,  rapidly 
leading  to  death  (in  our  own  country  by  Hardaway,  Fox,  Bulkley,  and 
others)  .  In  many  of  the  ordinary  clinical  types  variously  reported  tuber- 
culous tendencies  in  the  families  of  patients,  or  the  presence  of  scrof- 
ulous glands  or  other  signs  of  this  constitutional  state  have  been  noted, 
and  many  of  the  cases  eventually  succumb  to  pulmonary  disease.  In 
fact  Besnier  and  Hutchinson  have  found  tuberculosis  more  frequently 
associated  with  lupus  erythematosus  than  with  lupus  vulgaris.  Sequeira8 
and  Baleau's  study  also  show  a  probable  tuberculous  relation.  Fordyce 

1  Kaposi,  Diseases  of  Skin,  p.  509;  Schamberg  records  (Jour.  Cutan.  Dis.,  1906,  p. 
381,  with  illustration)  a  case  in  a  child  (girl)  aged  five  years,  appearing  when  aged  four 
years  and  three  months. 

2  Jamieson,  Brit.  Jour.  Derm.,  1893,  p.  115. 

3  Two  cases  in  a  family  are  such  a  rarity  that  it  is  worthy  of  mention  that  Rona, 
Archiv,  1901,  vol.  Ivi,  p.  381,  had  under  treatment  2  sisters  aged  twenty-four  and 
twenty-eight;  and  Sequeira,  Brit.  Jour.  Derm.,  1903,  p.  171,  met  with  2  cases  in  sisters, 
one  aged  seven  and  the  other  aged  ten;  and  another  instance  of  2  cases  in  two  sisters 
aged  respectively  twenty-six  and  twenty-eight. 

4  Fordyce,  Jour.  Cutan.  Dis.,  1896,  p.  89. 

_  5  Boeck,  Brit.  Jour.  Derm.,  Sept,  10,  1898;  Ibid.,  Oct.,  1898;  Archiv,  1898,  vol. 
xlii.  p.  71;  and  Trans.  Fourth  Internal.  Derm.  Cong.,  Paris,  1900,  p.  108. 

6  Hallopeau,  La  semaine  med.  1898,  vol.  xviii,  p.  225. 

7  Darier,  "Precis  de  Dermatologie,"  p.  552. 

^  8  Sequeira  and  Raleau,  Brit.  Jour.  Derm.,  1902,  p.  367  (disseminated  variety  asso- 
ciated with  the  presence  of  tuberculous  disease  in  70  per  cent,  and  discoid  variety  in 
18  per  cent.;  history  of  tuberculoses  in  the  family  in  not  less  than  80  per  cent.). 


LUPUS  ERYTHEMATOSUS  761 

and  Holder1  have  recently  reported  a  few  instances  of  associated  tuber- 
culosis, and  a  most  admirable  judicial  presentation  of  the  subject  has 
been  made  by  Roth,2  who  collated  about  250  cases  of  lupus  erythema- 
tosus,  and  of  these,  in  over  70  per  cent,  there  was  evidence,  more  or  less 
pronounced,  of  tuberculosis.  His  view,  in  the  absence,  so  far,  of  bacilli 
findings  in  the  lesions,  is  that  possibly  the  toxin  generated  was  the  causa- 
tive agent,  which  accords  with  French  opinion  on  the  subject.  The 
association  of  so-called  papulonecrotic  tuberculides  or  other  tuberculides, 
now  and  then  observed,  is  thought  to  strengthen  this  belief.3  It  is  only 
fair  to  state,  however,  that  many  prominent  observers,  among  whom 
Duhring,  Kaposi,  Crocker,  Leloir,  Jadassohn,4  and  others  fail  to  sub- 
scribe to  this  view,  although  Crocker5  admits  the  undoubted  frequency 
of  the  disease  in  those  of  tuberculous  family  history.6 

Pathology. — In  addition  to  the  French  view  of  the  disease 
being  due  to  the  tubercle  bacilli  toxins,  probably  by  their  action  on 
or  through  the  blood-vessels  of  the  part,  other  theories,  as  succinctly 
stated  in  Fordyce  and  Holder's  papers,  "have  been  advanced  from  time 
to  time,  such  as  regarding  it  as  an  angioneurosis,  as  cutaneous  inflamma- 
tion due  to  local  causes,  a  specific  infectious  disease  due  to  micro-organ- 
isms ;  a  form  of  skin  tuberculosis  produced  by  a  species  of  bacilli  supposed 
to  differ  from  those  found  in  the  lungs  and  in  lupus  vulgaris,  a  neuritic 
inflammation  of  the  skin,  the  result  of  the  growth  of  the  tubercle  bacilli 

1  Fordyce  and  Holder,  Med.  Record,  N.  Y.,  July  14,  1900  (refer  also  to  suggestive 
cases  by  Jackson  and  Bronson). 

2  Roth,   "Ueber  ide  Beziehungen   des  Lupus  Erythematosus  zu  Tuberculose," 
Archiv,  1900,  vol.  li,  pp.  3,  247,  and  395,  with  brief  resume  of  all  cases  reported,  with 
bibliography;  Polland,  Dermatolog.  Zeilschr.,  1894,  vol.  ii,  p.  482,  recently  met  with 
lupus  erythematosus  and  erythema  induratum  in  the  same  patient  (woman),  who  had 
lost  two  sisters  from  lung  disease. 

3  Wile,  Jour.  Cutan.  Dis.,  May,  1911,  p.  286,  records  a  case  of  lupus  erythematosus 
of  face  associated  with  what  seemed  to  be  a  papulonecrotic  tuberculide  of  the  forearm — 
the  histologic  findings  are  not  conclusive,  but  are  somewhat  suggestive  as  to  relation- 
ship; Bunch,  "On  Necrotic  Tuberculides,"  Brit.  Jour.  Derm.,  1912,  p.  357,  in  his  two 
remarkable  cases  presented,  notes  that  in  one  there  existed  also  a  well-marked  lupus 
erythematosus,  appearing  some  time  after  the  tuberculide  had  developed. 

4  Jadassohn,  "Lupus  Erythematosus,"  Mracek's  Handbook,  gives  a  good  critical 
review  of  the  whole  subject  from  the  opposite  standpoint. 

5  Crocker,  Discussion,  Brit.  Jour.  Derm.,  1898,  p.  375;  Bunch,  Brit.  Jour.  Derm., 
1907,  p.  411,  took  the  tuberculo-opsonic  indices  of  10  lupus  erythematosus  patients 
(from  Crocker's  service);  in  3  he  found  the  opsonic  index  to  tubercle  low;  the  other  7 
showing  indices  well  within  the  margin  of  health,  in  several  instances  approximating 
the  normal.     In  the  3  patients  with  low  index  there  was  found,  upon  subsequent 
inquiry,  to  be  a  strong  history  of  tubercle  in  near  relatives. 

6  The  investigations  by  Zieler,  Much,  Friedlander  and  others  on  tubercle  toxins  and 
Much's  organisms  may  help  to  clear  up  the  question — a  late  review  of  the  subject,  with 
references,  will  be  found  in  Friedlander's  two  papers:   "The  ^Etiology  of  Lupus  Ery- 
thematosus and  a  report  of  thirteen  cases  tested  by  the  Moro  reaction"  Jour.  Cutan. 
Dis.,  1911,  p.  417,  and  "The  Value  of  Much's  Granules  and  the  Antiformin  Method 
in  Determining  the  ^Etiology  of  the  so-called  Tuberculides,  with  especial  reference  to 
Lupus  Erythematosus,"  Brit.  Jour.  Derm.,  1912,  p.  13;.  Friedlander  is  rather  non- 
committal, inclining  to  believe  it  to  be  due  to  a  toxin,  "but  whether  due  to  a  tuberculous 
or  other  toxin  is  not  so  clear";  Freshwater,  "Etiology  of  Lupus  Erythematosus," 
Brit.  Jour.  Derm.,  1912,  pp.  57  and  99,  also  gives  an  exhaustive  review  of  all  sides  of 
the  question,  with  bibliography — with  conclusions  unfavorable  to  the  tuberculosis 
view,  and  rather  supporting  the  belief  of  defective  or  weakened  circulation  plus  some 
irritant  from  without  or  within  among  which  might  be  the  tuberculous  toxin;  and 
Ravogli,  "Considerations  on  Lupus  Erythematosus,"  Jour.  Cutan.  Dis.,  1912,  p.  4  (in 
support  of  tuberculous  origin  with  bibliography  bearing  thereon). 


762  NEW  GROWTHS 

in  the  nerve-fibers  in  analogy  with  the  skin  changes  caused  by  nerve 
leprosy."  As  yet,  however,  these  several  theories  are  purely  speculative. 

The  cutaneous  lesions  are,  judging  from  theoretic,  clinic,  and  anatomic 
aspects,  in  all  probability  a  result  of  two  forces:  a  toxic  one  from  within 
(tubercle  bacilli  products?),  acting,  as  Boeck  and  others  suggest,  primarily 
upon  the  vasomotor  centers  of  the  skin,  and,  in  the  second  place,  on  the 
parts  of  the  skin  in  which  the  vasomotor  disturbances  are  set  up — the 
latter  being  superinduced  by  such  local  influences  as  flushing,  seborrhea, 
dermatitis  seborrhoica,  erythema  or  other  local  conditions1  Boeck 
states  that  the  main  anatomicopathologic  changes  are  vasomotor  dilata- 
tion of  vessels,  secondary  intoxication  of  the  tissue  cells,  and  inflammation, 
the  whole  resulting  very  often  in  atrophy. 

The  histologic  studies  (Neumann,  Vidal,  Thin,  Crocker,  Fordyce 
and  Holder,  Robinson,  and  others)  of  the  disease  do  not  agree  abso- 
lutely in  the  findings,  probably  due,  in  a  measure,  to  the  stage  and  char- 
acter or  activity  of  the  disease  process  in  the  patch  examined.  Nor 
do  investigators  place  the  same  interpretation  upon  the  histologic  changes 
observed.  One  of  the  latest  contributions  on  the  subject  is  that  by  Rob- 
inson,2 who  reviews  the  entire  subject  and  gives,  in  brief,  the  findings  of 
others.  While  clinically  the  process  would  suggest  an  essential  involve- 
ment of  the  epidermic  tissue,  examinations  show  that  the  alterations  in 
the  epidermis  (hyperkeratosis,  etc.)  are  secondary  and  unimportant,  and 
that  the  principal  changes  are  to  be  found  in  the  corium,  especially  about 
the  blood-vessels,  and  that  the  primary  lesion  is  focal  in  character,  and 
when  fully  developed,  constituting  in  reality  a  new  growth,  reticular  in 
structure,  and  connected  especially  with  the  lymph-channels;  that  there  is 
an  associated  perivascular  infiltration,  most  marked  where  the  blood- 
vessels are  most  numerous,  as  around  the  glandular  structures  and  hori- 
zontal blood-vessels;  no  giant-cells  and  no  polynuclear  cells;  the  ex- 
cretory parts  of  the  glandular  structures  show  some  invasion  of  infiltrated 
cells;  the  plugs  are,  according  to  Unna,  the  result  of  acanthosis,  and  are 
not  sebaceous  material.  There  is  variable  edema  of  the  prickle  layer 

1  Warde,  Brit.  Jour.  Derm.,  1902,  pp.  332  and  380,  1903,  p.  161,  believes  that  lupus 
erythematosus  is  not  a  disease,  but  merely  a  stage  in  the  course  of  many  different  affec- 
tions— the  damaged  part,  when  unable  to  be  self-reparative,  undergoing  destruction 
and  replacement  by  fibrous  tissue.     He  calls  attention  to  its  frequent  association  with 
chronic  atrophic  and  hypertrophic  rhinitis  and  ozena,  suggestive  of  an  allied  nature  or 
relationship;  Galloway  and  Macleod,  "Erythema  Multiforme  and  Lupus  Erythemato- 
sus: Their  Relationship  to  General  Toxaemia,"  Brit.  Jour.  Derm.,  1903,  p.  81,  are  in- 
clined to  ascribe  the  malady  to  an  inderlying  toxemia,  which  sometimes  may  produce 
erythema  multiforme;  in  others,  from  lack  of  reparative  power,  lupus  erythematosus; 
also  another  interesting  paper  by  the  same  writers,  ibid.,  1908,  p.  65,  on  the  same  sub- 
ject (with  case  report),  as  well  as  bearing  upon  the  question  of  relationship  to  tuber- 
losis  (with  references);  Ormsby,  "Erythema  Toxicum  Resembling  Lupus  Erythemato- 
sus," Jour.  Cutan.  Dis.,  1910,  p.  477  (case  demonstration;  face  and  hands;  more  or  less 
persistent;   this  and   similar  cases  of  simple   erythema   and  erythema   multiforme 
resemble  it,  and  doubtless  sometimes  lead  to  it;  Hartzell,  "Lupus  Erythematosus  and 
Raynaud's  Diseases,"  Amer.  Jour.  Med.  Sci.,  Dec.,  1912,  p.  793  (cites  cases  of  his  own 
and  other  observers  in  which  there  were  pronounced  vasomotor  symptoms,  and 
believes  there  is  an  intimate  relation  between  the  two  diseases — that  lupus  erythemato- 
sus is  a  toxic  erythema). 

Concerning  the  views  of  various  other  observers,  see  paper  by  Civatte,  "  Les  opin- 
ions d'aujourhin  sur  la  nature  du  lupus  erythemateux,"  Annales,  1907,  p.  263. 

2  Robinson,  Trans.  Amer.  Derm.  Assoc.for  1898  (with  some  literature  references). 


LUPUS  ERYTHEMATOSUS  763 

and  of  the  cutis.  Unna  lays  stress  upon  a  lymph  canalization  of  the 
infiltration.  Fordyce  and  Holder1  found  the  sebaceous  glands  affected 
with  hypersecretion,  and  later  their  ducts,  as  well  as  the  sweat-gland 
ducts,  as  others  have  observed,  are  the  seat  of  infiltration,  and  subse- 
quently undergo  degenerative  changes,  to  which  the  punctate  or  sieve- 
like  character  of  the  scar  is  due.  These  observers  are  inclined  to  believe 
that  capillary  obstruction  is  the  primary  step  in  the  pathologic  process, 
although  admitting  that  it  may  be  the  effect  and  not  the  cause  of  the  con- 
nective-tissue change.  Schoonheid2  states  that  the  progressive  inflam- 
matory changes  noted  lead  to  typical  degeneration  of  the  elastic  fibers, 
and  that  it  is  especially  this  that  is  an  important  factor  in  the  resulting 
scar-like  atrophy. 

From  his  own  repeated  examinations  and  from  a  review  of  those 
of  others  Robinson  concludes  that:  "Lupus  erythematosus  is  a  chronic 
inflammatory  disease  of  the  cutis  with  special  histologic  characters, 
as  shown  by  the  changes  in  the  blood-vessels — new  blood-vessels  in  the 
affected  area,  lymph-vessels,  and  lymph-channels,  and  the  new  formation 
of  an  adenoid-like  tissue, — reticular  tissue, — the  presence  of  mononu- 
clear  and  absence  of  polynuclear  cells  in  the  cell  infiltration;  and  these 
changes  must  depend  upon  the  presence  of  a  poison  generated  in  loco. 
In  other  words  lupus  erythematosus  is  a  local  infective  process — a  granu- 
loma." 

Diagnosis. — As  a  rule,  there  is  no  difficulty  in  the  recognition 
of  this  disease,  as  its  features — the  sharply  circumscribed  outline,  the 
reddish  or  violaceous  color,  the  elevated  border,  the  tendency  to  central 
depression  and  atrophy,  the  plugged-up  or  patulous  gland-ducts,  the 
adherent  grayish  or  yellowish  scales,  together  with  the  region  attacked 
(usually  on  the  nose,  cheeks,  ears,  or  other  parts  of  the  face),  the  slow 
course,  and  the  age  of  the  patient  are  quite  characteristic.  It  is  not 
to  be  confused  with  eczema,  dermatitis  seborrhoica,  lupus,  and  syph- 
ilis, and  on  the  scalp  with  alopecia  areata  and  folliculitis  decal- 
vans.  The  itchy  nature  of  eczema,  its  diffused  character  and  lack  of 
sharply  defined  border,  and  often  the  presence  of  vesicles,  papules,  or 
oozing,  with  no  disposition  to  atrophy,  together  with  its  history,  distin- 
guish it  from  this  disease.  Dermatitis  seborrhoica  may  be  sharply  bor- 
dered, but  the  greasy  or  oily  character  of  the  scales  and  crusts,  and  its 
usual  association  with  seborrheic  condition  of  the  scalp,  and  absence  of 
the  other  features  of  lupus  erythematosus  usually  suffice.  It  is  not  to 
be  forgotten,  however,  that  lupus  erythematosus  sometimes  develops 
from  a  seborrhea. 

Lupus  vulgaris  in  the  vast  majority  of  cases  begins  in  early  life, 
and  there  are  tubercles,  usually  a  tendency  to  ulceration,  and  tough 
cicatricial  formation — features  wanting  in  lupus  erythematosus;  in  rare 
instances  the  non-ulcerative  type  of  the  former,  in  which  the  tubercles 
consist  more  of  a  flattened,  diffused  infiltration,  bears  some  slight  re- 
semblance, and,  as  already  noted,  a  mixed  type  of  the  two  diseases  is 

1  Fordyce  and  Holder,  loc.  cit.  (with  8  histologic  cuts). 

2  Schoonheid  (Ehrmann's  laboratory),  Archiv,  1900,  vol.  liv,  p.  163  (an  elaborate 
investigation,  with  6  colored  cuts). 


764  NEW  GROWTHS 

within  the  range  of  possibility,  but  confusing  examples  are,  nevertheless, 
extremely  rare.  A  confluent  patch  of  flattened,  slightly  scaly,  non- 
ulcerating,  tubercular  syphiloderm  may  exceptionally,  if  hastily  exam- 
ined, be  confused  with  it,  but  the  individual  tubercles  can  usually  be 
made  out  on  close  inspection,  and  there  are  no  patulous  or  plugged  gland- 
ducts,  and  the  sharply  denned  border  of  lupus  erythematosus  is  wanting. 
The  acute  disseminated  type  may  remind  one  possibly  of  a  mild  psoriasis 
of  the  seborrheic  type  or  an  ill-defined  erythema  multiforme,  but  the 
tendency  to  atrophy  noted  in  some  of  the  patches,  the  constitutional 
symptoms  commonly  present,  and  the  absence  of  the  usual  distribution 
of  psoriasis  are  points  of  difference;  the  same  features  serve  to  distinguish 
it  from  erythema  multiforme.  In  fact,  this  type  is  so  exceptional  that 
it  scarcely  needs  to  be  considered. 

Patches  on  the  hand  are  also  so  extremely  rare  that  the  question 
of  differentiation  would  seldom  arise,  but  in  these  cases,  even  if  such 
patches  be  obscure,  others  usually  found  on  its  common  sites  will  be  of 
aid.  Lupus  erythematosus  of  the  scalp  differs  from  both  alopecia 
areata  and  folliculitis  decalvans  in  its  slightly  or  moderately  sharply 
elevated  border,  and  the  often  present  patulous  or  stuffed  gland-ducts; 
moreover,  in  alopecia  areata  there  are  no  inflammatory  signs,  and  in 
folliculitis  decalvans  the  patch  is  likely  to  be  irregular  or  jagged  in  shape. 

Prognosis. — Lupus  erythematosus  is  a  chronic  disease,  slow  in 
its  course,  lasting  indefinitely,  and  extremely  rebellious  to  treatment. 
Some  cases  are  capricious,  after  a  time  spots  disappearing,  and  some- 
times without  a  trace,  in  others — the  majority — with  atrophic  scar- 
ring. Even  in  such  cases,  however,  new  patches  usually  arise  as  others 
are  retrogressing.  In  most  instances  the  individual  areas  are,  however, 
persistent.  After  some  years  the  affected  parts  are  seen  to  be  the  seat 
of  flourishing  areas  interspersed  with  superficial,  soft  scars  or  atrophic 
thinning.  In  some  instances,  unfortunately  few  in  number,  after  an 
uncertain  duration  the  disease  disappears.  As  already  elsewhere  stated, 
tuberculous  or  suggestive  pulmonary  disease  has  been  noted  to  be  the 
final  development  in  some  cases  of  the  malady,  and  of  which  it  would 
seem  to  be  one  of  the  earliest  signals.  Upon  the  whole,  however,  except 
in  the  acute  disseminated  type,  in  which  the  outlook  is  always  grave, 
the  patients  do  not  seem  to  suffer  in  any  way  from  the  disease,  either 
locally  or  constitutionally,  and  its  principal  role  and  existence  seem  to  be 
as  "a  destroyer  of  good  looks,"  and,  unfortunately,  its  victims  are  mostly 
women. 

As  to  the  possibilities  of  treatment,  the  areas  present  can  almost 
invariably  be  benefited,  sometimes  much  improved,  sometimes  com- 
pletely cured;  but  as  to  freedom  from  new  spots  and  a  disappearance 
of  the  malady,  no  positive  opinion  can  be  vouchsafed  without  qualifica- 
tion. Some  cases  respond  to  persistent  measures,  and  in  those  instances 
in  which  the  disease  activity  has  already  ceased,  permanent  cure  results; 
in  others,  especially  those  in  which  the  tendency  to  new  spots  is  still 
present,  treatment  is  often  disappointing. 

Treatment. — In  the  management  of  this  disease  both  constitu- 
tional and  external  remedies  are  in  most  instances  to  be  prescribed. 


LUPUS  ERYTHEMATOSUS  76$ 

While  certain  drugs  internally  administered  have  from  time  to  time 
been  extolled,1  the  fact  remains,  I  believe,  that  the  best  plan  of  general 
medication  which  is  most  likely  to  have  an  influence  is  that  which  con- 
siders the  patient,  instead  of  his  cutaneous  malady;  in  other  words,  to 
be  based  upon  indications  in  the  individual  case.  Three  conditions, 
it  has  seemed  to  me,  may  tend  to  retard  favorable  effect  from  local  treat- 
ment— digestive  disturbances  and  constipation,  a  general  debilitated 
state,  and  nervous  worry  or  other  neurasthenic  influences.  For  the 
relief  of  these  the  ordinary  plans  or  suggestions  referred  to  in  the  treat- 
ment of  eczema  can  be  consulted.  The  bowels  should  be  kept  free,  and 
all  foods  and  work  or  indulgences  which  tend  to  flush  the  face  avoided. 
Alcoholic  drinks  in  any  form,  as  well  as  hot,  rich  soups,  and  pleasures 
or  employment  which  require  great  exertion  or  stooping,  and  exposure 
to  sun  or  wind,  are  therefore  prejudicial.  Likewise  excessive  coffee- 
or  tea-drinking  and  the  too  free  use  of  tobacco.  There  are  several 
remedies  which  in  some  cases  have  seemed  to  be  of  special  influence. 
Of  these,  in  strumous  subjects  and  those  of  enfeebled  nutrition  cod-liver 
oil,  in  small  or  moderate  dosage,  is  sometimes  of  distinct  value.  Arsenic 
has  cured  some  patients,  according  to  Hutchinson  and  others,  and  in 
sluggish,  persistent  cases  may  be  worthy  of  a  trial.  lodid  of  starch, 
according  to  McCall  Anderson,  proved  effectual  in  some  cases  and  bene- 
fited others.  Phosphorus  in  moderate  doses  has  been  commended  by 
Bulkley,  and  ichthyol  in  5-  to  i5-drop  doses  three  times  daily  by  Unna, 
Crocker,  and  others.  Both  Unna2  and  Brocq3  speak  well  of  remedies 
which  tend  to  reduce  cutaneous  hyperemia,  or  modify  the  conditions 
which  produce  it,  the  former  commending  quinin,  digitalis,  belladonna, 
and  ergo  tin,  and  the  latter  ichthyol,  ammonium  carbonate,  and  sodium 
salicylate.  Salicin  and  quinin  in  large  doses  have  been  warmly  spoken 
of  by  Crocker,4  and  the  latter  remedy  is  also  endorsed  by  Eddowes,5 
Payne,  and  Hartzell.6  lodoform,  originally  recommended  by  French 
dermatologists  (Besnier  and  others),  but  later  more  or  less  abandoned, 
has  recently  been  credited  by  Whitehouse7  with  a  cure  of  an  obstinate 
and  extensive  case,  given  in  the  dosage  of  i  grain  (0.065)  after  each  meal. 
Of  the  remedies  mentioned,  my  own  observations  would  give  the  most 
value  to  cod-liver  oil,  salicin,  sodium  salicylate,  and  quinin,  but  as  these 
various  drugs  are  usually  administered  conjointly  with  external  treat- 
ment, it  is  difficult  to  gauge  more  than  approximately  the  amount  of 
influence  they  exert.  The  selected  drug  is  prescribed  three  times  daily  in 
dosage  of — salicin,  10  to  20  grains  (0.65-1.35) ;  sodium  salicylate,  5  to  20 
grains  (0.35-1.35),  and  quinin,  5  to  8  grains  (0.35-0.55).  Pernet  believes 
that  the  mortality  of  the  acute  general  cases  might  be  reduced  by  early 
confinement  to  bed  and  the  administration  of  large  doses  of  quinin. 

!J.  C.  White,  "Lupus  Erythematosus:  its  Amenability  to  Treatment,"  Jour. 
Culan.  Dis.,  1898,  p.  457,  refers  to  the  various  remedies,  both  internally  and  externally, 
prescribed  from  time  to  time  for  this  disease. 

2  Unna,  "The  Treatment  of  Lupus  Erythematosus,"  Jour.  Cutan.  Dis.,  1898,  p.  465. 

3  Brocq,  "Traitement  des  maladies  de  la  Peau." 

4  Crocker  (regarding  salicin),  Brit.  Jour.  Derm.,  1898,  p.  8. 

5  Eddowes,  discussion,  ibid.,  1898,  p.  375. 
8  Hartzell,  personal  communication. 

7  Whitehouse,  New  York  Med.  Jour.,  1899,  vol.  Ixix,  p.  159 


766 


GROWTHS 


The  essential  part  of  the  management  of  this  disease  is,  however, 
the  external  treatment,  and  should  be  prescribed  in  every  case.  The 
choice  of  application  is  guided  by  the  degree  of  inflammatory  action 
or  hyperemia  and  the  irritability  of  the  skin.  Recent  years  have  seen 
the  gradual  abolition  of  the  destructive  methods  or,  rather,  their  use 
has  become  limited  to  comparatively  few  cases.  Upon  the  whole,  as 
both  the  personal  experience  of  White  and  Unna  and  their  reviews  of 
the  subject  show,  the  mildest  applications  have  the  widest  field  of  use- 
fulness and  are  to  be  depended  upon  in  most  instances.  My  experience 
is  fully  in  accord  with  this,  although  recent  observations  with  the  use  of 
carbon-dioxid  snow,  if  confirmed  by  larger  experience,  might  change  my 
opinion  to  that  extent.  As  a  rule,  unless  extremely  sensitive  and  irri- 
table, the  parts  are  to  be  washed  with  soap  and  water  nightly  before  the 
remedial  application;  and  if  at  all  sluggish,  the  tincture  of  green  soap  may 
be  employed.  There  are  two  applications  which  are  often  valuable  in 
all  types,  but  especially  in  the  markedly  hyperemic  cases,  and  which  I 
can  commend  highly  —  the  calamin-zinc-oxid  lotion  and  the  lotion  of 
zinc  sulphate  and  potassium  sulphuret  (see  Acne).  The  former  is  mild, 
but  nevertheless  often  making  a  favorable  impression;  the  latter,  origi- 
nally suggested  by  Duhring,  is  moderately  stimulating,  but  astringent 
and  almost  always  well  borne.  With  one  or  the  other  of  these  prepara- 
tions it  is  a  good  plan  to  begin  the  treatment  of  every  case,  and  later  they 
can  be  employed  in  the  interim  between  more  active  applications.  The 
lotion  is  to  be  thoroughly  dabbed  on,  both  night  and  morning  if  possible. 
Should  roughness,  increased  accumulation  of  scaliness,  or  irritability 
arise,  it  can  be  omitted  for  a  day  or  two  and  a  simple  ointment  applied; 
for  this  latter  purpose  one  of  cold  cream,  with  10  to  20  grains  (0.65-1.35) 
each  of  precipitated  sulphur  and  salicylic  acid  to  the  ounce  (32.),  can 
be  used.  After  a  few  weeks,  once  weekly  or  every  ten  days,  I  am  in  the 
habit  of  applying  liquor  potassae,  pure  or  diluted,  according  to  the  con- 
ditions, permitting  to  dry  on  and  painting  over  several  coats  of  collodion; 
this  remains  on  for  two  to  three  days,  after  which  the  patient  again 
applies  the  lotion  and  thus  this  conjoint  plan  is  continued  so  long  as  good 
results.  This  plan  is  a  modification  of  that  prescribed  by  Unna,  who 
applies  a  paint  consisting  of  i  to  2  parts  sapo  viridis  and  10  parts  collodion, 
and  which  can  be  made  more  active  by  the  addition  of  3  to  5  per  cent,  of 
salicylic  acid. 

Another  valuable  application  as  a  preparatory  one,  or  for  intermittent 
use,  is  one  of  Lassar's  paste  with  \  to  i  dram  (2.  -4.)  of  precipitated  sul- 
phur to  the  ounce  (32.),  and  sufficient  calamin,  about  i  to  3  per  cent., 
to  give  it  the  skin  tinge.  This  can  advantageously  be  combined  with 
energetic  washings  with  sapo  viridis  or  its  tincture.  Indeed,  in  the  milder 
cases  this  latter,  used  with  any  plain  ointment,  is  extremely  useful. 
Exceptionally,  in  hyperemic  cases,  this  stronger  soap  is  too  irritant. 
Another  valuable  mild  method  is  with  soap  washing  and  the  nightly,  and 
during  the  day  too  if  possible,  application  of  mercurial  plaster.  Unna's 
ichthyol  plaster-mull  is  also  beneficial  in  some  cases.  In  addition  to 
these  various  mild  applications  ointments  of  sulphur  and  ichthyol  and 
the  several  sulphur  lotions  mentioned  under  acne  can  often  be  used  with 


LUPUS  ERYTHEMATOSUS  767 

varying  benefit.  The  ichthyol  collodion  application  of  Unna— ichthyol 
i  part,  collodion  10  parts — is  a  compressing  application  of  some  value, 
but  it  is  dark  colored  and  temporarily  disfiguring.  Hebra,  Jr.,1  had 
good  results  from  cooling  applications — alcohol  alone  or  a  mixture  of 
equal  parts  of  alcohol,  ether,  and  spirits  of  mint;  the  application  is  to 
be  made  frequently, — at  short  intervals, — and  the  oftener  the  better. 

If,  after  a  time,  no  improvement  has  taken  place,  then  more  active 
measures  are  to  be  adopted,  and  this  is  more  especially  advisable  if 
the  patches  are  persistent,  with  no  indication  of  spontaneous  or  capri- 
cious changes.  Of  these  measures  painting  over  the  diseased  area 
(G.  H.  Fox)  pure  liquid  carbolic  acid  deserves  special  mention;  if  there 
are  more  than  several  patches,  not  more  than  two  or  three  should  be 
painted  at  the  one  time,  as  there  is  occasionally  some  pain  from  the  appli- 
cation; it  should  be  repeated  a  few  days  after  the  film-like  crust  produced 
by  it  has  fallen  off — about  a  week  or  ten  days  after  the  painting.  In 
some  instances  several  repetitions  are  necessary  to  remove  the  patch, 
and  in  others  again  the  effect  is  slight  and  temporary,  or  entirely  negative, 
and  exceptionally  aggravation  results.  The  painting  of  a  solution  of 
salicylic  acid  in  collodion,  from  20  to  60  grains  (1.33-4.)  to  the  ounce  (32.), 
is  also  useful  in  some  cases,  repeated  according  to  its  effect  daily  or  every 
second  day  for  several  days,  and  then  discontinuing  until  the  film  comes 
off,  and  resuming  the  painting  again,  and  so  on  so  long  as  the  action  is 
favorable.  Resorcin  in  alcoholic  solution  or  in  collodion — the  former  of 
10  to  50  per  cent,  strength,  and  the  latter  3  to  20  per  cent. — is  sometimes 
beneficial,  but  the  collodion  solution  must  be  used  weak  at  first,  as  it 
sometimes  acts  with  unexpected  energy.  Solution  of  silver  nitrate, 
from  10  to  60  grains  (0.65-4.)  to  the  ounce  (32.),  painted  on  at  intervals 
of  a  few  days  or  a  week,  will  also  prove  serviceable  in  some  instances, 
but  it  has  the  disadvantage  of  discoloration. 

A  method  recently  introduced  by  Pusey,  Zeisler,  and  others,  and 
one  of  great  value  is  the  use  of  carbon-dioxid  snow  (q.  v.) ;  this  is  applied 
from  20  to  40  or  50  seconds,  according  to  the  degree  of  thickening,  with 
a  moderate  degree  of  pressure.  A  patch  may  need  one  or  more  repeti- 
tions. The  snow  acts  as  a  caustic,  and  should  not  be  used  over  more 
than  i  to  2  square  inches  of  contiguous  surface  at  the  one  treatment, 
although  small  separated  patches  may  be  attacked  at  the  one  time. 

In  cases  in  which  the  patches  have  been  long  stationary  and  are 
sluggish  in  character,  and  which  have  failed  to  be  influenced  by  the 
milder  remedies,  stronger  or  cauterizing  applications  can  be  resorted 
to,  the  first  in  selection  being  carbon-dioxid  snow  just  referred  to.  A 
point  to  be  kept  in  mind,  however,  is  that  these  preparations  may  pro- 
duce scarring,  and  this  in  a  disease  in  which  patches  sometimes  disappear 
without  trace  or  with  but  slight  atrophic  thinning.  Among  the  other 
valuable  caustic  applications,  and  only  exceptionally  destructive  to  any 
marked  degree,  are  pyrogallol  and  arsenical  applications.  Pyrogallol  can 
be  applied  in  ointment  or  paint  form;  in  the  former,  with  salicylic  acid, 
and  consisting  of  20  to  40  grains  (1.35-2.65)  of  salicylic  acid,  30  to  60 
grains  (2.~4.)  of  pyrogallol,  and  4  drams  (16.)  each  of  simple  cerate  and 
1  Hebra,  Wien.  med.  Wochenschr.,  1899,  p.  14. 


768  NEW  GROWTHS 

vaselin;  it  is  applied  as  a  plaster,  changing  twice  daily,  and  continued 
until  some  action  is  effected,  and  then  one  of  the  milder  applications  or 
a  plain  salve  used.  Its  disadvantage  is  that  it  blackens  the  surface  for 
the  time.  In  collodion  with  salicylic  acid,  as  first  suggested  by  Brooke, 
it  is  much  more  active,  and  the  weaker  proportions  should  be  first  em- 
ployed; the  formula  most  commonly  prescribed  (Brocq)  consists  of  i 
part  salicylic  acid,  3  parts  pyrogallol,  and  40  parts  flexible  collodion; 
Bukovsky,1  following  Brooke,  recommends  even  a  stronger  proportion, 
with  1 6  parts  salicylic  acid,  4  parts  pyrogallol,  and  40  parts  collodion. 
Pyrogallol  in  collodion  often  acts  with  great  energy  and  needs  close  su- 
pervision. Arsenical  salve  paste,  as  used  in  lupus  vulgaris,  may  be  tried 
in  limited  obstinate  patches;  it  is  destructive,  however,  if  used  with  too 
much  freedom.  A  safer  plan  of  using  arsenic,  which  I  have  employed 
with  satisfaction  in  a  few  sluggish  cases,  is  that  suggested  by  Schiitz, 
of  painting  the  patches  with  a  weak  solution,  composed  of  i  part  Fowler's 
solution  to  4  or  5  parts  water  twice  daily  for  several  days  until  an  inflam- 
matory reaction  is  produced,  and  then  applying  soothing  remedies  until 
this  subsides,  and  resuming  the  paintings,  and  so  continue  if  improve- 
ment is  noted.  Joseph2  indorses  the  careful  application  to  the  areas, 
from  time  to  tune,  of  equal  parts  of  lactic  acid  and  water,  a  mild  ointment 
to  be  used  in  the  interim. 

Schiff 's3  observations  as  to  the  favorable  action  of  the  Rb'ntgen  rays 
in  this  disease  have  been  confirmed  by  others.  I  have  had  good  results 
in  several  instances.  The  method  does  not  seem  efficacious  in  all 
cases,  in  some  having  no  influence  whatever  and  in  others  producing 
aggravation.  The  Finsen-light  method  is  also  one  that  can  be 
employed  in  some  cases  with  excellent  results. 

Neither  Rontgen-ray  treatment  nor  the  Finsen  treatment  is  as  valu- 
able, however,  in  this  disease  as  in  lupus  vulgaris.  A  new  plan  of  treat- 
ment, which  has  proved  serviceable  in  some  cases,  is  that  by  the  high- 
frequency  current,  using  preferably  the  flat,  hammer-shaped  vacuum 
electrode,  and  at  a  distance  of  |  to  \  inch  from  the  surface;  it  should 
be  applied  for  3  to  10  minutes — sufficiently  long  to  bring  about  some 
reaction.  It  is  repeated  at  intervals  of  5  to  10  days,  the  calamin-zinc- 
oxid  lotion  or  the  compound  lotion  of  zinc  sulphate  and  potassium 
sulphuret  being  applied  in  the  intervals. 

The  operative  methods  which  have  been  commended  from  time  to 
time  are  curetting  and  punctate  and  linear  scarification;  and  of  these 
the  scarification  methods  have  been  almost  entirely  abandoned;  and 
curetting  also,  whether  wisely  or  unwisely,  is  not  much  in  vogue  at 
present.  The  latter  is,  however,  still  a  favorite  method  with  G.  H. 
Fox.4  Both  linear  scarification  and  punctate  scarification  are  proce- 

1  Bukovsky,  Wien.  med.  Wochenschr.,  1899,  pp.  1450  and  1500  (a  review  of  the 
various  plans  favored  by  different  authorities). 

2  M.  Joseph,  Lchrbuch  der  Hautkrankheiten,  1898,  p.  235. 

3  Schiff,  "Fortschritte  der  Gebiette  der  Rontgenstrahlen,"  vol.  ii,  No.  4;  abs.  ref. 
in  Monatshefte,  1899,  vol.  xxix,  p.  340. 

4  In  a  recent  friendly  letter  of  criticism  Dr.  George  Henry  Fox,  the  well-known  distin- 
guished and  skilful  dermatologist,  protested  against  the  few  words  T  had  given  to  the  cu- 
retting method  in  the  treatment  of  lupus  erythematosus,  and  he  stated  it  had  in  his  hands 
always  been,  and  is  still,  the  most  valuable  method  of  all  in  the  treatment  of  this  disease. 


SYPHILIS  769 

dures  that,  as  a  rule,  require  several  repetitions,  usually  at  intervals  of 
one  or  two  weeks.  In  addition  to  these  methods,  galvanocauterization 
by  means  of  variously  shaped  cautery-points  or  knives  and  by  the 
Paquelin  thermocautery  has  been  in  favor  with  some  French  derma- 
tologists, employed  as  in  lupus  vulgaris.  All  these  operative  procedures 
are  now,  however,  but  little  employed,  and,  indeed,  the  tendency  is  to 
depend  more  and  more  upon  the  milder  measures,  and  in  this  respect 
the  experience  of  Duhring,  White,  Crocker,  Hyde,  Brocq,  and  most 
other  observers  is  fairly  in  accord. 

SYPHILIS 

Synonyms. — Pox;  Lues;  Lues  venerea;  Fr.,  Syphilis;  Verole;  Ger.,  Syphilis;  Lust- 
seuche. 

The  syphilitic  virus  finds  its  way  into  the  system  by  inoculation, 
usually  as  a  result  of  impure  sexual  intercourse  or  through  accidental 
contamination,  the  first  evidence  of  the  malady  being  the  so-called 
"initial  lesion"  or  chancre.  This  may  present  the  appearances  of  a 
slightly  scaly,  flattened  papule,  a  film  of  infiltration,  a  surface  abrasion 
with  underlying  infiltration,  or  a  variously  sized,  usually  small,  crateri- 
form  ulcer  with  moderate  or  marked  underlying  and  surrounding  in- 
filtration. Still  another  type  is  occasionally  encountered,  consisting 
of  an  abraded  surface,  with  but  slight  or  moderate  infiltration,  and  cov- 
ered more  or  less  completely  with  a  somewhat  tenacious,  firmly  adherent, 
pseudomembranous  film  or  exudation.  The  most  common  site  for  the 
initial  lesion  in  the  male,  as  well  known,  is  some  part  of  the  genital  region, 
usually  on  the  glans,  at  the  corona,  on  the  prepuce,  or  shaft  of  the  organ; 
in  the  female,  on  the  small  or  large  labia,  on  the  clitoris,  or  within  the 
vaginal  entrance,  or  higher  up.  The  lesion  as  thus  met  with  belongs  more 
distinctly  to  the  province  of  the  genito-urinary  specialists,  and  for  de- 
tailed description  the  reader  is  referred  to  works  on  venereal  diseases. 

The  extragenital  or  "non-venereal"  chancre  is  a  matter  of  not  uncommon 
dermatologic  observation.  It  may  be  seen  upon  any  part  of  the  body, 
although  by  far  most  frequently  about  the  face,  particularly  the  lips. 
The  tongue  is  likewise  sometimes  the  seat  of  the  lesion,  and  it  is  occa- 
sionally found  upon  the  tonsil.  The  finger,  especially  at  the  lateral 
nail-groove,  is  also  a  not  uncommon  situation.1  On  these  extragenital 
situations  chancres  do  not  differ  from  those  seen  on  the  genitalia.  On 
the  lip  the  superficial  flat  lesion,  with  the  pseudomembranous  coating, 
it  is  not  unusual,  although  in  other  instances  it  has  the  typical  subjacent 
and  surrounding  infiltration  and  the  crateriform  ulcer.  This  latter 
variety  is  also  generally  that  seen  on  the  tonsil.  Both  on  the  lip  and 
about  the  finger-nail  the  first  evidence  is  often  a  persistent  fissure.  In 
the  latter  region  sometimes  the  lesion  is  exceedingly  insignificant. 

As  a  rule,  there  is  rarely  much  difficulty  in  the  diagnosis  of  ex- 
tragenital chancres,  presenting,  as  they  generally  do,  the  slow  develop- 

1  D.  W.  Montgomery,  "The  Location  of  Extrapenital  Chancres,"  Jour.  Cntan.  Dis., 
1905,  p.  342,  covers  the  subject  well;  based  upon  his  own  cases  and  those  reported  by 
others,  with  bibliography;  considers  also  relative  frequency  (more  than  5  per  cent.) 
as  compared  to  genital  chancres. 

4!) 


770 


NEW  GROWTHS 


ment  and  course  and  the  characteristic  induration.  A  patient  coming 
with  the  statement  that  he  has  had  a  "persistent  fissure  or  fever  blister 
on  the  lip  which  will  not  get  well"  should  always  lead  to  careful  inspec- 
tion. If  such  lesion  has  been  of  a  few  weeks'  duration,  an  examination 
will  often  show  a  beginning  chancre.  Any  sore  on  the  lip  which  has 
existed  several  or  more  weeks  must  be  looked  upon  with  suspicion,  as 
ordinarily,  if  not  epithelioma,  it  is  the  initial  induration  of  syphilis.  A 
suspicious  lesion,  of  a  few  weeks'  duration,  with  enlargement  of  the  near- 
est anatomically  connected  lymphatic  glands,  is  almost  invariably  found 
to  be  a  chancre.  A  persistent  crack  at  the  border  of  the  nail,  in  those 
unaccustomed  to  fissuring  or  chapping,  should  always  be  carefully 
watched;  not  infrequently  induration  will  be  disclosed  and  beginning 
enlargement  of  the  neighboring  glands.  In  fact,  a  single  circumscribed 
and  hardened  lesion  or  ulcer  on  any  part,  whether  integument  or  mucous 
membrane,  points  commonly  to  either  chancre  or  epithelioma,  and  if 
this  is  borne  in  mind,  a  correct  conclusion  is  generally  easily  reached. 
It  is  by  overlooking  the  fact  that  a  chancre  is  not  necessarily  always 
a  genital  and  venereal  lesion  that  mistakes  are  ordinarily  due,  for,  as 
a  rule,  when  this  is  recognized,  the  differentiation  from  other  diseases 
is  rarely  difficult. 

CUTANEOUS  MANIFESTATIONS  OF  ACQUIRED  SYPHILIS 

Synonyms. — Syphilis  cutanea;  Syphilis  of  the  skin;  Derma tosyphilis;  Syphiloder- 
ma;  Syphilid. 

Syphilitic  manifestations  of  the  skin  constitute  an  important  class 
of  dermatologic  cases,  and  the  presence  of  such  lesions,  history  of  their 
occurrence,  or  resulting  scars  often  furnish  important  clues  to  the  possi- 
bility or  probability  that  some  existing  obscure  organic  or  constitutional 
condition  may  be  due  to  the  same  cause.  The  various  syphilodermata 
can  be  conveniently  considered  dermatologically  without  special  division 
of  the  so-called  secondary  or  tertiary  stages,  incidental  mention  being 
made  on  this  point  in  connection  with  each  variety  of  eruption.  After 
the  appearance  of  the  initial  lesion  of  syphilis  there  is,  as  is  well  known, 
a  variable  period  of  a  few  weeks  or  longer,  known  as  the  "period  of  second 
incubation,"  in  which  the  disease  is  apparently  quiescent,  except  that 
slowly  and  gradually  following  the  enlargement  of  the  nearby  lymphatic 
glands  there  is  a  general  invasion  of  this  glandular  system,  although 
glands  in  other  situations  never  reach  the  same  development  in  this 
particular  as  the  lymphatic  structures  connected  anatomically  directly 
with  the  chancre.  In  fact,  quite  frequently  this  glandular  involvement 
fails  to  be  general,  at  least  to  the  degree  of  special  significance.  The 
adenopathy  is  usually  readily  recognized  by  palpation  of  the  more  super- 
ficial glands,  as  the  postauricular,  occipital,  submental,  submaxillary, 
anterior  and  posterior  cervical,  axillary,  epitrochlear,  inguinal.1  It 

1  Friedlander  (''  The  Value  of  Lymphatic  Gland  Examination  as  a  Factor  in  the 
Diagnosis  of  Syphilis,"  Jour.  Cutan.  Dis.,  1912,  p.  14)  contributes  an  interesting  and 
analytic  paper  on  this  subject  with  tabulations;  he  found  enlargement,  especially 
if  bilateral,  of  the  epitrochlear,  occipital,  and  posterior  cervical  glands  to  be,  in  the 
order  named,  of  the  greatest  diagnostic  significance. 


PLATE   XXI. 


Chancre  of  the  lip :  a  not  uncommon  type,  with  but  slight  to  moderate  underlying  indu- 
ration and  a  quite  characteristic  pseudo-membranous  coating  frequently  observed. 


Chancre  of  the  lip:  a  common  type,  with  considerable  underlying  and  surrounding 
infiltration  and  induration. 


SYPHILIS 


771 


usually  reaches  its  greatest  development  at  about  the  time  of  or  during 
the  outbreak  of  the  secondary  cutaneous  symptoms.  The  enlargement 
varies,  exceptionally  being  so  slight  as  to  be  scarcely,  if  at  all,  recog- 
nizable, and  in  occasional  instances  attaining  considerable  dimensions. 
As  a  rule,  however,  in  the  various  situations  named  one  or  several  of 
the  glands  are  found  pea-  to  bean-  and  small-nut-sized  or  somewhat 
larger,  and  are  hard,  indolent,  and  painless,  with  no  tendency,  in  uncom- 
plicated cases,  to  suppurative  action.  In  scrofulous  subjects  and  in 
others  where  accidental  pyogenic  inoculation  also  takes  place,  the  glands, 
more  especially  those  anatomically  connected  with  the  site  of  the  chancre, 
may  undergo  softening  and  break  down.  Such,  however,  is  not  of  com- 
mon occurrence.  The  adenopathy  of  syphilis  usually  persists,  more  or 
less,  though  the  secondary  stages  of  the  disease,  and  often,  especially  in 
those  patients  untreated,  somewhat  indefinitely.  It  is  not,  however, 
a  part  of  a  late  tertiary  cutaneous  manifestation,  except  sometimes  in 
nearby  glands,  and  more  particularly  when  there  is  ulceration  with  sup- 
puration— the  glandular  enlargement  or  sympathy  being  then  due  rather 
to  the  latter  process  than  to  the  malady  itself. 

The  advent  of  the  secondary  stage  of  syphilis,  the  most  character- 
istic symptoms  of  which  are  the  more  or  less  generalized  cutaneous 
eruptions,  occurs  a  somewhat  variable  time  after  the  date  of  exposure  or 
inoculation,  varying  within  considerable  limits  from  four  or  five  weeks 
to  some  months.  Most  authors  place  the  average  at  about  eight  weeks, 
and  this  accords  with  general  experience,  although  the  outbreak  is  not 
uncommon  about  the  sixth  week,  and  the  possibility  of  a  much  longer 
period  is  also  to  be  recognized.1 

Preceding  the  eruptive  outbreak  for  several  days  or  one  or  two 
weeks  certain  other  symptoms — one  or  several — are  not  infrequently 
observed,  such  as  rheumatism,  especially  about  one  or  two  joints,  severe 
persistent  headache,  neuralgia,  bone  pains,  some  loss  of  weight,  a  dinginess 
or  unhealthy-looking  skin  tint  (especially  the  face  and  particularly  about 
the  chin  and  mouth,  which  often  presents  a  slightly  macular,  mottled 
appearance),2  febrile  action  (syphilitic  fever),  and  a  general  feeling  of 
lassitude,  and  occasionally  a  distinctly  cachectic  condition  (syphilitic 
cachexia).  According  to  White  and  Martin,  examinations  of  the  blood 
at  this  time,  and  also  earlier,  usually  show  a  slight  increase  in  the  white 
blood-corpuscles,  a  lessening  of  the  red  corpuscles,  and  a  marked  diminu- 
tion in  the  hemoglobin  percentage.  These  various  symptoms,  if  present, 
often  persist  for  days  or  weeks,  or  subside  measurably  or  completely 
upon  the  full  development  of  the  eruption,  or  they  may  show  no  tendency 
to  abate  until  active  and  energetic  treatment  is  instituted.  The  syphil- 

1  Bergh's  review  (Monalshefte,  1893,  vol.  xvii,  p.  593)  of  the  subject  on  this  point  is 
of  value,  naturally,  indicating  considerable  variation,  although  the  period  just  men- 
tioned can  be  considered  the  rule.     His  own  statistics  of  254  cases  in  males  show  that 
in  2  cases  the  general  eruption  appeared  in  the  fourth  week,  in  it  in  the  fifth,  20  in  the 
sixth,  28  in  the  seventh,  32  in  the  eighth,  21  in  the  ninth,  30  in  the  tenth,  23  in  the 
eleventh,  16  in  the  twelfth,  13  in  the  thirteenth,  24  in  the  fourteenth,  27  in  the  fifteenth, 
3  between  the  twentieth  and  twenty-fourth,  and  4  between  the  latter  and  the  twer«ty- 
ninth;  the  extremes  being  twenty-four  and  two  hundred  and  four  days. 

2  Trimble,  "  The  Mottled  Chin  of  Syphilis,"  Jour.  Cutan.  Dis.,  i9",P-  569>  ca'ls 
particular  attention  to  this  not  uncommon  symptom. 


772 


NEW  GROWTHS 


itic  fever  is  occasionally  sufficiently  severe  to  simulate  or  suggest  other 
febrile  diseases.  Some  cases,  may,  however,  remain  absolutely  free 
from  any  such  disturbances,  and  the  eruption  be  the  first  sign  of  con- 
stitutional syphilis.  In  fact,  the  secondary  stage  of  the  disease  may  be 
so  extremely  mild  in  all  respects  that  its  occurrence  is  overlooked,  and 
if  the  chancre  has  been  slight,  or  in  women  and  in  concealed  situations, 
it  may  be  that  late  tertiary  eruptions  or  other  syphilitic  symptoms  may 
be  the  first  recognized  evidences  of  the  malady.  This  is  not  an  uncom- 
mon observation  in  married  women  who  have  contracted  the  disease 
unknowingly  through  the  marital  relation.  As  a  rule,  however,  sec- 
ondary manifestations  of  the  disease  are  sufficiently  pronounced  to  lead 
to  seeking  of  medical  advice,  even  though  the  initial  lesion  had  escaped 
the  patient's  notice.  A  few  remarks  upon  some  of  the  characteristics 
of  syphilitic  eruptions  in  general  may  be  of  value  before  describing  the 
various  types  individually. 

General  Observations  and  Diagnostic  Characters.— 
Syphilis,  not  only  in  its  cutaneous  symptoms,  but  in  all  its  relations,  varies 
considerably  in  different  cases.  It  may  be  benign  in  character  (benign 
syphilis),  scarcely  making  any  impression,  or  in  occasional  instances 
extremely  severe  or  malignant  (malignant  syphilis),  striking  the  patient 
with  tremendous  force,  giving  rise  to  profound  anemia,  marasmus,  and 
even  death.  Ordinarily,  however,  its  course  is  mild  or  only  moderately 
severe;  in  some  instances  quite  pronounced,  with  a  variable  degree  of 
malignancy.  Sometimes  this  severe  or  malignant  character  seems  to 
be  mainly  shown  in  the  type,  persistence,  and  recurring  tendency  of  the 
skin-lesions,  the  general  health  remaining  fairly  good. 

Syphilis,  in  its  cutaneous  manifestations,  at  least,  can  truly  be  said 
to  be  a  great  imitator,  as  there  is  scarcely  an  eruption,  exclusive  of  some 
of  the  exanthemata,  that  cannot,  in  a  measure,  and  sometimes  strikingly, 
be  simulated.  Nevertheless,  the  syphilodermata  in  most  instances 
are  sufficiently  distinctive  in  some  features  to  make  their  recognition 
ordinarily  a  matter  of  but  little  difficulty;  on  the  other  hand,  the  resem- 
blance to  other  affections  may  sometimes  be  so  great  as  to  demand  most 
careful  investigation  as  well  as  recourse  to  blood  test,  and  examination 
for  spirochetes,  or  several  days'  or  one  or  two  weeks'  observation, 
before  a  positive  conclusion  can  be  reached. 

Distribution. — The  earlier  cutaneous  manifestations — those  of  the 
secondary  period  of  the  malady — are  more  or  less  general  and  symmetric 
in  distribution,  although  in  many  instances  the  different  types  may  show 
a  preponderance  on  certain  regions,  as  will  be  referred  to  in  describing 
the  individual  eruptions.  It  may  be  said,  however,  that  in  many  cases 
the  upper  part  of  the  forehead,  just  at  the  margin  of  the  hair,  the  angles 
of  the  mouth,  the  nasolabial  folds,  the  palms,  soles,  region  of  the  anus, 
and  genitalia  are  frequently  the  seat  of  lesions.  The  syphilitic  eruptions 
may  be  abundant  or  somewhat  scanty,  and  vary  considerably  in  duration. 
In  relapses  the  eruption  is  much  more  scanty  and  usually  of  less  general 
dissemination,  with  a  disposition  to  irregular  or  ill-defined  grouping  or 
aggregations.  The  late  syphilodermata,  those  of  the  declining  active 
or  secondary  stage,  and  particularly  those  of  the  tertiary  period,  are 


SYPHILIS 


773 


rarely  of  wide  distribution,  but,  on  the  contrary,  are  commonly  confined 
to  one  or  several  regions,  with  a  distinct  grouping  tendency. 

Configuration  and  Color. — In  the  earlier  syphilitic  eruptions,  as 
already  remarked,  there  is  exhibited  but  little,  if  any,  tendency  to  special 
grouping  or  configuration.  The  lesions  are  usually  rounded  or  ovalish, 
sometimes  irregularly  so.  In  occasional  cases  of  the  erythematopapular 
manifestation,  especially  in  negroes,  some  of  the  lesions,  more  particu- 
larly about  the  mouth,  lower  part  of  the  face,  and  neck  are  distinctly 
annular.  In  the  later  secondary,  relapsing  outbreaks  irregular  grouping 
occurs,  sometimes  with  a  segmental  or  circinate  tendency,  but,  as  a  rule, 
these  characters  are  reserved  for  the  later  or  tertiary  eruptions,  of  which 
the  tubercular  syphiloderm  is  representative.  Here  the  tendency  to 
segment,  circinate,  and  serpiginous  arrangement  is  more  or  less  constant, 
and,  taken  together  with  chronicity,  is  almost  diagnostic. 

The  color  of  the  syphilodermata  is  a  dingy,  sluggish,  or  dull  red, 
often  coppery.  In  the  earliest  part  of  the  outbreak,  more  particularly 
of  the  macular  syphiloderm,  the  hue  may  be  a  brighter  one,  often  of  a 
quite  distinctly  inflammatory  aspect,  but  this  is  soon  lost,  and  the  dull 
red  to  brownish  red  soon  presents,  and  which  finally  amounts  to  brownish 
pigmentation,  which,  however,  eventually  disappears.  The  dull  or  cop- 
pery red  is  often  very  suggestive,  but  color  alone  is  rarely  to  be  depended 
upon  for  positive  differentiation — it  is  simply  to  be  viewed  as  one  of  a 
group  of  diagnostic  factors,  which  together  are  clearly  conclusive. 

The  ulcers  of  early  pustular  syphilodermata  are  superficial,  and,  as 
a  rule,  have  no  special  characteristics;  those  of  the  later  forms  are  seg- 
mental, rounded,  or  kidney  shaped.  The  scars  resulting  from  syphilis 
are  usually  soft,  pliable,  and  somewhat  insignificant,  commonly  showing 
minute  puncta  or  perforations,  the  sites  of  former  follicles.  Those 
resulting  from  the  later  eruptions  take  the  shape  of  the  lesions  or  groups 
giving  rise  to  them,  and  the  segmental  or  horseshoe-shaped  scar  or  scars 
will  often  serve  as  the  key  to  the  past  or  associated  present  trouble. 
Such  scars  are  commonly  soft,  and  relatively  insignificant  compared  to 
the  preceding  ulceration;  they  are  rarely  tough  or  striated,  as  frequently 
noted  in  lupus  cicatrices,  although  this  tendency  and  a  keloidal  disposi- 
tion are  sometimes  observed  when  at  the  joints. 

Polymorphism. — While  the  generalized  or  secondary  syphilodermata 
can  rarely  be  said  to  be,  to  any  large  extent,  polymorphous,  the  type 
being  usually  more  or  less  uniformly  papular,  pustular,  etc.,  yet  it  is 
just  as  true  that  in  most  cases  several  or  more  characteristic  lesions 
of  another  variety  than  those  which  chiefly  make  up  the  eruption  are 
to  be  found  when  the  surface  is  carefully  inspected,  and  this  fact  is  often 
of  value  in  the  diagnosis — as,  for  example,  in  differentiating  the  papular 
syphilid  from  lichen  planus  and  the  papulosquamous  syphilid  from  psori- 
asis, etc.,  two  diseases  which  are  always  uniform.  In  the  macular  syphilo- 
derm will  often  be  found  some  scattered  lesions  with  a  papular  tendency 
— maculopapules,  and  commonly  also  clearly  defined  papules,  especially 
about  the  anal  and  genital  regions;  in  the  small  papular  syphilodermata 
several  or  more  well-developed  scattered  pustules  are  not  unusual,  and 
more  frequently,  especially  in  the  miliary  papular  syphilid,  many  of  the 


774 


NEW  GROWTHS 


papules  often  show  a  pustular  tendency  at  the  summit.  The  pustular 
syphilodermata  generally  exhibit,  here  and  there,  typical  papules  and  so 
on;  commonly,  too,  there  is  an  admixture  of  several  or  more  lesions  of  a 
larger  or  smaller  type  than  those  of  which  the  eruption  is  chiefly  made 
up,  as  some  large  pustules  in  the  miliary  pustular  syphilid,  some  large 
papules  in  the  miliary  papular  eruption,  etc.  Occasionally,  also,  the 
eruption  may  be  composed  of  lesions  of  intermediate  type,  as  in  the 
papulopustular  syphiloderm  and  papulo tubercular  syphiloderm. 

Subjective  Symptoms. — The  syphilitic  eruptions  are  usually  unac- 
companied by  subjective  symptoms,  and  this  factor  can  sometimes  be 
utilized  as  a  differential  point  in  some  instances.  An  exception  must  be 
made  to  this  statement  as  to  the  negro,  if  we  are  to  accept  his  word  for  it, 
inasmuch  as  in  this  race  slight  or  moderate  itching  is  usually  complained 
of,  although  it  is  rarely  sufficiently  severe  to  give  rise  to  active  scratching 
and  resulting  excoriations.  The  miliary  papular  and  miliary  pustular 
syphilodermata  seem  to  be  most  troublesome  in  this  respect,  and  these 
forms  occasionally  give  rise  to  insignificant  pruritus  in  the  white  race 
as  well.  Pain  likewise  is  rarely  noted  in  the  early  syphilodermata, 
although  about  the  anus  and  genitalia,  where  they  are  subjected  to  con- 
siderable heat,  moisture,  and  friction,  not  only  may  the  lesions  become 
somewhat  painful,  but  be  also  itchy  to  a  varying  degree.  The  state- 
ment of  many  patients  with  such  eruptions,  either  voluntarily  or  upon 
interrogation,  that  they  are  or  have  recently  been  suffering  with  an  attack 
of  what  they  think  hemorrhoids  is  not  an  uncommon  one,  and  is,  indeed, 
often  a  suggestive  one.  In  the  later  ulcerating  syphilodermata  there 
may  or  may  not  be  more  or  less  pain;  as  a  rule,  however,  it  is  rarely 
sufficiently  great  to  give  rise  to  complaint. 

Course  and  Duration. — The  syphilodermata  of  the  active  or  sec- 
ondary stage  usually  appear  somewhat  rapidly  and  attain  full  develop- 
ment in  one  or  two  weeks,  after  which,  except  generally  in  the  macular 
syphiloderm,  it  is  not  uncommon  for  a  few  new  lesions  to  show  them- 
selves irregularly  for  a  short  time.  In  some  cases  there  is  but  a  scanty 
scattered  outbreak  at  first,  followed  in  several  days  or  one  or  two  weeks 
with  a  more  or  less  profuse  outburst.  Exceptionally  the  eruption  re- 
mains scanty  throughout.  After  several  weeks  the  macular  syphilid 
has  generally  pretty  well  declined;  in  the  other  types  there  is  often  a 
somewhat  stationary  period  for  a  month  or  so,  with  now  and  then,  in 
some  cases,  a  slight  recrudescence.  Disappearance  gradually  takes 
place,  however,  in  a  few  months  in  some  instances,  much  longer  in 
others,  occasionally  leaving  more  or  less  persistent  lesions  on  certain 
regions,  as  the  palms.  The  papular  eruption  is  quite  prone  to  slight 
relapses  for  some  months.  In  the  late,  or  tertiary,  eruption  there  is  but 
little  tendency  to  spontaneous  disappearance. 

Concomitant  Symptoms. — Along  with  the  cutaneous  manifestations 
of  the  active  or  secondary  stage  of  syphilis  other  symptoms  of  the 
malady  are  usually  associated.  The  chancre,  as  is  well  known,  often 
persists,  or  its  mark  or  scar  is  found.  The  anatomically  connected 
glands  are  noted  to  be  enlarged,  and  general  adenopathy  is  likewise 
usually  readily  recognized.  Sore  throat,  mucous  patches,  or  superficial 


SYPHILIS 


775 


ulcers  on  the  inner  aspects  of  the  lips,  in  the  mouth,  pharynx,  etc.,  are 
commonly  observed,  in  some  cases  to  considerable  extent,  in  others 
slightly,  and  exceptionally  scarcely  at  all.  Iritis,  cephalagia,  bone 
pains,  etc.,  are  also  sometimes  noted.  The  skin  is  commonly  sallow  or 
dingy  looking,  and  the  patient  anemic,  and  with  a  tendency  at  first  to 
lose  flesh.  It  is  seldom,  however,  that  all  of  these  symptoms  are  observed 
in  one  case — sometimes  but  one  or  two.  In  the  late,  or  tertiary,  syphilo- 
dermata  concomitant  symptoms  are  often  wholly  wanting,  although 
sometimes  bone  lesions,  bone  pains,  alopecia,  superficial  glossitis,  leuko- 
plakia— one  or  more— may  be  present.  Much  more  frequently,  how- 
ever, only  evidences  of  former  disturbances  are  to  be  found,  such  as  scars, 
the  effects  of  iritis,  etc. 

Under  this  head  affections  of  the  appendages  of  the  skin — the  hair 
and  nails — due  to  syphilis,  which  are  also  incidentally  referred  to  under 
diseases  of  these  parts,  can  be  here  conveniently  briefly  described  before 
taking  up  the  individual  eruptions  proper.  Alopecia,1  or  hair  loss, 
consisting  of  a  general  falling  of  the  hair  (defluvium  capillorum),  more 
particularly  the  scalp  hair,  is  noted  in  the  early  period  of  the  secondary 
stage,  but  rarely  amounts  to  visible  baldnesSj  but  is  more  of  a  simple 
thinning.  The  amount  varies  in  different  cases,  in  some  the  loss  daily 
being  considerable,  in  others  slight,  and  frequently  scarcely  enough  to 
attract  the  patient's  notice.  It  is  not  only  due  directly  to  the  infection 
itself,  but  sometimes  indirectly  also  to  the  seborrheic  condition,  which 
the  disease  not  infrequently  engenders.  Exceptionally,  but  usually 
later  in  the  course  of  the  disease,  instead  of  a  general  thinning  it  occurs 
in  ill-defined  and  incomplete  small  and  irregular,  sometimes  coalescent, 
patches — not  the  clearly  cut  patches  of  true  alopecia  areata — which  give 
the  scalp  a  "moth-eaten  or  mangy  appearance,"  its  common  region  being 
the  posterior  half  of  the  scalp.  The  hair  also  shares  in  the  general 
"dinginess"  which  the  disease  often  produces,  becoming  dry,  more  or 
less  lusterless  and  lifeless  looking,  associated  with  the  sallow  or  dingy 
appearance  of  the  skin,  especially  of  the  face.  As  a  rule,  in  hair  loss 
due  to  this  disease,  full  or  tolerably  complete  regrowth  takes  place  if  the 
patient  is  not  advanced  in  years  or  has  no  family  tendency  to  baldness — 
in  such  the  loss  is  not  usually  replaced.  In  cases  where  ulcerative  lesions 
occur  upon  the  scalp,  as  occasionally  in  the  late  or  tertiary  stage,  and 
exceptionally  earlier,  the  follicles  are  destroyed,  and  in  such  spots  or 
areas  the  loss  is  permanent. 

The  nails  of  fingers  or  toes  (syphilis  of  the  nails}  are  also  occasionally 
involved,  either  one,  several,  or  more.  Both  onychia  and  paronychia  are 
met  with,  usually  in  the  active  secondary  stage,  in  acquired  syphilis,  as 
well  as  in  hereditary  syphilis,  referred  to  later.  The  usual  initial  factor 
is  the  presence  of  syphilitic  lesions,  generally  papules  or  ill-defined  infil- 
tration, of  the  bed,  matrix,  or  nail-folds.  There  is  commonly  observed 
resulting  nutritive  disturbance,  as  shown  by  thickening,  brittleness  or  fri- 
ability, and  opacity,  and  often  furrows,  depressions,  or  other  irregulari- 
ties; if  the  underlying  infiltration  is  marked  and  inflammatory,  sometimes 

1  Klotz,  "Remarks  on  Syphilitic  Alopecia,"  Jour.  Cutan.  Dis.,  1907,  p.  99,  con- 
tributes an  interesting  paper  on  this  greatly  overrated  symptom. 


•j-jb  NEW  GROWTHS 

with  a  tendency  to  ulceration,  the  nail  is  usually  uplifted,  but,  as  a  rule, 
more  or  less  incompletely,  at  first  at  least,  becoming  more  detached  later, 
and  not  infrequently  dropping  off.  Generally  the  nails  are  replaced, 
although  at  first  may  be  ill  formed.  In  other  instances  there  are  no 
visible  traces  of  distinct  irritation  or  infiltration  of  the  bed,  matrix,  or 
surrounding  parts,  the  nails  showing  merely  the  effect  of  the  general 
impaired  nutrition  produced  by  the  disease  and  its  exacerbations ;  they 
become  somewhat  opaque,  brittle,  tend  to  break  at  the  free  edges,  and 
occasionally  exhibit  furrows  or  other  evidences  of  nutritive  disturbance. 
Instead  of  chiefly  limiting  itself  to  the  bed  and  matrix  of  the  nail, 
the  inflammatory  or  infiltrating  process  may  extend  to  the  surround- 
ing parts,  or  it  may  begin  at  the  latter,  and  a  somewhat  variable  grade 
of  paronychia  results,  with  the  usual  symptoms  of  this  condition.  The 
skin  surrounding  the  nail  is  reddened,  swollen,  the  tissues  infiltrated,  and 
suppuration  or  ulceration  may  result,  and  give  forth  a  fetid  discharge. 
If  severe,  the  finger-end  may  show  club-like  enlargement,  but  this  is 
never  so  well  marked  as  in  infants  in  hereditary  syphilis.  In  fact,  cases 
vary  considerably;  Taylor  divides  paronychia  into  three  forms:  ulcera- 
tive,  indolent,  which  is,  as  a  rule,  non-ulcerative,  and  the  diffuse;  the  non- 
ulcerative  form,  usually  starting  as  a  more  or  less  continuous  band  of 
infiltration;  the  ulcerative  form,  beginning  as  a  papule  or  pustule  at  the 
lateral  edge  or  as  an  ulcer  or  fissure  at  the  border  of  the  lunula;  and  the 
diffuse  variety,  as  a  hyperemia,  involving  the  surrounding  parts,  and 
later  the  end  of  the  terminal  phalanx,  and  followed  by  infiltration  and 
bulbous  swelling.  The  nail  is  frequently  discolored,  and  also  often 
exhibits  other  changes,  such  as  just  referred  to,  and  may  fall  off.  In 
the  usual  grade  of  cases  met  with,  however,  this  does  not  result.  One 
or  several  may  be  involved,  and  either  of  the  fingers  or  toes.  As  a  rule, 
there  is  not  sufficient  pain  to  give  rise  to  actual  discomfort,  and  not  in- 
frequently, unless  knocked,  the  affected  part  is  practically  painless.1 

Macular  Syphiloderm  (Synonyms:  Macular  syphilid;  Eryth- 
ematous  syphiloderm  or  syphilid;  Syphiloderma  maculosum;  Syphilo- 
derma  erythematosum ;  Syphilis  cutanea  maculosa;  Roseola  syphilitica; 
Exanthematous  syphiloderm  or  syphilid). — This  is  usually  the  earliest 
and  most  common  of  the  secondary  syphilitic  cutaneous  manifestations, 
appearing  commonly  about  six  to  eight  weeks  after  inoculation,  although 
its  appearance  occasionally  is  somewhat  later.  It  is  generally  distributed, 
being  most  abundant,  as  a  rule,  on  the  sides  of  the  trunk  and  axillary  folds, 
the  umbilical  region,  the  neck,  and  the  flexor  aspects  of  the  arms.  The 
palms  and  soles  also  generally  show  numerous  lesions,  with  often  in  some 
a  tendency  to  become  maculopapular  or  papular.  The  face  and  dorsal 

1 1  have  never  been  able  to  convince  myself  that  the  nail  changes  in  syphilis — 
except  those  dependent  upon  or  associated  with  eruptive  lesions — present  any  special 
diagnostic  characteristics  or  condition  which  might  not  occur  with  or  in  the  wake  of 
other  constitutional  diseases  of  a  similarly  grave  and  prolonged  character.  Others  are, 
however,  not  of  this  opinion.  The  reader  interested  in  this  subject  is  referred  to  the 
general  literature  references  under  "Diseases  of  the  Nails,"  and  also  to  a  recent  paper  by 
Adamson  and  McDonagh,  Brit.  Jour.  Derm.,  1911,  p.  68,  who  in  reporting  two  unusual 
forms  of  syphilitic  nails,  give  a  good  brief  resume  (with  good  illustrations). 


Macular  syphiloderm,  with  some  maculopapules  on  the  lower  part. 


SYPHILIS  777 

surface  of  the  hands  and  feet  frequently  escape,  although  ill-defined 
papules  may  sometimes  be  seen  associated  at  the  corners  of  the  mouth 
and  at  the  nasolabial  folds.  The  eruption  may  come  out  at  once,  or 
gradually  for  a  period  of  several  days  or  longer,  and,  especially  in  in- 
stances of  sudden  outbreak,  is  often  preceded  and  for  a  time  accompanied 
with  febrile  action.  In  many  of  these  latter  cases  a  hot  bath  or  violent 
exertion  or  excitement  often  seems  to  be  the  immediate  exciting  factor. 

The  eruption  consists  of  small  or  large,  commonly  pea-  or  bean- 
sized,  rounded  or  irregularly  shaped,  sometimes  slightly  raised,  macules, 
which,  when  well  established,  do  not  entirely  disappear  under  pressure. 
They  show  no  disposition  to  crescentic  or  other  peculiar  shapes,  although 
in  a  few  instances  there  are  associated  maculopapular  or  papular  lesions 
about  the  mouth,  chin,  and  neck,  and  which  may  exhibit  a  tendency  to 
annular  configuration  (annular  or  circinate  syphiloderm).  At  first  the 
color  of  the  macules  is  a  pale  pink  or  dull,  violaceous  red,  later,  after  sev- 
eral days  or  a  week,  becoming  yellowish  red  or  coppery.  The  efflorescences 
are  usually  profuse,  frequently  crowded,  but  rarely  forming  coalescing 
areas;  often  they  are  faint,  and  do  not  show  clearly  until  the  surface 
has  been  exposed  for  several  minutes — cold  always  makes  the  eruption 
stand  out  more  boldly.  In  cases  in  which  the  lesions  are  of  a  violaceous 
tinge  the  skin  is  given  a  marbled  look,  especially  when  exposed  to  a  cool 
atmosphere.  In  some  cases,  instead  of  an  abundance  and  closely 
crowded,  the  macules  are  present  in  scanty  number  and  widely  scattered, 
and  could  readily  escape  observation.  In  fact,  in  quite  a  number  of 
instances  it  is  so  mild  that  patients  are  first  made  aware  of  its  presence 
by  the  physician,  who,  led  by  the  existence  of  suspicious  sore  throat, 
mucous  patches,  or  the  initial  sore  or  glandular  swelling,  for  one  or  all  of 
which  he  may  have  been  consulted,  makes  a  general  examination  of  the 
surface.  There  are  no  subjective  symptoms. 

After  persisting  for  one  to  several  weeks,  it  gradually  or  somewhat 
rapidly  disappears,  usually  without  desquamation,  although  slight 
scaling  or  exfoliation  is  not  uncommon  in  those  macules  which  tend 
to  papular  development,  and  which  is  not  unusual  with  lesions  on  the 
palms.  Slight  or  moderate  brownish-yellow  pigmentation  may,  in  some 
cases,  remain  for  some  weeks  or  longer.  Occasionally  there  may  be  a 
slight  recurrence,  in  which  the  macules  are  usually  scanty  in  number 
and  somewhat  larger  than  ordinarily,  and  sometimes  tend  to  annular  • 
configuration  (annular  or  circinate  syphilid). 

In  some  instances  many  of  the  lesions  of  the  macular  eruption  show 
a  tendency  toward  papular  development,  usually  reaching  a  midway 
stage,  forming  maculopapules ;  and  occasionally  this  occurs  with  almost 
the  entire  eruption,  so  that  it  is  more  clearly  designated  maculopapular 
in  type.  Even  if  this  tendency  does  not  present,  it  is  not  uncommon 
to  find  a  few  such  lesions  in  the  palms  or  soles  and  about  the  genitalia 
or  anus,  in  the  latter  two  situations  often  becoming  well-developed 
papules,  which  may  become  macerated  and  moist.  The  macular  syphilo- 
derm disappears  rapidly  under  specific  constitutional  remedies. 

The  diagnosis  of  the  macular  syphiloderm  is  rarely  attended  with 
difficulty,  inasmuch  as  it  is  commonly  associated  with  other  syphilitic 


NEW  GROWTHS 

manifestations,  such  as  a  few  or  more  scattered  maculopapules  or 
papules,  sore  throat,  mucous  patches,  moist  papules  about  the  anus, 
falling  of  the  hair;  and,  in  most  cases,  the  chancre  is  still  present.  The 
presence  or  absence  of  such  concomitant  symptoms  is  of  greatest  value  in 
the  diagnosis.  It  is  to  be  distinguished  chiefly  from  measles,  rotheln, 
tinea  versicolor,  and  some  drug  eruptions.  Measles  is  to  be  differentiated 
by  its  catarrhal  symptoms,  fever,  crescentic  and  blotchy  character,  and 
the  situation  of  the  eruption,  all  of  which  differ  materially  from  those 
of  the  macular  syphiloderm.  Too  much  stress  is  not,  however,  to  be 
placed  upon  the  febrile  action,  as  this  sometimes  may  be  quite  sharp  in 
syphilis.  In  rotheln  there  are  small,  roundish,  confluent,  pinkish  or 
reddish  patches,  with  no  tendency  to  pigmentation,  and  which  are  of 
short  duration;  there  is,  moreover,  usually  evidence  of  its  epidemic  char- 
acter, and  slight  catarrhal  symptoms,  as  in  measles.  The  erythematous 
drug  rashes  sometimes  following  the  ingestion  of  copaiba,  cubebs,  bella- 
donna, opiates,  etc.,  are  a  much  more  vivid  red  or  scarlet,  and  are,  as 
a  rule,  quite  itchy  and  of  short  duration.  The  evanescent  wheal  of  urti- 
caria, with  the  accompanying  itching,  and  the  punctate  scarlet  redness  of 
scarlatina,  are  so  unlike  the  macular  syphiloderm  that  confusion  with 
these  diseases  is  scarcely  possible.  The  differentiation  from  tinea 
versicolor  is  mentioned  under  the  latter  disease. 

Pigmentary  Syphiloderm1  (Synonyms:  Syphiloderma pigmento- 
sum;  Syphilitic  leukoderma;  Vitiligo  acquisita  syphilitica) — This  is  a  rare 
manifestation  about  the  correct  nosology  of  which  there  has  been  much 
difference  of  opinion.  It  is  now  pretty  generally  conceded,  however, 
that  it  is  of  syphilitic  origin,  although  some  authors  still  maintain  that 
it  has  no  direct  relationship  to  this  disease.  While  first  described  by 
Hardy  in  1853,  it  was  not  until  Fournier's  presentation  of  it  (1873) 
that  it  received  much  attention.  Since  then  various  observers,  among 
whom  G.  H.  Fox,  Atkinson,  Taylor,  Maireau,  Pcelchen,  Malherbe, 
Neisser,  and  Maieff  have  reported  cases  or  contributed  special  papers. 
It  is  essentially  a  macular  eruption,  although  totally  unlike  the  macular 
syphiloderm  as  commonly  met  with  and  just  described;  the  former  is  one 
of  pigmentary  changes  pure  and  simple,  the  latter  due  to  hyperemia. 
It  appears  during  the  earlier  secondary  stage  or  toward  the  end  of  the 
first  year,  although  it  sometimes  does  not  present  until  a  later  period. 
The  region  of  the  neck  and  shoulders  is  its  usual  location,  Fournier  stating 

1  Principal  literature:  Hardy,  Maladies  de  la  peau,  Paris;  Fournier,  Lefons  stir  la 
syphilis,  etudiee  phis  particulierment  chez  la  femme,  Paris,  1873,  p.  422  (with  colored 
plate);  G.  H.  Fox,  "On  the  So-called  Pigmentary  Syphilid,"  Amer.  Jour.  Med.  Sci., 
April,  1878;  Atkinson,  "The  Pigmentary  Syphiloderm,"  Chicago  Med.  Jour,  and  Exam., 
1878,  vol.  Ixxxvii,  p.  340;  Neisser,  "Ueber  das  Leucoderma  syphiliticum,"  Archiv, 
1883,  p.  491;  Taylor,  "On  the  Pigmentary  Syphilid,"  Jour.  Culan.  Dis.,  1885,  p.  97; 
Pcelchen,  "Vitiligo  acquisita  syphilitica,"  Virchow's  Archiv,  1887,  vol.  cvii,  p.  535 
(with  2  colored  plates);  Malherbe,  "Deux  cas  de  syphilide  pigmentaire  chez  rhomme," 
Gazette  med  de  Nantes,  Dec  12,  1895,  p.  13  (2  cases),  abs.  in  Annales,  1896,  p.  968; 
Maieff,  "Contribution  a  1'etude  de  la  syphilide  pigmentaire,"  Trans.  Internal.  Dermal. 
Congress,  Paris,  1889,  p.  677  (with  bibliography);  Maireau,  "Syphilide  pigmentaire," 
These  de  Pan's,  1884  (with  literature  references);  Lang,  Vorlesungen  uber  Pathologic  und 
Therapie  der  Syphilis,  Wiesbaden,  1896,  p.  208  (with  cut);  Ehrmann,  "Ueber  Haut- 
farbung  durch  secondar-syphilit.  Exanthemata,"  Archiv,  1891,  p.  79. 


SYPHILIS  779 

that  in  but  i  in  30  cases  is  it  found  elsewhere  than  on  the  neck,  although 
it  may  also,  however,  exceptionally  invade  other  parts. 

According  to  Taylor,  three  forms  are  encountered:  (i)  as  spots  or 
variously  sized  brownish  patches;  (2)  more  or  less  diffused  brownish 
discoloration,  which  subsequently  becomes  the  seat  of  small,  spotty, 
leukodermic  changes,  which  increase  in  size,  and  the  general  appearance 
of  which  is  retiform  (retiform  pigmentary  syphiloderm  or  syphilid); 
(3)  an  abnormal  or  uneven  distribution  of  pigment,  the  surface  having 
a  dappled  or  marmoraceous  aspect  (marmoraceous  pigmentary  syphilid). 
The  first,  spot  or  patchy  form,  varies  in  color  between  a  light  and  dark 
brown,  and  the  spots  or  patches  are  rounded  or  oval,  sometimes  with 
irregularly  jagged  edges,  and  not  commonly  with  uniform  pigmentation, 
the  bordering  part  frequently  showing  the  deeper  shade.  Intervening 
white  skin  looks  relatively  of  diminished  normal  pigmentation.  The 
second  or  diffused  form  is  the  most  usual  type  encountered,  beginning  at 


Fig.  176. — Pigmentary  syphiloderm  (neck  and  shoulders) ;  was  first  diffused  pig- 
mented,  the  vitiligo-like  spots  subsequently  appearing  (syphilitic  leukoderma);  pre- 
sented about  the  sixth  to  eighth  month  of  the  disease.  Patient  a  woman. 

the  neck,  especially  at  the  sides,  where  it  may  remain,  or  it  may  invade 
the  trunk  and  arms.  Its  appearance  may  be  rapid  or  gradual.  Sooner 
or  later  white  points  or  spots  show  themselves,  and  the  condition  is  some- 
what suggestive  of  leukoderma.  Generally  it  is  this  change  which  first 
calls  the  attention  of  the  patient  to  the  existing  discoloration.  The 
third  variety  is  the  rarest  of  all,  and  its  advent  is  insidious,  and  is  always 
seen  (Taylor)  on  the  sides  of  the  neck,  with  no  tendency  to  spread. 
According  to  Taylor,  there  is  no  hyperpigmentation,  primarily  at  least, 
but  the  process  is  more  that  of  irregular  pigment  absorption,  the  inter- 
vening remaining  normally  pigmented  spots  appearing  dark  by  compari- 
son; other  observers,  however,  have  noted  the  contrary.  For  some  time 
the  manifestation  was  considered  to  occur  in  women  only,  but  this  is 
now  known  to  be  erroneous,  as  it  has  been  also  observed,  although  much 
less  frequently,  in  males  by  Chambard,1  Malherbe  (loc.  cit.),  and  others. 
It  is  much  more  common  in  brunettes. 

1  Chambard,  cited  by  Crocker,  Diseases  of  the  Skin. 


780  NEW  GROWTHS 

There  is  a  diversity  of  views  as  to  whether  this  eruption,  if  it  may 
be  so  called,  arises  as  such  or  is  in  reality  a  vitiligo  of  syphilitic  origin, 
originating  in  the  spots  of  a  preceding  syphiloderm  (Fox,  Lang,  Neisser, 
Poelchen).  Its  duration  is  variable, — from  a  few  months  to  several  years 
or  more, — it  is  without  subjective  symptoms,  and  is  wholly  uninfluenced 
by  antisyphilitic  remedies,  in  this  respect  differing  from  all  other  syphilitic 
manifestations;  and  this  last  fact,  it  must  be  confessed,  gives  some 
grounds  for  at  least  questioning  whether  it  is  a  syphilitic  manifestation 
sui  generis,  or  a  chloasmic  condition  dependent  upon  a  syphilitic  cachexia 
or  upon  a  previous  evanescent,  ordinary,  macular  syphiloderm.  In 
some  instances  of  syphilodermata,  usually  in  the  late  secondary  stage, 
may  be  seen  dark  blue  or  livid  spots  on  the  trunk  chiefly,  interspersed 
among  the  eruptive  lesions;  Ehrmann  (1907),  who  first  described  them 
and  gave  the  name  Livedo  racemosa,  thought  them  due  to  endothelial 
proliferation  in  the  arterioles,  interfering  with  the  blood-current.1 

In  the  diagnosis  care  is  to  be  exercised  that  the  pigmentary  syphilo- 
derm be  not  confused  with  ordinary  chloasma,  vitiligo,  and  tinea  versi- 
color.  Its  usual  limitation  to  the  neck,  with  little  if  any  tendency  to 
appear  in  other  situations,  is  unusual  with  these  several  affections; 
tinea  versicolor,  moreover,  always  involves  at  least  the  upper  chest  region 
as  well,  and  its  slight  furfuraceous  or  branny  scaliness  noted  when  the 
skin  is  dry  is  another  differential  factor  to  which  many  more  would,  if 
necessary,  readily  suggest  themselves  by  referring  to  the  description  of 
that  malady. 

Papular  Syphiloderm  (Synonyms:  Papular  syphilid;  Syphilo- 
derma  papulosum;  Syphilis  cutanea  papulosa) . — There  are  several  va- 
rieties of  the  papular  syphiloderm,  which,  inasmuch  as  they  differ  ma- 
terially in  clinical  appearances,  can  be  most  conveniently  considered 
separately,  under  the  heads  of  the  miliary  papular  syphiloderm,  flat  pap- 
ular syphiloderm,  and  the  papulosquamous  syphiloderm. 

Miliary  Papular  Syphiloderm  (Synonyms:  Miliary  papular  syphilid; 
Acuminated  papular  syphiloderm  or  syphilid;  Follicular  syphiloderm 
or  syphilid ;  Syphilitic  lichen ;  Lichen  syphiliticus) . — The  miliary  papular 
syphiloderm  is  a  tolerably  common  manifestation  of  secondary  syphilis, 
but  much  less  so  than  the  flat  papular  eruption.  Other  associated  symp- 
toms of  the  active  stage  of  syphilis  are  naturally  usually  to  be  found. 
It  may  appear  apparently  independently  of  an  earlier  macular  syphilid, 
and  most  frequently  between  the  third  and  fourth  months.  In  contra- 
distinction from  the  flat  papular  eruption  it  is  follicular — connected  with 
the  hair-follicles.  There  are  two  varieties — the  small  miliary  papular 
syphiloderm  and  the  large  miliary  papular  syphiloderm,  although  there 
is  in  reality  but  slight  difference,  and  therefore  the  variety  is  not  always 
clearly  defined.  In  the  small  miliary  papular  syphiloderm  the  lesions 
are  pin-head  in  size,  in  the  larger  form  two  or  three  times  as  large.  They 
may  be  acuminate  or  somewhat  rounded.  As  a  rule,  the  eruption  comes 
out  rapidly,  and  continues  to  appear  for  several  days  or  one  or  two  weeks. 

1  Schmidt  (Archiv,  Oct.,  1912)  reports  an  additional  case,  and  briefly  reviews 
Ehrmann's  paper. 


SYPHILIS 


781 

It  is  usually  most  abundant  upon  the  shoulders,  upper  part  of  trunk, 
arms,  and  thighs.  It  is  also  frequently  in  profusion  upon  the  face.' 
The  lesions  are  often  closely  crowded,  with  a  tendency  to  form  groups 
and  aggregations,  this  being  especially  shown  in  relapses  or  when  the  erup- 
tion appears  rather  late.  In  relapses  they  may  also  tend  to  form  seg- 
mental  and  circular  grouping.  At  first  they  may  be  of  a  pinkish-red 
color,  but,  as  a  rule,  and  always  sooner  or  later,  they  are  of  a  dull  or 
ham-red  color,  with  a  brownish  or  violaceous  tinge,  are  solid  and  some- 
what rough  to  the  touch,  and  in  the  larger  lesions  there  may  be  slight  or 
scarcely  perceptible  central  depression  or  umbilication.  Generally, 
however,  they  are  somewhat  acuminate  or  conic,  often  with  a  slightly 


Fig.  177. — Papular  and  papulotubercular  syphiloderm;  eruption  general. 

scaly  apex,  and  not  infrequently  show  minute,  vesicopustular  or  pustular 
summits.  In  fact,  it  is  not  at  all  uncommon  to  see  a  slight  or  moderate 
sprinkling  of  miliary  pustules.  There  are  sometimes  also  several  or  more 
scattered  flat  papules,  especially  about  the  genitalia  and  anus,  where 
they  frequently  change  into  moist  papules.  After  lasting  for  some  weeks 
or  a  few  months  there  is  a  slight,  sometimes  moderately  well-marked, 
tendency  toward  spontaneous  disappearance;  the  color  becomes  duller 
or  more  somber,  and  especially  as  the  papules  sink  away  there  is  often 
around  the  outer  portion  a  collar  or  collarette  of  film-like  scaliness. 

The  miliary  papular  syphiloderm  is,  as  already  intimated,  somewhat 
chronic  in  its  course,  and  often  persists  for  months,  and  is,  when  com- 


782  NEW  GROWTHS 

pared  with  the  macular  and  flat  papular  syphilodermata,  slow  to  respond 
to  treatment.  Those  having  vesicopustular  or  pustular  summit  show  a 
capping  of  brownish,  thin,  desiccated  crusting.  During  its  existence 
it  is  not  uncommon  to  see  scattered  fresh  papules,  and  sometimes  a  few 
pustules  appear  at  irregular  intervals.  Like  the  others,  there  is  rarely 
any  complaint  of  subjective  symptoms,  but  in  the  negro  there  seems  to 
be  considerable  itching  associated  with  this  type.  Minute  brownish 
stains  marking  the  sites  of  the  lesions  are  left  for  a  variable  period — 
sometimes  for  months;  there  is  no  scarring,  unless  with  pustular  lesions, 
which  may  leave  insignificant  atrophic  or  cicatricial  points  or  pits. 

The  diagnosis  of  the  miliary  papular  syphiloderm  is  to  be  based 
upon  distribution  and  extent  of  the  eruption,  the  color,  the  tendency 
to  group  and  form  aggregations,  and  the  presence  usually  of  some  lesions 
with  pustular  summits,  often  scattered  minute  pustules,  and  occasion- 
ally a  few  large  papules  and  pustules;  these  features,  together  with  the 
existence  of  one  or  several  associated  symptoms  of  syphilis,  will  scarcely 
permit  of  error.  It  is  not  to  be  confused  with  keratosis  pilaris,  psoriasis 
punctata,  pityriasis  rubra  pilaris,  papular  eczema,  or  lichen  planus. 
Keratosis  pilaris  is  most  pronounced  and  often  limited  to  the  thighs, 
sometimes  also  on  the  arms,  but  rarely  on  the  trunk;  there  is  no  crowding 
or  aggregation,  it  is  often  itchy,  and  usually  already  of  long  duration 
when  advice  is  sought,  with  but  little  tendency  to  spontaneous  disap- 
pearance. The  lesions  of  psoriasis  in  the  earliest  formation  bear  some 
resemblance,  but  are  not  follicular,  do  not  tend  to  form  groups  and  aggre- 
gations, and  are  all  scaly  papules,  with  no  pustular  tendency,  and  the 
distribution,  while  it  may  be  more  or  less  general,  is  usually  most  pro- 
nounced about  the  extensor  surfaces  of  the  legs  and  arms;  it  is  chronic, 
and  commonly  a  history  of  long  duration  is  given,  and  there  is,  more- 
over, a  definite  tendency  to  enlargement  of  the  lesions  into  plaques, 
which  may  become  confluent.  Pityriasis  rubra  pilaris  is  a  scaly  papular 
follicular  disease,  but  without  disposition  to  pustulation,  and  with  a 
tendency  to  confluence,  marked  scaliness,  and  progressive,  persistent 
spread  and  chronicity.  The  marked  itchiness  of  papular  eczema,  its 
usually  limited  distribution  and  tendency  to  solid  confluent  patches, 
the  vivid  red  color,  and  often  associated  vesicles,  will  serve  to  prevent 
mistake.  Probably  its  strongest  resemblance  in  some  instances  is  to 
lichen  planus,  but  this  latter  is  rarely  generalized,  favorite  situations 
being  the  lower  part  of  the  legs  and  forearms,  to  which  it  is  often  limited; 
there  is  a  decided  tendency  to  confluence  and  solid  scaly  patch-formation; 
it  is  usually  slow  in  its  advent  and  persistent,  often  slowly  progressive, 
and,  as  a  rule,  very  itchy.  The  scattered  aggregations  of  relapses  may 
suggest  lichen  scrofulosus,  but  this  latter  is  a  rare  affection,  usually 
occurring  as  several,  rarely  more,  livid  or  brownish  papular  aggregations, 
of  chronic,  persistent  character,  and  commonly  associated  with  other 
evidences  of  the  scrofulous  diathesis. 

Flat  Papular  Syphiloderm  (Synonym:  Lenticular  papular  syphilo- 
derm or  syphilid). — The  lesions  vary  in  size  from  that  of  a  pin-head  to 
a  bean  or  larger.  In  some  instances  the  eruption  is  made  up  entirely  or 
predominantly  of  papules  scarcely  larger  than  a  pea,  and  in  others  almost 


PLATE  XXIII. 


Miliary  papular  syphiloderm  with  a  tendency  in  some  lesions  to  become  pustular  at  the 
summit ;  shows  the  disposition  toward  small  aggregations. 


SYPHILIS  783 

all  the  lesions  are  large — pea-  to  large  coin-size — hence  the  two  so-called 
varieties — the  small  flat  papular  syphiloderm  and  the  large  flat  papular 
syphiloderm.  The  papules  are  flattened,  often  but  slightly  elevated, 
rounded  or  ovalish  in  contour,  dull  or  brownish  red  in  color,  and  to  the 
touch  often  disclose  considerable  infiltration  or  depth,  at  least  as  com- 
pared to  elevation  above  the  surface.  The  lesions  are  generally  dis- 
tributed, with  but  little  tendency  to  closely  crowded  aggregations, 
except  in  some  cases  of  the  small  papular  syphiloderm,  in  which  the  region 


Fig.   178. — Small  flat  papular  syphiloderm,  of  general  distribution   and  extensive 

development. 

of  the  nose  is  a  favorite  site  for  some  bunching,  here  partaking  sometimes 
of  the  nature  of  tubercles,  being  papulotubercular  in  character.  Ordi- 
narily in  the  flat  papular  syphiloderm  there  is  no  disposition  to  coa- 
lescence, the  lesions  remaining  discrete.  The  eruption  is  rarely  so  abun- 
dant as  in  the  miliary  papular  syphiloderm,  and,  as  a  rule,  there  is  less 
tendency  in  this  type  to  admixture  of  other  forms,  although  sometimes 
some  macules  or  maculopapules  and  a  few  scattered  pustules  can  be 
found,  and  occasionally  some  miliary  papules.  The  eruption  is  found 
on  all  parts — scalp,  face,  trunk,  and  limbs;  the  flexor  aspects  of  the  last 


784  NEW  GROWTHS 

usually  show  a  preponderance  over  the  extensor  surfaces.  The  corners 
of  the  mouth,  the  nasolabial  folds,  the  forehead  near  the  hair-border,  the 
palms,  and  the  genitocrural  and  anal  regions  are  favorite  situations  for 
lesions.  The  irregularly  arranged  line  of  papules  on  the  forehead,  at 
the  hairy  border,  is  commonly  present  in  this  and  sometimes  in  other 
forms  of  syphilitic  eruption,  and  has  been  termed  corona  veneris. 

This  syphiloderm  is  a  common  one,  and  may  be  in  some  cases  the 
first  recognized  cutaneous  eruption  of  syphilis,  occurring  usually  several 
or  more  months  after  the  appearance  of  the  initial  lesion.  In  other 
instances  it  follows  after  the  macular  syphiloderm — probably  much  more 
frequently  so  than  clinical  experience  would  indicate,  the  macular  erup- 
tion often  being  slight  and  readily  overlooked.  The  eruption  comes  out, 
as  a  rule,  somewhat  rapidly,  although  in  some  instances  its  full  develop- 
ment is  not  reached  for  several  weeks  or  more.  Occasionally  it  is  some- 
what scanty,  the  lesions  being  seen  chiefly  about  the  favorite  regions. 


Fig.  179. — Annular  syphiloderm. 

In  other  cases  they  are  merely  a  relatively  insignificant,  associated  part 
of  a  macular  syphilid.  At  first  the  papules  are  perfectly  smooth,  some- 
times the  surface  slightly  glossy,  but  later  it  is  not  uncommon  for  them 
to  become  covered  with  a  thin  film  of  exfoliating  epidermis. 

While  they  are  generally  all  rounded  or  oval  in  shape  and  persist 
as  such,  with  no  tendency  to  special  or  peculiar  configuration,  excep- 
tionally, however,  annular  or  distinct  ring-like  patches  (annular  syph- 
iloderm, circinate  syphiloderm)  are  observed,  especially  about  the 
region  of  the  mouth,  forehead,  and  neck,  in  association  with  the  eruption 
of  ordinary  rounded  or  oval  patches  on  other  parts.  This  lesion  consists 
of  a  distinctly  elevated,  solid  ridge  or  band  peripherally,  and  a  more 
or  less  flattened  central  portion.  It  seems  to  have  its  origin  from  an 
ordinary,  usually  scaleless  or  slightly  scaly,  large  papule,  the  central 
portion  of  which  has  been  incompletely  formed  or  has  become  sunken 
and  flattened;  and  also  from  a  spreading  small  papule,  the  central  part 
sinking  or  disappearing  as  it  extends.  It  may  doubtless  occasionally 


PLATE  XXIV. 


Papular  and  papulosqunmous  syphiloderm. 


SYPHILIS 


785 


develop  from  other  lesions  (Hazen),  possibly  may  exceptionally  arise 
as  ring-shaped  lesions  from  the  beginning.  It  is  also  seen  occasionally 
in  association  with  the  macular  eruption,  in  which  the  band-like  ring  is 
but  slightly  elevated.  It  is  an  unusual  manifestation  in  the  whites,  but 
not  at  all  uncommon  in  the  negro.1  In  very  rare  instances  the  eruption, 
especially  about  the  face  and  scalp,  may  present  as  closely  arranged 
segments,  sometimes  of  such  elaborate  arrangement  or  design  as  to  sug- 
gest a  resemblance  to  scroll  work. 

In  most  cases  after  several  weeks  or  a  few  months  they  begin  to  de- 
cline, passing  away  by  absorption,  leaving  slight  pigmentation,  which 
eventually  disappears.  Not  infrequently  there  is  tendency  from  time 
to  time  to  less  extensive  outbreaks,  and  the  eruption  may  thus  persist 


1 80. — Annular  syphiloderm    (cour- 
tesy of  Dr.  Howard  Fox). 


Fig.  181. — Annular  syphiloderm — 
showing  scroll-work  tendency  (courtesy 
of  Dr.  Howard  Fox). 


for  some  months.  As  a  rule,  it  responds  rapidly  to  treatment,  although 
palmar  and  also  plantar  lesions  are  often  obstinate,  and  on  these  regions 
persistency  and  recurrence  are  frequently  noted — palmar  syphiloderm, 
plantar  syphiloderm.  In  some  situations,  moreover,  as  about  moist, 
contiguous  surfaces,  papules  are  apt  to  undergo  certain  changes,  resulting 
in  the  formation  of  the  moist  papule.  These  several  forms  will  be  espe- 
cially referred  to  later. 

1  Howard  Fox,  "The  Annular  Lesions  of  Early  Syphilis  in  the  Negro,"  Archrv.,  1912, 
cxiii,  with  brief  review,  and  excellent  case  illustrations;  refers  to  previous  papers  on 
the  same  subject  by  Atkinson,  Jour.  Cutan.  Dis.,  1883,  p.  15;  Gilchrist,  Maryland  Med. 
Jour.,  1900,  p.  200,  and  his  own  earlier  paper,  "Observations  on  Skin  Diseases  in  the 
Negro,"  Trans.  VI,  Internal.  Dermal.  Congress,  1907,  vol.  i,  p.  198.  Hazen,  "The 
So-called  'Annular  Syphilis'  of  the  Negro,"  Jour.  Cutan.  Dis.,  1913,  p.  148  (with  illus- 
trations). 
50 


786  NEW  GROWTHS 

In  some  cases  of  the  flat  papular  syphiloderm  there  is  a  distinct 
tendency,  at  times  early  in  the  eruption,  at  others  later,  toward  scale- 
formation,  constituting  the  type  known  as  the  papulosquamous  syph- 
ilodenn  or  syphilid  (also  termed  syphilis  cutanea  squamosa,  squamous 
syphiloderm,  or  syphilid;  and,  from  its  resemblance  to  psoriasis,  the 
misleading  and  erroneous  designation  of  syphilitic  psoriasis,  psoriasis 
syphilitica,  has  sometimes  been  used).  This  tendency  of  the  large  pap- 
ular eruption  to  become  scaly  is,  when  exhibited,  more  or  less  common 
to  all  the  papules,  although  in  some  instances  it  is  observed  only  here 
and  there.  The  papules  usually  become  slightly  less  elevated,  and  are 
covered  with  a  dry,  grayish  or  dirty-gray,  somewhat  adherent  scale. 
The  scaling  on  some  lesions  is  simply  film-like  and  somewhat  wrinkled, 
in  others  more  abundant;  as  a  rule,  as  compared  to  that  of  psoriasis,  it 
is  less  imbricated,  less  shining  or  glistening,  and  relatively  slight  in 
amount.  If  removed,  the  solid,  flat,  dusky-red  colored  papule  is  dis- 
closed. The  eruption  may  be,  as  in  the  ordinary  flat  papular  eruption, 
general,  as  usually  the  case  in  the  earlier  months  of  the  disease,  or  it 
may  appear  as  a  relapse  or  a  later  manifestation,  and  be  limited  in  ex- 
tent. As  a  late  limited  eruption  it  is  most  frequently  seen  on  the  palms 
and  soles,  known  commonly  as  the  palmar  and  plantar  syphiloderm. 
The  distribution  in  the  generalized  cases  is  the  same  as  that  of  the  more 
usual  papular  syphiloderm,  and  is  less  abundant  on  the  extensor  than 
flexor  surfaces  of  the  limbs,  and  there  is,  likewise,  but  little  tendency  to 
coalescence.  It  is  commonly  more  or  less  persistent  for  several  months 
or  longer,  although  it  usually  responds  fairly  promptly  to  treatment. 
There  are  no  subjective  symptoms,  although  in  this  papular  syphiloderm, 
occurring  in  the  negro,  as  in  other  forms,  itching  is  frequently  compl  ined 
of. 

In  the  diagnosis  of  the  flat  papular  syphiloderm  in  the  ordinary 
or  relatively  scaleless  forms  there  is  rarely  any  difficulty.  The  more 
or  less  generally  distributed,  variously  sized,  brownish-red  or  copper- 
colored,  flattened  papules,  showing  infiltration,  are  characteristic;  moist 
papules  are  also  usually  to  be  found  about  the  anus  and  genitalia.  As  it 
is  an  eruption  of  the  active  or  secondary  period  of  syphilis,  other  cor- 
roborative symptoms  will  be  found.  The  differentiation  between  the 
papulosquamous  syphiloderm  and  psoriasis  is  considered  under  the  latter 
disease. 

Palmar  and  Plantar  Syphiloderm.— The  palms  (palmar 
syphilodenn)  and  soles  (plantar  syphiloderm),  especially  the  former, 
are  not  uncommon  seats  of  the  dry  syphilodermata — macular,  macu- 
lopapular,  papular,  papulotubercular,  and  tubercular.  These  parts 
usually  share  in  the  more  or  less  generalized  eruptions  of  the  active 
or  secondary  stage  of  syphilis,  but  they  are  not  infrequently  alone  the 
sites  of  the  relapsing  secondary  eruption,  and  often  show  the  papulo- 
squamous form  at  later  periods  of  the  disease.  It  is  usually  the  latter 
which  furnishes  the  cases  of  the  so-called  palmar  and  plantar  syphiloderm. 
The  thickness  of  the  epiderm  on  these  parts  gives  rise  to  considerable 
modification;  the  lesions  are  but  slightly  elevated  above  the  surrounding 


SYPHILIS 


787 


level,  are  often  rather  ill  defined  peripherally,  and  when  first  appearing 
are  much  more  suggestive  of  macules  than  papules.  There  is  some 
elevation,  however,  and  also  distinct  infiltration.  They  are  rounded  or 
somewhat  irregularly  shaped,  and  in  their  early  stage  brownish  yellow 
or  brownish  red  in  color;  later,  owing  to  the  collection  of  slight  scaliness 
or  from  being  covered  with  dry,  shriveled,  broken  epidermis,  they  are 
dirty  gray  or  grayish  white,  but  when  deprived  of  this  covering,  the 
underlying  surface  or  lesion  has  the  usual  brownish-red  or  ham  color. 
Not  infrequently  there  is  a  slight  central  grayish  or  brownish-gray, 
callus-like  thickening,  surrounded  by  a  partly  visible  band  of  brownish- 
red  underlying  papular  infiltration,  the  color  being  disclosed  by  the  partial 


Fig.  182. — Flat  maculopapular  and  papular  syphiloderm,  with  scaling  tendency; 
generalized,  the  lesions  on  other  parts  being  maculopapular,  papular,  and  papulo- 
squamous. 


or  more  or  less  complete  removal  of  the  thin  scale;  beyond  this  an  en- 
circling rim  of  partially  detached  epidermis,  with  its  loose,  elevated, 
usually  ragged  edge  directed  inwardly.  There  is  often  a  disposition 
toward  coalescence  of  contiguous  lesions,  and  this  results  in  the  formation 
of  irregular,  segmental,  crescentic,  and  serpiginous  patches  or  tracts. 
This  tendency,  particularly  the  serpiginous  and  circinate,  is  observed 
with  the  late  papulotubercular  manifestation,  and  such  patches  often 
creep,  with  a  slightly  elevated  spreading  border,  on  to  the  fingers  or 
up  the  wrist,  and  not  infrequently  toward  and  sometimes  over  to  the 
dorsal  surfaces  of  the  hand  and  fingers.  The  general  appearances  of  the 
papulotubercular  and  tubercular  forms  differ  but  little  from  that  of  the 
ordinary  papulosquamous  just  described,  the  sole  difference  being  that 


788  NEW  GROWTHS 

the  lesions  are  usually  somewhat  deeper  and  showing,  as  a  rule,  more 
infiltration,  and  occasionally  the  tubercular  exhibiting  a  slight  disposi- 
tion here  and  there,  at  the  spreading  edge,  to  superficial  ulceration. 
The  difference  is  so  slight  that,  after  the  eruption  is  once  established, 
it  is  scarcely,  if  at  all,  recognizable;  the  spreading  elevated  infiltrated 
edge  with  ulcerative  tendency  always,  of  course,  indicates  the  papulo- 
tubercular  or  tubercular  syphilid. 

In  some  cases  there  is  a  tendency  to  fissuring  and  the  fissures  may 
be  superficial  or  deep.  The  scaliness  is,  as  a  rule,  scanty,  more  of  the 
nature  of  fragmentary,  ragged,  partially  detached  epidermis,  and  is 
reproduced  slowly.  Occasionally,  however,  it  may  be  more  abundant, 
and  sometimes  collects  to  slight  thickness;  it  is  noted  to  be  quite  hard 
and  horny.  Now  and  then  these  hard,  horny  collections  are  small  and 


Fig.  183. — A  papulosquamous  syphiloderm,  of  the  palm  only;  late  eruption. 


rather  sharply  circumscribed,  extend  somewhat  deeply,  and  which  can, 
with  some  force,  be  dug  out;  sometimes  they  show  "sieve-like  perforations; 
the  French  writers  called  attention  to  this  condition,  which  they  de- 
scribed under  the  name  of  syphilide  cornee.  Exceptionally  palmar  and 
plantar  lesions  remain  more  or  less  persistently  as  maculopapules  or 
papules,  showing  some  epidermic  thickening,  with  but  little  tendency  to 
scale-formation. 

The  eruption  is  sometimes  observed  on  both  palms  and  soles  more  or 
less  symmetrically;  it  may  be  scanty  or  abundant.  More  commonly 
it  is  limited  to  the  palms,  and  not  infrequently  to  one  hand.  It  may  also 
be  confined  to  one  or  both  soles.  It  is  usually  slow  in  its  advent,  spreads 
gradually,  but,  as  a  rule,  does  not  become  extensive,  sometimes  remain- 
ing more  or  less  stationary  for  an  indefinite  time.  The  central  portion 


SYPHILIS  789 

of  the  palm,  the  ball  of  the  thumb,  and  the  volar  surfaces  of  the  fingers 
are  favorite  situations  on  the  hand.     It  is  not  itchy,  but  if  fissuring  is 


Fig.  184. — A  palmar  spreading  papulo-  and  tuberculosquamous  syphiloderm  of  the 
late  period,  showing  the  well-defined  border,  leaving  pigmentation  and  slight  atrophy; 
no  eruption  elsewhere. 

present,  is,  for  this  reason,  often  painful;  the  process  is  sluggish,  more  of 
the  nature  of  an  infiltration  than  inflammation,  although  it  commonly, 


Fig.  185. — A  palmar  papulosquamous  syphiloderm  of  the  late  period;  no  eruption 

elsewhere. 

especially  in  spreading  areas,  presents  on  the  parts  traversed  a  reddish, 
sluggishly  or  slibacutely  inflammatory  aspect,  sometimes  with  an  ap- 


NEW  GROWTHS 


790 

pearance  of  thinning,  and  commonly  scantily  covered  with  adherent 
and  detached  fragments  of  epithelial  scales. 


Fig.  1 86. — A  palmar  tuberculosquamous  syphiloderm  of  the  late  period,  showing  seg- 
mental  configuration;  no  eruption  elsewhere. 

The  palmar  and  plantar  syphiloderm  occurring  late  in  the  disease 
is  a  persistent  obstinate  manifestation,  and  often  extremely  rebellious 


Fig.  187. — A  palmar  papulotubercular  spreading  syphiloderm  of  the  late  period,  with 
ulcerative  tendency,  and  showing  the  sharply  denned  border;  no  eruption  elsewhere. 

to  treatment.     As  a  part  of  a  generalized  eruption  of  the  early  or  active 
stage  it  disappears  usually  along  with  the  eruption  on  other  regions, 


PLATE  XXV. 


Papulotubercular  squamous  syphiloderm ;  undergoing  involution  (courtesy  of  Dr.  M.  B. 

Hartzell). 


SYPHILIS  791 

although  it  may  remain  much  longer  on  these  parts,  finally  yielding 
to  remedies.  As  a  recurrence  of  the  early  generalized  type,  and 
limited  to  these  regions,  it  is  somewhat  obstinate,  but  much  less  so 
than  when  appearing  several  years  or  more  after  the  contraction 
of  the  disease.  The  papulotubercular  or  tubercular  form,  more 
especially  that  with  ulcerative  tendency,  is  generally  much  more 
readily  cured. 

The  diagnosis  of  the  palmar  syphiloderm  is  often  a  matter  of  great 
difficulty.  It  bears  resemblance  to  eczema,  dermatitis  seborrhoica, 
and  possibly  to  psoriasis.  As  a  part  of  an  early  generalized  syphiloderm 
a  conclusion  is  naturally  easily  reached,  but  special  reference  is  here 
made  to  the  eruption  as  fottnd  limited  to  this  region.  Psoriasis  can, 
I  believe,  be  readily  excluded  by  the  fact  that  it  is  never  limited  to  these 
parts  alone,  but  if  found  here,  lesions  will  surely  be  found  about  the 
elbows,  scalp,  and  probably  elsewhere.  It  is  true,  a  few  instances  of 
psoriasis  confined  to  the  palms  have  been  reported,  but  such  have  been 
so  extremely  rare,  and  inasmuch  as  the  clinical  appearances  of  psoriasis 
of  these  parts,  when  seen  exceptionally  in  connection  with  a  generalized 
psoriasis,  are  so  much  like  some  cases  of  eczema,  especially  dermatitis 
seborrhoica,  and  even  like  palmar  syphilis,  that  the  alleged  cases  of 
limitation  to  these  regions  could  much  more  reasonably  be  placed  to  the 
credit  of  either  of  the  latter  two  maladies. 

In  fact,  in  the  diagnosis  only  eczema  and  dermatitis  seborrhoica 
need  be  considered.  Eczema  can  usually  be  differentiated  by  the  more  in- 
flammatory aspect,  the  common  and  often  predominant  involvement 
of  the  fingers  and  finger-ends,  and  generally  its  appearance  also  on  the 
backs  of  the  hands,  as  well  as  the  presence  of  variable  heat  and  itching; 
often,  too,  there  is  present  in  one  or  two  places  the  eczematous  discharge, 
or  a  history  of  such;  there  is  no  tendency  to  crescentic,  serpiginous,  or 
circinate  forms,  as  often  observed  in  syphilis;  and  not  infrequently  it 
occurs  in  those  who  have  to  do  with  irritating  substances,  as  dyers, 
plasterers,  pasters,  polishers,  etc.  Sometimes,  too,  in  such  eczema 
cases  the  eruption  in  its  characteristic  aspects  is  seen  on  forearms,  and 
possibly  elsewhere.  It  is  with  the  differentiation  from  dermatitis  sebor- 
rhoica, which,  however,  is  luckily  somewhat  rare  in  this  situation, 
that  the  most  difficulty  is  likely  to  be  encountered,  as  itching  and 
burning  are  often  absent  in  this  malady,  and  it  may  show  a  slight 
tendency  to  crescentic  configuration.  A  careful  consideration  of  both 
diseases  is  occasionally  necessary,  sometimes  supplemented  by  observa- 
tion and  treatment,  before  a  positive  conclusion  can  be  reached.  Derma- 
titis seborrhoica  is,  however,  much  less  likely  to  form  segmental, 
crescentic,  and  serpiginous  shapes  than  syphilis,  and  with  such  as  a  pre- 
dominant feature  the  latter  diagnosis  would  be  the  more  probable  unless 
there  were  good  reasons  for  the  contrary.  Dermatitis  seborrhoica, 
fortunately,  is  commonly  associated  with  the  same  disease  on  one  or 
more  of  its  more  usual  situations,  as  the  scalp,  eyebrows,  nasolabial  folds, 
bearded  region,  interscapular  and  sternal  regions;  when  on  the  hands,  it 
is  usually  long  after  it  has  already  existed  elsewhere.  Moreover,  in 
dermatitis  seborrhoica  there  is  not  the  usually  distinctly  recognizable 


792 


NEW    GROWTHS 


infiltration  of  the  syphilid.  In  many  instances  in  these  cases  of  palmar 
and  plantar  syphilid  often  a  history  of  syphilis  is  obtainable,  or  evidences, 
such  as  scars,  of  former  syphilitic  manifestation  can  be  found.  Occurring 
during  the  active  or  secondary  period  of  the  disease,  of  course,  other 
associated  symptoms  are  commonly  present,  but  when  occurring  a  few 
years  or  longer  after -the  contraction  of  the  malady,  such  positive  cor- 
roboration  is  generally  wanting.  In  urgent  cases  the  Wassermann  test 
might  be  a  help. 

Moist  Papule  (Synonyms:  Mucous  patch;  Mucous  papule;  Fr., 
Plaques  muqueuses;  Ger.,  Schleimhautpapeln) .— The  usual  sites  on  the 
general  integumental  surface  for  moist  papules  are  on  contiguous  or 
opposing  surfaces,  where  there  is  a  good  deal  of  natural  heat  and  moisture, 
and  possibly  friction.  They  are  usually  met  with  during  the  active 
or  secondary  stage  of  syphilis,  as  a  part  of  a  general  eruption  or  inde- 
pendently. The  most  common  situation  is  around  the  anus,  and  about 
the  genitalia,  especially  in  women;  the  corners  of  the  mouth,  the 

nasolabial  folds,  the  axillae,  and  um- 
bilicus are  also  not  unusual  situa- 
tions. They  are  also  occasionally 
met  with  oetween  the  fingers  and 
toes,  just  at  the  web,  and  beneath 
the  mammary  glands  in  women. 
They  commonly  begin  as  ordinary 
papules,  which  flatten  down  some- 
what, become  macerated,  generally 
slightly  soft  or  even  spongy,  and  are 
grayish  or  brownish  gray  in  appear- 
ance. Their  surface  is  covered  with 
a  mucoid  secretion,  \vhich,  when 
drying  slightly,  may  resemble  some- 
Fig.  188.— Moist  papules  (after  Miller).  what  a  thin,  diphtheroid  membrane. 

Ordinarily,   however,   the    surface 

is  kept  moist  and  macerated.  At  first  they  are  commonly  fairly  well 
defined,  but  later,  often  from  flattening  down,  especially  peripherally, 
become  much  less  so.  On  the  other  hand,  instead  of  flattening  down 
they  may  become  hypertrophied,  distinctly  elevated,  the  surface  some- 
what irregular  or  uneven,  and  constitute  the  lesion  or  form  known  as 
the  broad  or  flat  condyloma.  Contiguous  plaques  may  coalesce  and  cover 
considerable  surface,  encircling  the  anus  or  also,  in  the  female,  involving 
and  surrounding  the  vulva.  The  irregular  and  uneven  surface  may 
sometimes  become  clearly  warty  or  papillomatous,  the  papular  base 
sharing  in  the  hypertrophy,  and  the  vegetations  prominent  and  closely 
packed,  giving  rise  to  the  manifestation  known  as  the  hypertrophic 
papillomatous  or  vegetating  papule,  sometimes  designated  the  vegetating 
syphiloderm,  syphilis  cutanea  vegetans,  syphiloderma  framboesioides. 
This  latter  'development  is  also  sometimes  observed  in  the  various  ulcera- 
tive  syphilodermata.  There  is  usually  considerable  mucoid  or  muco- 
purulent  secretion,  which,  together  with  the  macerated  epithelium,  soon, 


793 

unless  extreme  cleanliness  is  practised,  gives  rise  to  an  exceedingly  foul, 
offensive  odor.  If  neglected,  the  irritating  discharge  may  produce  still 
further  maceration,  and  ulceration,  more  especially  between  the  papil- 
lary growths,  results.  Such  cauliflower-like  formations  are  also  occa- 
sionally met  with  elsewhere  on  the  surface,  where  the  papules,  or  some- 
times other  syphilitic  lesions,  have  undergone  irritation,  or  from  neglect — 
as,  for  instance,  the  scalp. 

The  moist  papule  is  one  of  the  common  symptoms  of  the  active  stage 
of  syphilis,  especially  about  the  anus  in  males,  and  the  anus  and  vulva 
in  females,  and  are  often  present  when  the  syphilitic  eruptive  manifesta- 
tions are  scant  on  other  parts.  For  this  reason  it  is  of  value  in  diagnosis. 
As  the  heat,  moisture,  and  friction  of  the  parts  necessarily  continue,  some 
tenderness  or  soreness  often  results,  and  patients  usually  believe  they 
have  an  attack  of  hemorrhoids.  As  a  rule,  moist  papules,  if  thorough 
cleanliness  is  practised,  show  a  tendency  to  disappear,  and  are  generally 
rapidly  responsive  to  treatment.  Inasmuch  as  their  characters  are  well 
defined,  the  diagnosis  is  not  attended  with  difficulty.  They  should  not 
be  confused  with  verruca  acuminata  (q.  v.}. 

The  lesion  which  occurs  on  the  mucous  membrane,  especially  of  the 
lips  and  mouth,  usually  known  as  the  mucous  patch,  is  a  somewhat 
similar  formation,  and  may  often  be  looked  upon  as  a  flattened,  abraded 
papule  on  a  mucous  surface.  They  are  also  seen  on  the  labia  minora 
surfaces  of  the  vulva  and  on  the  mucous  membrane  of  the  anus.  About 
the  mouth,  their  usual  situation,  they  are  most  commonly  found  just 
within  the  vermilion  border,  often  extending  on  to  the  latter,  and  espe- 
cially at  the  corners  of  the  mouth  and  the  lower  lip.  The  inner  surface 
of  the  cheeks  is  a  favorite  location,  especially  opposite  or  near  the  last 
molar.  The  tongue,  uvula,  tonsils,  velum  palati  and  its  pillars,  and  the 
gums  are  also  frequently  its  site.  There  may  be  one,  several,  or  more — 
generally  two  or  three.  They  are  usually  observed  during  the  active  or 
second  stage  of  the  disease,  especially  the  early  period  of  it,  although 
they  are  also  seen  later.  They  are  sometimes  called  "opaline  patches," 
owing  to  the  appearance  presented;  they  have  a  grayish- white  color, 
such  as  is  produced  by  penciling  with  silver  nitrate,  often  with  a  pinkish- 
red  periphery.  This  term  opaline  is  probably  more  properly  applicable 
to  the  very  slight  opalescent,  insignificant  patches  which  occur  occa- 
sionally on  the  tongue,  and  sometimes  so  numerously  as  to  give  it  a  map- 
like  appearance.  As  a  rule,  mucous  patches  are  but  slightly  elevated, 
always  flattened,  and  not  infrequently  slightly  depressed;  are  rounded, 
ovalish,  or  irregular  in  outline,  and  of  various  sizes.  Sometimes,  instead 
of  grayish  or  grayish-white  color,  they  are  a  pale  rosy  or  rosy- white; 
and  not  infrequently,  when  closely  examined,  show  a  thin,  film-like 
membranous  coating,  which  may  be  an  intimate  and  closely  agglutinated 
part  of  the  patch  or  somewhat  loosened.  If  detached,  the  underlying 
surface  is  noted  to  be  reddish,  appearing  as  a  superficial  abrasion  or  ero- 
sion, often  distinctly  raw  looking.  It  is  not  uncommon  in  some  cases 
to  see  several  plaques,  their  appearances  varying  as  just  described. 
They  are  sometimes  quite  painful,  especially  when  taking  hot  drinks  and 
hot  foods  and  acid  fruits.  The  patches,  more  particularly  the  abraded 


794 


NEW  GROWTHS 


plaques,  have  a  slight  or  moderate  mucoid  discharge,  commonly  collecting 
as  a  thin  coating,  and  which  is  extremely  contagious. 

In  some  instances  the  abraded  or  eroded  surface  of  a  plaque  becomes 
more  deeply  invaded,  and  a  rounded  or  irregular  superficial  ulceration 
results,  with  a  mucoid  or  mucopurulent  discharge;  occasionally  the 
ulcerative  action  extends  deeply  and  causes  considerable  destruction. 
Later  in  the  disease  the  grayish-white  plaques  sometimes  undergo  thick- 
ening, become  more  or  less  opaque,  and  doubtless  constitute  some  cases 
of  leukoplakia  buccalis  (q.  ».)• 

In  the  early  stage  of  active  syphilis  it  is  not  uncommon  to  find  a 
patchy  or  confluent  redness  of  the  posterior  fauces,  which  may  be  asso- 
ciated with  well-defined  mucous  patches.  Very  often,  however,  it  is 
simply  a  catarrhal  redness,  sometimes  extending  into  the  larynx;  there  is 
frequently  a  feeling  of  tenderness  and  soreness,  which  is  more  marked 
when  mucous  patches  are  present. 

As  a  rule,  mucous  patches  of  the  mouth  are  more  or  less  persistent, 
unless  treated,  but  will  often  disappear  rapidly  under  constitutional 
measures,  and  usually  promptly  under  local  applications.  Occasionally, 
especially  the  opaline,  superficial  patches  of  the  tongue  seem  to  lead  to 
a  tendency  to  fissuring,  with  variable  hyperplasia  and  eventually  to  well- 
marked  leukoplakia.  As  the  mucous  patch  in  the  mouth  is  commonly 
one  of  a  group  of  symptoms  of  syphilis  the  diagnosis  is,  as  a  rule,  readily 
made.  The  acuteness,  generally  sensitive,  and  evanescent  character 
of  the  "aphthous  sores"  frequently  seen  in  the  mouth,  and  usually  asso- 
ciated with  attacks  of  indigestion,  will  serve  to  distinguish  them  from  the 
syphilitic  lesions. 

Vesicular  Syphiloderm  (Synonyms:  Syphilodermavesiculosum; 
Syphilis  cutanea  vesiculosa;  Varicelliform  syphiloderm  or  syphilid. — 
This  is  a  rare  form  of  the  syphilodermata  occurring  in  the  secondary 
period  of  the  malady.  Its  existence  has  frequently  been  called  in  ques- 
tion, but  the  observations  of  Bassereau,1  Hardy,2  and  other  French 
observers,  as  well  as  Duhring,3  White  and  Martin,4  Hutchinson,5  and 
others,  attest  its  occurrence,  although  admittedly  extremely  exceptional. 
I  have  never  met  with  a  case,  although  occasionally  with  instances  of 
the  pustular  syphiloderm  in  which  the  earliest  stage  of  formation  of  some 
lesions  was  noted  to  be  vesicular,  or  more  commonly  vesicopustular. 
With  so  rare  a  manifestation  the  possibility  of  its  occasionally  being  due 
to  drug  idiosyncrasy  is  not  to  be  lost  sight  of;  potassium  iodid  has  been 
known  to  be  exceptionally  productive  of  vesicles,  and  this  drug  is  some- 
times prescribed  in  the  early  stages  of  syphilis. 

The  vesicular  syphilid  may  occur  in  one  of  several  forms:  the  lesions 
may  be  minute,  eczematoid,  disseminated,  and  grouped;  larger,  irreg- 

1  Bassereau,  Traite  des  affections  de  la  peau  symptomatiques  de  la  syphilis,  Paris, 
1852. 

2  Hardy,  Lefons  sur  la  scrofule  et  les  scrofulides  et  sur  la  syphilis  et  les  syphilides, 
Paris,  1864. 

3  Duhring,  Diseases  of  the  Skin,  third  edit.,  p.  519. 

4  White  and  Martin,  Genito-  Urinary  and  Venereal  Diseases. 
6  Hutchinson,  Clinical  Manual  on  Syphilis. 


SYPHILIS  795 

ularly  scattered,  somewhat  similar  to  varicella  (varicelliform  syphilid), 
and  in  other  cases  occurring  in  ill-defined  herpetiform  groups,  consti- 
tuting the  so-called  herpetiform  syphilid.  Both  Hutchinson1  and 
Crocker2  have  also  observed  a  vesicular  eruption  similar  to  herpes  zoster, 
except  that  the  lesions  are  not  limited  to  one  side  or  region,  but  somewhat 
symmetrically  distributed,  and  of  longer  duration  than  true  shingles. 
In  the  vesicular  syphiloderm  an  association  of  papules  is  commonly 
noted,  and  the  vesicles,  which  may  be  rounded  or  umbilicated,  consti- 
tuting one  form  of  the  varioliform  syphilid,  soon  become  seropurulent 
or  purulent.  The  vesicle  generally  has  a  dusky-red,  solid,  papular  base, 
the  vesicular,  vesicopustular,  or  pustular  apex  usually  drying,  leaving  a 
more  or  less  characteristic  small  papule,  which,  disappearing,  gives  place 
to  a  dark  stain  of  some  duration,  as  observed  in  other  syphilodermata. 

Other  evidences  of  the  active  stage  of  syphilis  are,  as  in  other  sec- 
ondary eruptions,  generally  present,  and  can  be  utilized  in  the  diagnosis. 
The  usually  solid  papular  base,  its  slow  evolution,  and  its  duration  and 
sluggish  characters  are  also  points  which  distinguish  it  from  vesicular 
eczema  and  variceUa. 

The  pustular  syphilodermata  occur  in  several  distinct  types,  and 
are  therefore  best  described  separately.  They  are  much  less  frequent  than 
the  papular  forms,  and  are  observed  more  commonly  in  individuals  of  poor 
general  nutrition  and  in  a  depraved  condition  of  general  health.  They 
are  relatively  much  more  frequent,  therefore,  in  dispensary  and  hospital 
practice  than  among  private  cases,  and  are,  moreover,  often  somewhat 
persistent,  and  occasionally,  for  a  time,  somewhat  rebellious  to  treat- 
ment. The  pustular  eruption  usually  indicates  a  greater  probability  of 
a  more  severe  type  of  syphilis  than  do  the  macular  and  papular  forms. 
It  ordinarily  occurs  within  the  first  six  or  eight  months,  either  independ- 
ently of  earlier  eruptions  of  other  type  or  subsequently;  but  it  may  be 
also  observed  usually  as  a  relapse,  or  more  limited  manifestation  later 
in  the  disease.  The  several  varieties  encountered  are:  the  miliary  or 
small  acuminated  pustular  syphiloderm,  the  large  acuminated  pustular 
syphiloderm,  the  small  flat  pustular  syphiloderm,  and  the  large  flat 
pustular  syphiloderm. 

Miliary  or  Small  Acuminated  Pustular  Syphilodenn. — This  is  not 
an  uncommon  form  of  the  pustular  syphilodermata,  the  lesions  being 
minute,  pin-head  or  slightly  larger  in  size,  and  generally  connected  with 
the  hair-follicles.  In  many  respects  this  eruption  is  similar  to  the  miliary 
papular  syphiloderm,  and  many  of  the  lesions  in  their  early  stage  are 
purely  papular,  becoming  later  capped  with  a  small  pustule.  While 
the  eruption,  as  a  whole,  is  clearly  pustular,  many  papules  will  usually 
be  found  showing  but  slight,  and  sometimes  not  any,  tendency  to  pustula- 
tion.  The  lesions  are,  as  a  rule,  numerous,  and  although  generally  dis- 
tributed, often  show  a  tendency  to  groups  and  aggregations.  This  dis- 
position is  especially  noted  in  relapses,  which,  though  slight,  are  not  un- 
common in  this  form.  Almost  all  the  pustules  have,  at  first  at  least,  a 

1  Hutchinson,  quoted  by  Crocker,  Diseases  of  the  Skin. 

2  Crocker,  ibid. 


796  NEW  GROWTHS 

somewhat  solid,  dusky  or  brownish-red  papular  base,  which  continues 
with  many,  but  in  others  becomes  later  transformed  into  a  part  of  the 
pustule.  A  slight  depression  of  the  central  part  of  the  summit  is  observed 
in  some  lesions.  The  eruption  makes  its  appearance  either  somewhat 
rapidly,  with  or  without  some  febrile  action,  or  appears  gradually  in 
irregular  crops  and  generally  without  systemic  disturbance.  There  are 
no  subjective  symptoms;  occasionally  slight  soreness  or  tenderness,  and, 
in  the  negro,  as  with  the  other  syphilodermata,  often  variable  itching. 
It  is  an  eruption,  usually  profuse,  of  the  secondary  stage  of  syphilis,  and 
commonly  appears  during  the  first  six  or  eight  months— on  an  average 
about  the  third  month;  it  may,  however,  occur  somewhat  later,  but  or- 
dinarily as  a  relapse  and  as  a  more  or  less  limited  eruption.  Macules 
are  occasionally  seen  in  association  with  it,  more  especially  when  it  makes 
its  appearance  early,  but  miliary  papules,  as  already  stated,  and  sparsely 


Fig.  189. — A  papulopustular  syphiloderm  with  ulcerative  tendency;  on  face  and  arms, 
of  limited  character;  following  as  a  relapse  after  a  generalized  pustular  eruption. 

scattered  flat  papules  or  flat  pustules  are  much  more  usual.  This 
eruption  is  of  a  sluggish  course,  often  somewhat  persistent,  and  less  readily 
responsive  to  treatment  than  the  papular  syphilodermata.  The  general 
health  is  commonly  noted  to  be  bad,  and  a  more  or  less  profound  anemia 
is  occasionally  associated.  The  pustules  dry  to  crusts,  which  fall  off, 
and  often  leaving  temporarily  a  slight  fringe-like  exfoliation  or  scale 
around  the  base,  constituting  a  grayish  ring  or  collar.  Scarring,  con- 
sisting of  minute  points  or  pits,  may  be  left  in  some  places,  although  it 
may  also  disappear  without  a  trace,  except  stains  which  finally  fade. 

The  miliary  pustular  syphiloderm  is  so  unique  and  characteristic 
that  a  mistake  in  diagnosis  can  scarcely  be  made,  although  corrobo- 
ration  is  usually  readily  found  in  the  presence  of  some  of  the  concomitant 
symptoms. 

Large  Acuminated  Pustular  Syphiloderm  (Synonyms:  Acneiform 
syphiloderm  (sometimes  improperly  termed  acne  syphilitica) ;  Vari- 


PLATE  XXVI. 


Acneiform  syphiloderm  of  general  distribution;    showing  a  few  intermingled  large  flat 

papules  and  pustules. 


SYPHILIS  797 

oliform  syphiloderm) . — This  occurs  as  a  more  or  less  generalized  eruption, 
usually  within  the  first  six  or  eight  months  of  the  disease,  and  consists 
of  small  or  large  pea-sized,  disseminated  or  irregularly  grouped,  acumi- 
nated or  rounded  pustules,  bearing  some  resemblance  to  the  lesions  of 
both  acne  and  variola.  They  often  show  a  connection  with  the  follicles. 
As  a  rule,  they  begin  as  pustules,  some  as  papules,  although  all  at  first 
are  generally  seated  upon  a  slight  or  insignificant  papular  base;  this  in 
the  earliest  stage  is  often  pinkish  red  in  color,  with  some  colored  areola, 
later  becoming  dusky  or  coppery  red.  Occasionally  some  lesions  in  their 
first  formation  are  vesicopapular,  vesicular,  or  vesicopustular,  rapidly, 
however,  becoming  qlearly  pustular.  It  is  not  uncommon  here  and 
there  to  find  a  pustule  with  central  depression  or  umbilication,  and  occa- 
sionally this  tendency  is  so  generally  and  strikingly  shown  that  there  is 
a  somewhat  close  resemblance  to  variola,  and  to  these  cases  especially 
the  descriptive  term  varioliform  is  quite  appropriate. 

This  pustular  syphilid,  as  with  the  other  syphilodermata,  varies  as 
to  scantiness  or  abundance  considerably  in  different  cases,  but,  as  a 
rule,  it  is  more  or  less  profuse,  especially  when  occurring  in  the  first 
three  or  four  months;  later,  and  also  in  relapses,  it  is  usually  scanty 
and  shows  a  tendency  to  the  formation  of  scattered  groups  or  aggre- 
gations. The  eruption  may  appear  quite  rapidly,  and  sometimes  with 
well-defined  precursory  and  accompanying  febrile  action  and  general 
malaise,  or  more  gradually  and  with  or  without  systemic  disturbance. 
As  a  rule,  however,  in  all  cases  new  lesions  continue  to  appear  for  one 
or  two  weeks  or  longer,  and  slight  recurrent  crops  are  sometimes  observed. 
It  is  not  uncommon  to  find  sparsely  scattered  flat  pustules  and  papules. 
After  the  first  outbreak  is  well  established  febrile  action,  if  present, 
quickly  subsides.  This  pustular  syphiloderm  is  usually  accompanied 
by  more  or  less  anemia,  and  patients  are  generally  pale,  weak,  and 
debilitated.  Other  symptoms  or  evidences  of  syphilis  are  always  to  be 
found.  The  course  of  the  eruption  is  sluggish,  for  some  weeks,  as  a  rule, 
showing  but  little  disposition  to  spontaneous  disappearance,  during  which 
time  many  of  the  older  lesions  have  dried  to  crusts  and  new  lesions  often 
appear.  It  is  generally,  however,  more  quickly  responsive  to  treatment 
than  the  miliary  pustular  syphilid.  The  crusts  are  of  various  thickness, 
and  when  first  formed,  are  usually  seated  upon  superficially  eroded 
bases.  Becoming  finally  detached,  they  leave  behind  brownish  pig- 
mentation, and  sometimes  atrophic  thinning  or  slight  scarring,  which 
may  in  some  instances  be  depressed  or  pit-like.  In  most  cases,  how- 
ever, permanent  scarring,  of  any  significance  at  least,  does  not  occur. 

Ordinarily  the  diagnosis  of  the  large,  acuminated  pustular  syphilo- 
derm is  readily  made,  but  its  resemblance,  in  some  instances,  to  acne, 
variola,  and  the  iodid  eruptions  cannot  be  gainsaid,  but  especially  to 
variola.  Its  confusion  with  acne  is,  however,  possible  only  with  the 
ignorant  or  careless,  as  acne  is  an  eruption  practically  limited  to  the 
face,  neck,  and  shoulders,  sometimes  also  on  breast  and  back;  it  is  made 
up  of  blackheads,  beginning  papules,  usually  with  a  blackhead  centrally, 
pustules  in  all  stages,  and  not  infrequently  with  deeper-seated  nodules 
or  abscess-like  lesions;  moreover,  the  duration,  sluggish  character, 


GROWTHS 

history,  absence  of  lesions  on  scalp  and  other  parts,  will  together  furnish 
sufficient  points  of  difference. 

It  is  the  case  of  pustular  syphiloderm  of  acute  development  and 
associated  with  febrile  action  and  malaise  which  is  most  likely  to  be 
confounded  with  variola.  The  Wassermann  test  and  examination 
for  the  spirochaetae  can  be  resorted  to  in  urgent  cases.  The  fol- 
lowing considerations  are,  however,  ordinarily  sufficient  to  differ- 
entiate: the  syphiloderm  is  generally  distributed  without  any  especially 
greater  abundance  on  any  region,  although  often  more  numerous 
on  the  trunk:  variola  is  almost  invariably  strikingly  more  profuse 
on  the  face  and  backs  of  the  hands  and  on  the  wrists; -the  lesions 
of  syphilis  are  usually  pustular  from  the  start,  or  first  papular,  but 
the  papules  are  projecting;  the  initial  start  of  a  variola  lesion  is  a 
deep-seated,  scarcely  at  all  projecting,  shot-like  papule,  which  is  trans- 
formed into  a  somewhat  deep-seated  vesicle,  with  umbilication,  and 
later  into  a  pustule;  the  syphilitic  pustule  commonly  has  a  firm,  papu- 
lar base:  that  of  variola  is  usually  all  pustular;  the  covering  wall  of  the 
former  is  somewhat  thin,  easily  broken:  that  of  variola  is  generally  firm 
and  tough,  and,  at  first  at  least,  not  readily  ruptured;  the  lesions  of  syphi- 
lis are  in  various  stages  of  development,  and  new  ones  continue  to  appear 
irregularly  for  one,  two,  or  more  weeks,  while  those  of  variola,  though 
possibly  of  different  sizes,  are  at  about  the  same  stage,  and,  after  once 
out,  new  lesions  rarely  appear*;  the  febrile  action  of  the  syphilitic  eruption 
is  generally  slight  and  abates  gradually  and  disappears:  that  of  variola 
is,  as  a  rule,  relatively  severe,  and  abates  rapidly  on  the  outbreak  of 
the  eruption,  to  appear  again  as  pustulation  takes  place;  the  other 
general  symptoms  in  syphilis  are  slight,  while  in  variola  they  are  often 
severe.  Far  above  all  these,  however,  in  value  to  the  inexperienced 
must  be  placed  the  presence  or  absence  of  other  symptoms  of  syphilis. 
This  latter  point  can  also  be  used,  when  necessary,  in  the  differentiation 
from  ordinary  acne  and  from  iodid  acne.  This  last  is  rarely  profuse, 
and,  as  a  rule,  not  generally  distributed,  but  more  commonly  on  the 
ordinary  acne  situations,  and  there  will  be  a  history  of.  iodid  administra- 
tion. Indeed,  in  all  cases  of  obscure  dermatoses  the  elimination  of  the 
possibility  of  its  being  due  to  drug  ingestion  should  receive  first  attention. 

Small  Flat  Pustular  Syphiloderm  (Synonyms:  Impetigiform  syph- 
iloderm or  syphilid;  Impetigo  syphilitica) . — This  form  of  the  pustular 
syphiloderm,  while  not  frequent,  is  not  uncommon,  and  is  characterized 
by  an  eruption  of  flat,  discrete,  sometimes  irregularly  grouped,  pea- 
to  small  finger-nail-sized  pustules,  and  occur  usually  within  the  first 
six  or  eight  months  of  the  secondary  or  active  period,  sometimes  later. 
There  is  occasionally,  when  the  lesions  are  abundant,  in  one  or  two  re- 
gions, as  on  the  scalp  and  face,  especially  about  the  nose  and  mouth,  a 
tendency  toward  coalescence.  The  eruption  may  be  more  or  less  gen- 
eralized, but  probably  more  frequently  present  about  the  face,  mouth, 
scalp,  and  genitalia  in  association  with  macules,  maculopapules,  or 
papules  on  other  parts.  The  pustules  form,  as  a  rule,  somewhat  rapidly, 
arising  as  such  or  from  pre-existing  macules  or  papules,  and  soon  dry 
to  crusts,  which  are  often  quite  adherent,  and  beneath  which  is  found  su- 


SYPHILIS 


799 


perficial  erosion  or  ulceration.  So  rapidly  in  most  instances  does  crust- 
ing follow  the  pustule  formation  that  the  pustulocrustaceous  character 
is  usually  pronounced,  and  for  this  reason,  in  such  cases  the  term  pustu- 
locrustaceous syphiloderm  or  syphilid  is  sometimes  heard.  The  crusts, 
brownish-yellow  or  brownish,  sometimes  with  a  greenish  hue,  are  some- 
what thick,  often  uneven,  and  ordinarily  granular  or  friable,  although 
they  may  be  tough ;  they  may  not  entirely  cover  the  base,  in  which  event 
the  peripheral  portion  of  the  base  is  either  superficially  ulcerative  or 
slightly  infiltrated  or  papular,  with  possibly  an  areola;  or  the  crust  may 
extend  beyond  the  underlying  lesion  proper.  The  peripheral  basal 
portion,  if  visible,  and  the  areola,  when  present,  are  dusky  red  or  ham 
colored.  When  the  eruption  is  extensive,  there  are  usually  an  associated 
depraved  state  of  the  health  and  a  more  or  less  profound  anemia,  but  if 
limited  in  extent  or  occurring  as  a  part  of  a  macular  or  papular  syphilo- 
derm, it  is  generally  of  benign  nature.  In  the  generalized  cases  some 
lesions  may  show  somewhat  deep  ulceration;  in  the  limited  forms  the 
surface  is  merely  eroded,  or,  at  the  most,  superficially  ulcerated,  although 
there  are  exceptions  in  which  the  destruction  extends  more  deeply. 
As  a  rule,  however,  it  is  rarely  deep.  There  is  sometimes,  especially  in 
relapses,  a  tendency  to  circinate  or  segmental  grouping.  It  is.,  in  the 
benign  cases,  generally  readily  responsive  to  treatment,  although  in  the 
extensive  disseminated  cases  often  more  or  less  rebellious. 

In  the  diagnosis  pustular  eczema  and  impetigo  are  to  be  excluded. 
The  confluent  crusted  patches  sometimes  observed  in  scalp,  bearded 
region,  and  about  the  mouth  are  somewhat  suggestive  of  pustular  eczema, 
but  in  most  cases  the  underlying  erosion,  often  amounting  to  distinct 
ulceration,  is  a  differential  factor;  moreover,  characteristic  papular  or 
pustular  lesions  of  syphilis  are  almost  always  present  on  other  parts  of 
the  surface,  and  these,  as  well  as  other  corroborative  symptoms  of  the 
disease,  will  prevent  error.  Pustular  eczema  is  likewise  quite  itchy. 
About  the  same  differential  factors  will  serve  to  prevent  a  mistake  with 
impetigo,  the  latter  usually  occurring  on  face  and  hands,  mild  in  charac- 
ter, superficial,  without  ulceration,  and  of  comparatively  short  duration. 

Large  Flat  Pustular  Syphiloderm  (Synonyms:  Ecthymaform  syph- 
iloderm or  syphilid;  Syphilitic  ecthyma;  Ecthyma  syphiliticum).— 
In  many  respects  the  large  flat  pustular  syphiloderm  is  similar  to  the  small 
flat  variety,  except  that  the  lesions  are  finger-nail-sized  and  larger. 
This  is  especially  so  with  the  superficial  variety,  in  which  the  pustules 
are  flat,  drying  to  yellowish-brown  or  brownish  crusts,  which  are  some- 
what adherent,  and  which  in  the  earlier  stages  are  seated  upon  an  eroded 
or  superficially  ulcerated  base,  sometimes  having  a  slightly  infiltrated, 
dark-red  or  ham-colored  border  or  areola.  If  at  this  stage  the  crust  is 
removed,  there  is  disclosed  an  eroded  or  ulcerated,  purulent,  secreting 
surface.  Sometimes  they  dry  so  rapidly  to  crusts  as  to  give  rise  to  the 
designation  of  pustulocrustaceous  syphiloderm  or  syphilid.  The  lesions 
may  be  numerous  or  scanty,  and  associated  with  papules  or  smaller  pus- 
tular lesions. 

The  deeper-seated  variety  is  much  less  commonly  observed  than 
the  superficial  form.  There  is  always  superficial  ulceration,  sometimes 


8oo 


NEW  GROWTHS 


quite  distinct,  beneath  the  crust.  The  crusting  is  of  darker  color, 
sometimes  reddish  brown,  brownish  black,  with  not  infrequently  a 
greenish  tinge,  and  much  more  bulky  and  usually  harder.  As  in  the  su- 
perficial variety,  they  may  remain  flattened,  with  an  uneven  surface. 
Sometimes  the  ulcerative  feature  is  quite  pronounced,  and  hence  the 
designation  pustulo-ulcerative  syphiloderm  or  syphilid.  Or  the  crusting 
may  be  the  most  striking  feature,  and  they  may  become  heaped  up  and 
stratified;  when  this  latter  is  of  conspicuous  character,  as  it  sometimes 
is,  the  eruption  is  commonly  known  as  rupia.  The  crust,  greenish  or 
blackish,  is  raised  and  bulky,  conic,  and  formed  of  several  layers,  with 
that  of  small  dimensions  at  the  top — similar,  in  fact,  to  the  stratification 


Fig.  190. — Large  flat  pustular  syphiloderm  of  general  distribution;  about  forehead  and 
scalp,  of  pustulocrustaceous  type  and  rupial  tendency. 

observed  in  an  oyster  shell.  In  these  cases  the  pustules,  with  a  distinctly 
ulcerated,  discharging  base,  are  somewhat  slow  in  formation ;  the  surface 
crust  dries,  and  from  the  irritation  of  the  hemmed-in  secretion  below  or 
spontaneously  the  discharge  is  probably  increased,  the  basal  ulceration 
spreading  peripherally;  the  already  dried  layer  of  crust  is  thus  lifted  up, 
and  then  the  under  part  again  dries,  forming  naturally  a  crust  of  the  size 
of  the  increased  base,  and  this  is,  in  turn,  lifted  up,  and  thus  the  process 
continues  for  some  time,  the  aggregate  crust  being  made  up  of  several 
or  more  layers,  the  uppermost  small,  and  the  strata  beneath  larger  and 
larger  as  the  base  is  approached.  The  ulcerations  beneath  these  lesions 
are  usually  rounded  or  irregularly  shaped,  having  a  greenish-yellow, 
puriform  secretion.  This  same  form  of  crusting  is  sometimes  observed, 


PLATE  XXVII. 


Pustular  syphiloderm  of  the  pustulocrust.aceous  and  rupial  type  ;  general,  but  of 
greatest  abundance  and  development  on  the  scalp  and  upper  trunk.  Initial  lesion 
about  six  months  previously. 


SYPHILIS  80 1 


but  much  less  scantily  and  characteristically,  with  the  rarer  bullous  lesion, 
and  also  occasionally  with  the  tubercular  ulcerative  and  gummatous 
syphiloderm. 

In  both  the  superficial  and  deep-seated  varieties  the  eruption  may 
be  sparse  or  more  or  less  abundant;  rarely,  however,  is  it  profuse.  The 
former  variety  is  sometimes  seen  in  association  with  the  papular  syphilo- 


Fig.  191. — Large  flat  pustular  syphiloderm  of  general  distribution,  and  of  the  pustulo- 
crustaceous,  rupial  type  (courtesy  of  Dr.  W.  T.  Corlett). 

derm,  and  also  with  the  small  flat  pustular  eruption,  consisting  of  scat- 
tered, isolated  pustules,  or  being  present  in  one  or  several  irregular 
groups  in  one  or  more  regions.  The  lesions  begin  as  pustules  or  as  macu- 
lopapules,  papules,  or  papulotubercles,  the  last  not  infrequently  with 
the  deep-seated  variety.  As  a  rule,  in  both  types  the  pustules  are  most 
abundant  on  the  shoulders,  back,  and  extremities;  the  rupial  formations 

51 


802  NEW  GROWTHS 

are  usually  most  characteristically  developed  on  the  face  and  arms. 
The  superficial  form  is  more  common  in  the  first  six  or  eight  months; 
the  deep-seated  type  variety  is  sometimes  a  later  manifestation.  The 
former  is  generally  relatively  benign,  but  not  infrequently  is  associated 
with  grave  systemic  disturbance,  as  profound  anemia;  the  deep  variety 
is  almost  always  indicative  of  a  grave  type  of  the  disease.  Untreated, 
they  are  more  or  less  persistent,  but,  as  a  rule,  respond  to  specific 
remedies,  although  sometimes  slowly.  Scarring,  with  associated  brown- 
ish pigmentation,  often  exceedingly  superficial,  at  other  times  deeper, 
usually  marks  the  site  of  the  lesions,  which  become  gradually  less  dis- 
tinct; the  pigmentation  is  extremely  slow  in  disappearing,  more  especially 
on  the  lower  extremities,  where,  indeed,  it  may  be  more  or  less  lasting. 
Other  symptoms  of  syphilis  are  commonly  to  be  found. 

The  only  disease  which  is  to  be  considered  in  the  diagnosis  is  ecthyma, 
but  the  syphilitic  eruptions  differ  in  the  lesions  being  more  numerous, 
in  being  attended  with  superficial  or  deep  ulcer ation,  and  in  being  fol- 
lowed by  more  or  less  scar-formation;  moreover,  the  history  and  frequent 
presence  of  other  syphilitic  cutaneous  lesions,  as  well  as  other  corrobora- 
tive symptoms  of  the  disease,  have  an  important  diagnostic  value. 

Bullous  Syphiloderm  (Synonyms:  Syphiloderma  bullosum;  Syph- 
ilis cutanea  bullosa;  Pemphigus  syphiliticus). — The  bullous  syphiloderm 
of  acquired  syphilis  is  extremely  rare, — so  much  so  that  its  existence 
has  been  denied, — although  it  is  not  unusual  in  the  hereditary  disease 
(q.  v.)  in  the  newborn.  Its  occurrence  in  the  acquired  disease,  though 
rare,  cannot,  however,  be  denied.  It  is  a  late  manifestation,  occurring 
in  those  in  a  depraved  condition  of  health,  which  latter  itself  may  be  due 
to  the  syphilitic  poison,  as  this  syphiloderm  is  to  be  considered  as  indi- 
cative of  a  grave  type.  It  is  commonly  associated  with  other  eruptive 
lesions  and  symptoms  of  syphilis.  It  appears  in  the  form  of  discrete, 
disseminated,  rarely  abundant,  rounded  or  ovalish,  pea-  to  walnut- 
sized,  partially  or  fully  distended  blebs,  having  usually  cloudy  or  puriform 
contents,  sometimes  with  a  slight  admixture  of  blood.  In  some  instances 
they  are  distinctly  pustular  from  the  beginning.  The  lesions  have  a 
dark  or  dusky  red  areola,  and  commonly  with  variable  infiltration. 
They,  either  with  or  without  rupturing,  collapse  and  dry  to  thick  crusts 
of  a  yellowish-brown  or  dark,  greenish-black  color,  with  an  irregular 
and  uneven  surface,  flattened  or  somewhat  rounded  and  conic.  The 
underlying  surface  is  eroded  or  ulcerated,  generally  the  latter,  which 
may  be  superficial  or  deep,  and  secrete  a  greenish-yellow  fluid.  There 
is  sometimes  the  same  tendency  displayed  in  this  manifestation  to  the 
formation  of  stratified  or  oyster-shell-like  conic  crusts  (rupia) ,  as  described 
in  the  large  flat  pustular  syphiloderm  (q.  v.~).  Its  course  is  somewhat 
uncertain  and  variable,  but  it  is  favorably  influenced,  although  usually 
slowly,  by  specific  and  properly  associated  treatment. 

The  diagnosis  in  bullous  syphiloderm,  owing  to  the  characters  of 
the  lesions,  the  crusts,  underlying  base,  and  usual  peripheral  infiltration, 
as  well  as  to  the  presence  of  additional  symptoms  of  syphilis,  either 
cutaneous  or  other,  is  not  difficult,  and  such  factors  are,  as  a  rule,  suffi- 


SYPHILIS  803 

cient  to  distinguish  it  from  ordinary  pemphigus  and  other  pemphigoid 
eruptions. 

Tubercular  Syphiloderm  (Synonyms:  Syphiloderma  tubercu- 
losum ;  Nodular  syphiloderm  or  syphilid ;  Syphilis  cutanea  tuberculosa)  .— 
The  tubercular  syphiloderm  may  exceptionally  occur  within  the  first  year 
as  a  more  or  less  generalized  eruption,  of  characteristic  brownish-red  or 
ham-colored,  small  to  large  pea-sized  tubercles,  but  even  in  such  gen- 
eralized cases  the  lesions  are  usually,  for  the  most  part,  more  of  the  na- 
ture of  papulotubercles  (papulotubercular  syphiloderm)  than  tubercles. 
Less  rare  is  it,  although  not  at  all  common,  to  find  papulotubercular  and 
tubercular  lesions  on  the  face,  especially  about  the  nose,  forehead,  and 
chin,  and  somewhat  crowded  together,  in  association  with  the  typical 
papular  eruption  on  other  parts.  As  a  rule,  however,  it  is  a  tertiary  mani- 


Fig.  192. — Tubercular  syphiloderm,  with  slight  ulcerative  tendency;  showing  the  char- 
acteristic spreading  border;  of  several  years'  duration. 

festation,  appearing  several  or  more,  sometimes  many,  years  after  the 
contraction  of  the  disease;  limited  in  extent  and  appearing  on  one  or  sev- 
eral regions,  and  exhibiting  a  decided  tendency  to  occur  in  groups  of 
segmental,  circinate,  and  serpiginous  configuration. 

The  tubercles  are  of  the  same  characters  in  the  late,  limited  mani- 
festation as  in  the  rare  generalized  cases.  They  present  commonly  as 
several  or  more  groups  of  somewhat  firm,  circumscribed,  slightly  or  mod- 
erately elevated  lesions  extending  into  the  corium  and  sometimes  more 
deeply.  They  have  a  smooth  surface,  with  often  a  glistening  aspect, 
or  covered  with  thin  epidermic  exfoliating  scales;  are  rounded  or  acu- 
minated in  shape,  occasionally  somewhat  flattened  and  of  a  brownish- 
red  or  coppery  color,  and  usually  the  size  of  small  or  moderately  sized 
peas.  They  are,  as  a  rule,  closely  set  together,  forming  a  segmental 
or  ring-like  grouping,  and  showing  often  a  tendency  to  actual  and  intimate 


804 


NEW  GROWTHS 


coalescence.  Several  contiguous  groups  may  coalesce  and  form  a  ser- 
piginous  tract  of  an  irregular,  winding,  snake-like  character;  or  the  older 
lesions  of  a  segmental  or  circulate  group  disappear,  new  ones  appearing 
on  the  outer  edge  or  just  beyond  the  border,  and  in  this  manner  the  seg- 
ment or  circle  enlarges,  in  a  slowly  creeping  manner,  the  lesions  within 
this  spreading  border  undergoing  involution,  and  leaving  a  pigmented, 
often  atrophic,  area  behind,  constituting  the  so-called  serpiginous  tuber- 
cular syphiloderm.  Where  the  creeping  and  widely  extending  tendency 


Fig.  193. — Tubercular  syphiloderm  with  ulcerative  tendency,  and  showing  the  well- 
defined  spreading  border;  of  one  to  two  years'  duration. 

is  not  exhibited,  the  terms  circinate  tubercular  syphiloderm  and  seg- 
mental tubercular  syphiloderm  are  sometimes  employed,  according  to 
circumstances.  The  individual  lesions  usually  develop  slowly,  are 
sluggish  in  their  course,  remaining  at  times  for  weeks  or  months  without 
material  change.  As  a  rule,  however,  they  terminate  sooner  or  later  in 
absorption  and  exfoliation,  leaving,  as  already  described,  a  more  or  less 
permanent  pigmentation,  with  or  without  slight  atrophy  or  cicatricial 
thinning,  the  disease  continuing  by  the  formation  of  new  lesions  appear- 
ing at  the  edge  or  closely  adjacent.  This  form  of  the  eruption,  in  which 


SYPHILIS 


805 


ulcerative  tendency  is  not  displayed,  is  not  at  all  uncommon,  and  is 
known  as  the  non-ulcerating  tubercular  syphiloderm,  with  often  the 
additional  qualifying  terms,  circinate,  segmental,  or  serpiginous,  accord- 
ing to  the  configuration.  In  a  few  of  these  cases  the  scaliness  may  be 
more  pronounced  than  ordinarily  observed,  and  have  a  psoriatic  appear- 
ance, and  such  examples  are  sometimes  termed  tuberculosquamous 
syphiloderm  or  squamous  syphiloderm.  In  other  instances,  especially 
when  about  the  nose,  the  lesions  may  partake  of  the  nature  of  both 
papules  and  tubercles, — papulotubercles  (papulotubercular  syphiloderm), 
— and  some  of  which  sometimes  break  down  centrally  and  form  pus- 
tules (tuberculopustular  syphiloderm)  which  may  leave  pit-like  scars. 


Fig.  194.- 


-Tubercular  syphiloderm,  with  but  little  destructive  tendency,  showing  the 
segmental  configuration;  of  several  years'  duration. 


In  the  majority  of  cases,  however,  of  the  tubercular  syphiloderm, 
instead  of  the  lesions  undergoing  absorption  and  exfoliation,  ulcera- 
tion  takes  place,  and  this  may  be  displayed  from  the  beginning  or  occur 
after  a  well-formed  group  or  patch  has  lasted  for  some  weeks,  consti- 
tuting the  ulcerating  tubercular  syphiloderm.  The  patches  or  groups 
have  the  same  tendency  to  the  special  configurations  of  segmental, 
circinate,  and  serpiginous,  already  mentioned,  and  hence  one  of  the  de- 
scriptive terms,  depending  upon  the  characters  displayed,  is  sometimes 
added,  giving  rise  to  the  names  "ulcerating  serpiginous  tubercular  syphil- 
oderm," etc.  In  these  cases  there  are,  therefore,  found  tubercles,  ulcera- 
tions,  and  usually  crusting.  The  ulceration  may  be  superficial  or  deep 
in  character,  and  involve  several  or  all  the  lesions  forming  the  group. 
This  may  consist,  therefore,  of  small,  discrete,  punched-out  ulcers,  or 


8o6 


NEW  GROWTHS 


one  or  more  continuous  ulcers  of  segmental,  crescentic,  or  serpiginous 
shape.  Ordinarily  they  are  quite  shallow,  although  in  some  cases  the 
ulceration  extends  to  considerable  depth.  They  are  either  covered  with 
a  gummy,  grayish-yellow,  purulent  secretion,  or  are  crusted,  the  secre- 
tion drying  to  crusts.  Not  infrequently  the  patch  spreading  peripher- 
ally shows  an  extending,  elevated,  infiltrated  border,  made  up  of  closely 
contiguous  or  coalescent  tubercles,  which  have  lost  their  individuality 
and  form  a  line  of  infiltration,  which,  toward  their  inner  border,  have 
already  undergone  ulceration,  usually  covered  with  crusts;  and  so  the 
patch  gradually  invades  the  surrounding  healthy  surface,  while,  as  a 
rule,  healing  with  consequent  cicatricial  tissue,  and  commonly  more 
or  less  yellowish-brown  or  brownish  pigmentation,  are  noted  on  the  part 
already  traversed.  In  some  instances  the  tubercles  form  into  closely 


Fig.   195. — Tubercular  syphilodcrm  with  ulcerative  tendency,  of  a  year's  duration, 
showing  the  clearing  central  portion  and  spreading  border. 

packed  areas  of  infiltration,  the  patch  presenting  both  tubercular  and 
gummatous  characters,  often  rapidly  ulcerating  in  places  or  more  or 
less  uniformly;  or  the  lesions,  while  close  but  discrete,  may  also  occa- 
sionally be  of  a  mixed  tuberculogummatous  nature;  such  cases  give  rise 
to  the  term  tuberculogummatous  syphiloderm. 

Sometimes  there  is  but  a  sluggish  tendency  toward  healing,  and 
the  ulcerations  show  a  disposition  to  papillary  hypertrophy  or  vegeta- 
tions, with  an  offensive,  yellowish  or  greenish-yellow,  puriform  discharge, 
probably  occurring  most  frequently  upon  the  scalp,  constituting,  again, 
as  referred  to  in  some  cases  of  moist  papules,  the  modification  or  variety 
often  designated  the  papillomatous  or  vegetating  syphiloderm  or  syphilid 
(also  called  syphilis  cutanea  papillomatosa,  syphilis  cutanea  vegetans). 
Exceptionally  the  ulcerated  segmental  groups  crust  over,  gradually  ex- 


8o/ 

tend,  and  become  crusted  over  with  several  or  more  stratified  layers  of 
crust,  the  smallest  at  the  top,  oyster-shell  like,  as  observed  in  the  rupial 
formation  of  the  large  flat  pustular  syphiloderm.  The  favorite  region 
is  the  face,  especially  the  region  of  the  nose  and  mouth,  but  it  is  quite 
common  also  on  the  upper  part  of  the  trunk,  and  the  arms  and  legs; 
in  fact,  no  region  is  exempt.  It  may  be,  and  commonly  is,  limited  to 
one  region,  but  not  infrequently  areas  of  small  or  large  size  are  seen  on 


Fig.  196. — Tubercular  syphiloderm  involving  arm  and  forearm,  of  several  years' 
duration,  showing  the  serpiginous.  spread  and  the  small  soft  scars  of  the  earlier  eruption; 
disease  contracted  some  years  previously. 

two  or  more  parts.  There  are  generally  no  subjective  symptoms, 
although  occasionally  the  ulcerations  are  tender  and  painful.  Its 
course  is  usually  slow,  and  while  there  is,  as  a  rule,  a  tendency  displayed 
toward  involution  or  ulceration  and  healing  in  the  older  lesions,  new 
tubercles  continue  to  appear,  so  that  complete  spontaneous  cure,  while 
it  may  occasionally  result,  is  not  to  be  expected,  and  the  eruption  con- 
tinues indefinitely.  It  is,  however,  almost  invariably  rapidly  responsive 
to  specific  constitutional  treatment. 


8o8 


NEW  GROWTHS 


The  diagnosis  of  the  tubercular  syphiloderm  is,  as  a  rule,  not  diffi- 
cult, although  it  often  resembles  closely  lupus  vulgaris.  The  differ- 
ential points  are  considered  under  this  latter  disease.  The  diagnostic 
features  of  this  syphiloderm  are  the  tendency  to  form  segments,  crescents, 
or  circles,  its  method  of  spread,  the  color,  ulceration,  pigmentation,  and 
atrophy  or  scarring  of  the  older  part;  these,  together  with  the  history, 
and  sometimes  marks  or  scars  of  former  syphilitic  eruptions,  are  usually 
sufficient  to  warrant  a  conclusion. 


Fig.    197. — Tubercular    syphiloderm    with    ulcerative    tendency,    of    several    years' 
duration,  showing  segmental  configuration  and  scars  of  earlier  areas. 

Confusion  with  epithelioma,  acne  rosacea,  leprosy,  sycosis,  psoriasis, 
and  ringworm  has  occurred,  but  such  errors  are  almost  invariably  the 
result  of  hasty  examination  or  inexperience,  as  the  several  diagnostic 
features  of  the  tubercular  syphiloderm,  when  considered  together, 
furnish  sufficient  grounds  of  difference,  without  mentioning  the  differen- 
tiating characters  of  the  other  diseases  named.  The  lesion  of  epithelioma 
is  usually  single,  has  an  infiltrated,  often  roll-like  border,  and  often  the 
peculiar,  semitranslucent,  "pearly-looking  tubercles  or  nodules  adjacent 
or  surrounding;  it  is  generally  much  slower  in  its  progress,  the  discharge 
is  not  commonly  profuse  or  offensively  purulent,  and  is  often  mixed  with 
a  little  blood;  it  is  more  common  after  fifty,  and  somewhat  infrequent 


SYPHILIS  809 

before  this  age — just  the  reverse  of  the  tubercular  syphiloderm.  In 
acne  rosacea  there  is  no  segmental  or  circinate  configuration,  no  distinct 
ulcerations,  the  tubercles  or  nodules  are,  as  a  rule,  vividly  red,  and  dilated 
capillaries  are  usually  present. 

When  the  tubercles  or  papulotubercles  of  syphilis  are  numerous 
and  crowded  together  on  the  face,  a  somewhat  leonine  aspect  is  given  to 
the  countenance,  and  a  suggestion  of  tubercular  leprosy;  but  in  cases 
of  the  latter  disease  there  are  found  symptoms  such  as  a  history  of  febrile 
attacks,  anesthetic  patches,  neuralgic  and  other  nervous  disorders,  and 
brown,  pigmented  areas.  Sycosis  vulgaris  is  follicular  in  origin,  with 
no  tendency  to  ring-like  or  segmental  configuration,  and  is  not  destruct- 
ive; that  form  known  as  ulerythema  sycosiforme  may,  however,  resemble 
syphilis  somewhat,  but  its  follicular  origin,  slow  progress,  and  usually 
rather  tough  cicatricial  formation,  resulting  not  from  distinct  ulceration, 
but  atrophic  changes,  will  serve  to  distinguish  it.  In  ringworm  sycosis, 
if  of  the  superficial  type,  there  is  the  ring-like  border,  but  this  is  not  dis- 
tinctly infiltrated,  and  is  lacking  the  ulceration  and  pea-sized  brownish 
tubercles  found  in  syphilis.  In  the  deep-seated  ringworm  sycosis  the 
subcutaneous  nodulations  or  lumpiness  are  characteristic,  especially 
when  taken  together  with  the  history  of  a  follicular  or  ringworm  patch 
origin.  The  circinate  tubercular  syphiloderm  has  been  mistaken 
for  ringworm  of  the  non-hairy  surface,  but  the  absence  of  defined  tuber- 
cles or  infiltrated  border,  pigmentation  and  atrophy  or  ulceration  and 
scarring  in  the  latter  should  serve  to  prevent  mistake.  The  history  is, 
moreover,  wholly  different.  In  cases  seemingly  like  ringworm,  micro- 
scopic examination  for  the  fungus  would  decide  if  doubt  still  remained. 
The  tuberculosquamous  type  of  this  syphilid  does  at  times  roughly  sug- 
gest psoriasis  ,but  could  scarcely  be  mistaken  for  it  (see  under  Psoriasis 
for  differential  points). 

GumtnatotlS  Syphiloderm  (Synonyms:  Syphiloderma  gumma- 
tosum;  Gumma;  Syphiloma;  Syphilis  cutanea  gummatosa) . — Thegumma- 
tous  manifestation  is  usually  a  late  tertiary  formation.  It  does  sometimes 
occur  in  the  secondary  stage  and  exceptionally  at  an  early  period  (syphilis 
praecox),  and  is  then  to  be  looked  upon  as  probably  indicating  a  malig- 
nant grade  of  syphilis,  and  in  such  instances  may  be  present  in  greater 
number  than  late  in  the  disease.  Generally,  however,  it  shows  itself 
as  one  or  several  painless  or  slightly  painful,  rounded  or  flattened,  more 
or  less  circumscribed  tumors,  moderately  projecting,  at  first  firm,  and 
having  their  seat  in  the  subcutaneous  tissue.  In  its  earliest  beginning 
it  can  be  felt  as  a  pea-sized  deposit  or  infiltration,  and  may  grow  slowly 
or  rapidly,  taking  one  or  two  weeks  to  several  months  before  reaching 
full  development.  As  it  increases  in  size  the  overlying  skin  is  slightly 
stretched,  and  changes  from  the  normal  color  to  a  dull  pinkish  or  pinkish- 
red  tint,  which  later,  with  increased  growth,  assumes  a  dusky  or  dark- 
red  color.  When  fully  developed,  it  may  be  the  size  of  a  walnut  or  much 
larger,  and  be  considerably  elevated.  While  firm  at  first,  it  soon,  as  it 
grows  in  size,  becomes  soft  and  doughy,  and  later  tends  to  break  down 
and  ulcerate.  It  may  even,  when  well  advanced,  disappear  by  ab- 


8io 


NEW  GROWTHS 


sorption,  but  usually  it  gradually  or  rapidly  breaks  down,  the  skin 
giving  way,  at  first  centrally  and  then  extending  or  at  several  points, 
and  resulting  in  a  small  or  large,  deep,  punched-out  ulcer,  with,  as  a 
rule,  free  gummy  puriform  secretion,  which  may  later  assume  a  greenish 
tinge  and  have  an  offensive  odor. 

In  other  instances,  instead  of  a  tolerably  well-circumscribed,  grow- 
ing subcutaneous  nodule,  the  gummatous  infiltration  is  more  diffuse, 
involving  a  palm-sized  or  large  area  and  without  being  at  all  sharply 
defined  peripherally;  but  the  central  portion  is  sometimes  considerably 
elevated,  and  there  is  a  gradual  sloping  into  the  surrounding  part;  the 
skin  is  at  first  usually  pinkish,  with  a  sluggish,  violaceous  tinge,  later 


Fig.  198. — Tubercular  syphiloderm,  with  decided  ulceration,  showing  a  rare  zosteriform 
distribution  (courtesy  of  Dr.  M.  B.  Hartzell). 

becoming  dull  reddish.  It  may  be  less  diffused  in  the  beginning  and  then 
spread  out,  or  it  may  start  as  a  large  area.  The  infiltration  gradually 
or  rapidly  becomes  more  marked,  and  the  skin  and  tissue  break  down, 
either  at  scattered  points  or  the  destructive  process  involves  the  whole 
plaque  uniformly;  there  results,  therefore,  either  a  dull  reddish  or  viola- 
ceous, somewhat  elevated,  or  later  flattened  area,  beset  with  several 
or  more  bean-  to  nut-sized,  sharply  cut  or  punched-out  ulcers,  which 
may  be  irregularly  disposed  or  exhibit  segmental  or  serpiginous  configu- 
ration, with  more  or  less  gummy  purulent  discharge,  and  which  may  at 
times  dry  to  thickish,  brownish  or  greenish  crusts;  or  one  extremely 
large,  scooped-out,  often  deep-set  open  ulcer  with  edges  well  defined, 
sometimes  slightly  sloping,  sometimes  sharply  cut.  In  occasional  in- 


PLATE   XXVIII. 


Gummatous    syphiloderm,   showing   diffused   gummatous   infiltration,  with  characteristic 
ulcers  and  scarring  from  former  lesions. 


SYPHILIS 


811 


stances  the  infiltration  is  more  superficial  and  but  slightly  elevated, 
having  the  dull,  sluggishly  inflammatory  aspect,  and  at  first  has  an  acute 
or  subacute  eczematoid  appearance,  soon  giving  way  here  and  there 
to  superficial  ulceration;  or  the  destructive  process  involves  the  entire 
area,  and  may  later,  as  in  other  forms  of  gummatous  infiltration,  extend 
somewhat  deeply. 

Sometimes  the  plaque  begins  similarly  to  that  just  described,  but 
is  the  seat  of  closely  set  or  crowded  tubercles  or  small  gummata,  lesions 
partaking  of  both  the  nature  of  tubercles  and  gummata,  occasionally 
producing  considerable  enlargement  of  the  part,  constituting  a  type 
which  is  sometimes  designated  tuberculogummatous  syphiloderm  or 
syphilid  or  infiltration.  When  involving  the  foot  and  lower  part  of  the 
leg,  it  presents  a  pseudo-elephantiasic  aspect,  which  might  be  mistaken 


Fig.  199. — Tubercular  syphiloderm  of  several  years'  duration,  and  in  an  unusual  region. 

for  both  elephantiasis  and  carcinomatous  disease.  In  these  larger 
diffused  gummatous  infiltrations  the  ulcers,  instead  of  being  irregularly 
rounded  or  ovalish,  may  be  somewhat  segmental  or  crescentic  in  shape. 
Occasionally  in  a  large,  infiltrated  plaque  absorption  or  slight  ulceration 
ensues  here  and  there,  and  the  area  therefore  sometimes  presents  irregular 
grooves,  nodular  infiltrations,  and  projections,  which  may  give  it  a  puck- 
ered aspect.  Exceptionally  a  gumma  may  be  somewhat  superficial,  not 
extending  deeply,  and  be  small,  hard,  and  more  or  less  sharply  circum- 
scribed, with  or  without  tendency  to  soften  and  break  down,  and  be  slug- 
gish and  slow  in  its  course.  Such  a  formation  has  sometimes  been  ob- 
served on  the  glans  penis  and  other  parts,  and  has  doubtless  often  been 
mistaken  for  a  relapsing  chancre  or  induration  (chancre  redux),  or  for 
the  initial  lesion  of  a  supposed  second  infection. 


812 


NEW  GROWTHS 


The  favorite  sites  for  the  gummatous  manifestation  of  syphilis  are 
the  soft  parts,  especially  of  the  thigh  and  calf  regions,  and  the  trunk. 
They  may  occur  upon  any  region,  however,  and  are  not  uncommon  on 
the  face,  flexor  aspects  of  the  arms,  and  other  parts.  The  course  of 
gumma  or  gummatous  infiltration  is  usually  slow,  although  at  times 
developing  with  rapidity;  the  ulcers  are,  as  a  rule,  persistent,  and  often 
grow  larger,  while  the  gummatous  process  is  extending  and  invading  the 
contiguous  tissues.  Sometimes  the  process  is  deeply  and  progressively 
destructive,  involving  bone  as  well  as  the  soft  parts,  so  that  not  infre- 
quently, especially  when  about  the  face,  considerable  disfigurement 
results.  In  the  tropics  a  pyogenic  or  other  infection  may  be  added, 


Fig.  200. — Tuberculogummatous  syphiloderm  involving  nose  and  upper  lip,  with  de- 
structive action;  duration  eight  months;  disease  contracted  some  years  previously. 

-* 

usually  giving  it  a  more  destructive  character  and  making  it  rebellious 
as  to  treatment;  probably  furnishing  not  infrequent  examples  of  the  so- 
called  "tropical  ulcer." 

In  the  various  syphilitic  ulcerations  treatment  is  commonly  followed 
by  rapid  improvement  and  finally  by  cure;  and  considering  the  amount 
of  destruction  generally  observed,  the  consequent  distortion  is  relatively 
slight,  ulcers  filling  up  and  healing  over  with  not  strikingly  conspicuous 
scar-formation.  At  times,  especially  if  about  the  joints,  the  cicatricial 
tissue  may  exhibit  a  keloidal  tendency,  but,  as  a  rule,  this  is  not  observed. 

The  diagnosis  of  gumma  in  the  earliest  stage  is  sometimes  difficult, 
as  there  is  a  resemblance  to  furuncle,  abscess,  enlarged  lymphatic  glands, 
sebaceous,  fatty,  fibroid,  and  other  tumors,  and  to  erythema  induratum. 


SYPHILIS  813 

A  definite  conclusion  is  sometimes  reached  only  by  attention  to  its  origin, 
course,  and  behavior,  together  with  the  history  of  the  case  and  the  pos- 
sible presence  of  other  cutaneous  lesions  or  scars  of  earlier  manifestations. 
Compared  to  most  of  these  formations  gumma  is  much  more  rapid  in  its 
development.  The  gummatous  ulcer  is  more  or  less  characteristic, 
being  usually  deep,  with  sharp,  punched-out  edges,  and  frequently  but 
slight  bordering  infiltration,  and 'has  a  rather  free  purulent  discharge. 
In  epithelioma  the  border  is  often  semitranslucent  and  roll-like,  or  beset 
with  several  or  more  small,  pearl-like  tubercles  or  nodules;  the  ulcer 
shows  less  discharge  and  exhibits  a  disposition  to  bleed  easily;  and  its 
progress  is  generally  slow,  and  its  history  often  materially  different 
from  that  of  a  gumma.  The  carcinomatous  infiltration  and  nodules 
often  seen  to  arise  in  the  skin  or  scar  of  the  breast  following  operation 
for  breast  cancer,  and  which  sometimes  arise  primarily,  can  readily  be 
excluded,  as  a  rule,  by  the  history,  the  much  harder  character  of  the 


Fig.  201. — Gummatous  infiltration  and  ulceration. 

infiltration  and  nodules,  the  peculiar  color,  and  the  progress,  supple- 
mented, if  necessary;  by  microscopic  examination  of  the  tissue.  I  have 
seen  a  few  cases^.in  consultation,  of  extensive  infiltration  involving  the 
female  genitalia,  strongly  suggesting  carcinoma,  but  which,  under  the 
influence  of  the  ordinary  specific  remedies,  made  full  recovery.  In  all 
obscure  cases  recourse  should  be  had  to  the  microscope  and  laboratory 
tests;  and  if  necessary,  owing  to  possible  doubt,  treatment  should  be 
tried  before  operative  measures  are  adopted.  The  differentiation  from 
erythema  induratum  is  considered  under  the  latter  disease. 

CUTANEOUS  MANIFESTATIONS  OF  HEREDITARY  SYPHILIS 

Hereditary  syphilis,  as  the  term  implies,  refers  to  the  disease  as 
transmitted  by  the  parent.  It  is  sometimes  also  designated  congenital 
syphilis  and  infantile  syphilis,  but  these  are  not  so  clearly  expressive, 
and  the  latter  could  just  as  well  be  applied,  as  in  fact  it  is,  to  the  ac- 
quired as  to  the  inherited  malady.  The  symptoms  of  acquired  syphilis 


8 14  NEW  GROWTHS 

in  the  infant  are  essentially  those  of  the  acquired  malady  in  the  adult, 
and  need  not  be  separately  discussed.  Nor  are,  in  fact,  the  syphilo- 
dermata  of  hereditary  disease  materially  different,  often  mixed,  and 
usually  of  the  macular,  papular,  or  bullous  type. 

In  a  syphilitic  pregnancy  in  which  the  fetus  has  escaped  abortion  or 
still-birth,  the  infected,  offspring  may  be  born  with  or  without  the  exist- 
ence of  manifestations  at  the  time  of  delivery,  and  hi  the  large  majority 
of  cases  the  child  in  reality,  when  born,  presents  every  indication  of  good 
health,  and  the  signs  of  the  malady  may  not  present  for  a  few  weeks 
or  a  few  months.1  A  child  born  of  syphilitic  parentage,  which  fails 
to  present  manifestations  within  the  first  six  months,  may  usually  be 
considered  to  have  escaped  infection,  although  some  exceptions  do  occur. 
Most  of  the  cases,  however,  which  have  been  described  as  examples 
of  syphilis  hereditaria  tarda,  in  which  osseous,  dermal,  and  other  lesions 
have  been  observed  as  the  first  evidences  in  later  years,  are  to  be  looked 
upon  with  considerable  question,  as  the  history  is  often  vague  or  obscure, 
and  there  is  a  probability  that  the  disease,  instead  of  being  hereditary, 
was  contracted  during  or  after  delivery  or  at  a  later  period,  with  latent 
or  mild  early  symptoms  which  escaped  observation.  Late  and  relapsing 
manifestations  may,  however,  sometimes  be  observed  in  those  who  have 
been  subject  to  the  usual  early  postnatal  symptoms,  although  it  must 
be  admitted,  fortunately,  that  the  hereditary  disease,  if  it  yields  to 
treatment,  shows,  if  the  latter  has  been  properly  carried  out,  but  little 
tendency  to  recurrences,  although  some  traces  of  its  ravages  or  influence 
may  remain.  These  latter  are,  however,  more  commonly  the  effect  of 
incomplete  or  neglected  treatment,  resulting  from  the  halting  or  damaging 
effect  the  disease  has  upon  nutritive  processes.  Among  such  symptoms 
as  are  of  dermatologic  interest,  and  which  are  also  not  uncommonly 
present  in  the  first  months  or  year,  may  be  mentioned  interstitial  kera- 
titis,  notched  teeth  (Hutchinson's  teeth),  disturbances  of  hearing,  irregu- 
lar thickenings  or  flattened  nodosities  of  the  skull,  dactylitis  (dactylitis 
syphilitica),  onychia  and  paronychia,  inflammation,  swelling,  and  tender- 
ness of  the  region  of  the  neck  of  the  long  bones,  and  sometimes  resulting 
pseudoparalysis.2 

1  In  1000  cases  observed  in  a  foundling  hospital  Miller  ("Die  friihesten  Symptome 
der  hereditaren  Syphilis,"  Jahrbuchfiir  Kinderheilkunde,  1888,  vol.  xxvii,  p.  359)  states 
that  the  disease  manifested  itself  in  64  per  cent,  in  the  first  month  (8.5  per  cent,  in  first 
week,  13.8  per  cent,  in  second,  24  per  cent,  in  third,  and  17.7  per  cent,  in  fourth)  and 
22  per  cent,  in  the  second  month.     As  the  infants  are  sent  out  to  the  country  at  the  end 
of  this  time  to  prevent  overcrowding,  no  further  careful  record  could  be  made  beyond 
this  time.     The  first  symptom  noticed  was  the  maculopapular  eruption  in  46  per  cent., 
papules  on  skin  and  mucosas  in  28  per  cent.,  rhagades  oris  et  ani  in  22  per  cent.,  maculae 
in  17.9  per  cent.,  bullous  eruption  in  8  per  cent.,  abrasions  and  ulcers  in  5.9  per  cent., 
paronychia  in  4  per  cent.,  and  pseudoparalysis  of  the  extremities  in  4  per  cent. 

2  Miller  (loc.  cit.),  in  his  analysis  of  1000  cases,  shows  that  the  affections  referable 
to  syphilis  and  seated  upon  or  in  immediate  relationship  with  the  skin  and  adjoining 
mucous  surfaces  were  as  follows:  Papules,  including  moist  papules  on  the  integument  or 
mucous  membrane,  were  present  in  74  per  cent.;  fissures  of  the  lips,  angles  of  the  mouth, 
and  anus  in  70  per  cent.;  rhinitis  in  58  per  cent.;  ulcers  of  the  hard  palate  in  52  per  cent.; 
macules  in  45  per  cent.;  ulcers  of  the  tongue  in  27  per  cent.;  bullae  in  25  per  cent.; 
onychia  (paronychia)  in  23  per  cent.;  lymphadenitis  chronica  in  29  per  cent.;  laryngitis 
in  17  per  cent.;  pseudoparalysis  of  the  extremities  in  7  per  cent.;  ulcers  in  4  per  cent.; 
ulcerative  gingivitis  in  4  per  cent.     The  eruption  was  maculopapular  in  46  per  cent, 
of  the  cases. 


SYPHILIS  815 

Hutchinson  was  the  first  to  call  attention  to  the  notched  condition 
of  the  teeth  as  commonly  indicative  of  syphilis,  but  this  condition  can 
scarcely,  as  originally  observers  were  inclined  to  believe,  be  absolutely 
diagnostic,  for  the  same  or  closely  similar  condition  may  occasionally 
be  observed  as  the  result  of  profound  nutritive  disturbance  upon  the  child 
from  other  causes  during  the  period  of  second  teething.  Nevertheless, 
it  possesses  considerable  import.  While  the  canines  and  other  teeth 
may  also  show  notching,  Hutchinson  places  the  chief  significance  upon 
the  upper  central  incisors.  At  first  they  are  noted  to  be  somewhat  short, 
with  thin  edges,  the  two  teeth  commonly  converging,  but  sometimes 
widely  separated;  later  the  central  border  breaks  or  crumbles  away,  and 
leaves  a  broad,  shallow  notch.  It  generally  disappears  between  the 
twentieth  and  thirtieth  years  from  wearing  down  of  the  projecting  parts. 

Syphilitic  dactylitis  is  usually  observed  in  the  early  months  of  the 
disease,  and  differs  in  no  respect  from  that  of  acquired  syphilis,  except 
that  there  is  ordinarily  considerable  bulbous  swelling.  It  is  persistent 
and  chronic,  but,  as  a  rule,  will  gradually  disappear  under  treatment. 
It  bears  close  resemblance  to  tuberculous  dactylitis,  from  which,  except 
by  history  and  other  symptoms,  it  often  cannot  be  distinguished,  and 
with  which,  in  fact,  it  may  be  associated.  As  a  rule,  however,  there 
is  a  greater  tendency  to  break  down  in  syphilitic  dactylitis.  The  hair 
is  likely  to  show  some  disturbed  condition,  thinning  out,  losing  its  luster, 
and  dry  and  lifeless-looking.  Lymphadenitis  is  an  occasional  occurrence, 
especially  in  those  of  scrofulous  tendency,  and  the  ordinary  adenopathy 
as  observed  in  acquired  syphilis  is  also  noted,  but  not  so  markedly  or 
even  so  commonly,  and  is  not  infrequently  practically  wanting. 

Coming  back  to  the  more  usual  conditions  observed,  the  child  born 
with  evidences  of  the  disease  is  generally  noted  to  present  a  thin,  wrinkled, 
old  appearance,  the  skin  of  a  brownish-yellow  tinge;  having  a  snuffling 
coryza,  commonly  a  hoarse,  peculiar  cry,  and  presenting  lesions  both 
upon  the  skin  and  mucous  surfaces.  The  lesions  in  such  cases  on  the 
skin  are  usually  vesicobullous  or  bullous,  with  cloudy  contents,  and 
often  becoming  purulent,  constituting  the  bullous  syphiloderm.  They 
are  more  or  less  general,  but  the  palms  and  soles  are  favorite  situations; 
there  may  be  interspersed  maculopapules  and  papules.  The  bullae  are, 
as  a  rule,  flaccid,  sometimes  distended,  and  are  often  surrounded  by  a 
brownish  or  coppery  rim  of  infiltration;  and  are  seated  either  upon  an 
excoriated,  eroded,  or  ulcerated  base.  About  the  anus  and  genitalia, 
especially  the  former,  moist  papules,  sometimes  coalescent  and  slightly 
hypertrophic,  constituting  the  flat  or  broad  condylomata,  are  not  in- 
frequently found.  The  angles  of  the  mouth  and  nose  may,  more  fre- 
quently than  in  the  acquired  disease,  be  the  seat  of  papules  or  fissures; 
mucous  patches  and  superficial  abrasions  or  ulcerations  are  quite  com- 
monly found  on  the  inner  side  of  the  lips  and  on  other  parts  of  the  oral 
cavity.  The  general  condition  becomes  worse,  the  marasmus  increases 
in  degree,  and  the  child  after  some  days  or  a  few  weeks,  as  a  rule,  succumbs. 

The  bullous  syphiloderm  is  always  indicative  of  a  malignant  form 
of  hereditary  disease,  and  usually  presages  a  fatal  end,  but  in  the  rarer 
instances  in  which  it  does  not  appear  until  later, — several  to  five  or  six 


816  NEW  GROWTHS 

weeks  after  birth,— while  still  of  generally  lethal  import,  exceptionally 
recovery  takes  place.  In  still  rarer  instances  of  children  presenting 
other  lesions  than  blebs  at  the  time  of  birth  the  manifestation  is  commonly 
macular  and  papular,  similar  to  the  same  eruptions  appearing  later  and 
to  be  immediately  described. 

As  already  remarked,  however,  the  syphilitic  offspring  at  birth, 
as  a  rule,  presents  but  little,  if  any,  active  evidences  of  the  infection, 
occasionally  being  thin,  shriveled,  and  with  an  old  look  and  a  sallow, 
dingy-looking  skin.  Ordinarily,  however,  the  child  exhibits  a  fair  con- 
dition of  health,  and  often,  indeed,  has  a  robust  appearance.  After 
some  days  or  a  few  weeks  slight  coryza  is  noted,  which  usually  develops 
into  a  well-marked  and  purulent  rhinitis, — "snuffles," — more  or  less 
completely  blocking  respiration  through  the  nose.  The  child  begins, 
in  most  instances,  to  fall  away,  often  shows  cracks  at  the  angles  of  the 
mouth,  and  possibly  one  or  more  mucous  patches  in  the  mouth.  Occa- 
sionally in  spite  of  the  disease  the  general  health  seems  to  be  but  little 
affected,  although,  with  few  exceptions,  it  sooner  or  later  suffers.  At 
about  the  same  time  there  appears  a  more  or  less  generalized  maculopapu- 
lar  eruption,  commonly  more  marked  on  the  palms,  soles,  and  face  and 
neck  than  in  the  acquired  disease.  About  the  anus,  genitalia,  and  folds 
they  frequently  become  abraded  and  moist,  forming  moist  papules, 
and  about  the  anus  showing  a  tendency  to  hypertrophic  enlargement, 
and  presenting  the  same  characters  as  the  moist  papules  in  the  acquired 
disease.  The  moist  papules  or  mucous  patches  in  the  mouth  are  also 
commonly  present.  The  macules  and  maculopapules  in  the  genitocrural 
region  sometimes  increase  in  number,  spread,  and  form  larger  plaques 
or  a  more  or  less  confluent  sheet,  of  a  dusky  red  or  ham  tint,  and,  in 
places  at  least,  somewhat  sharply  marginate.  There  may  or  may  not 
be  some  other  symptoms,  such  as  nail  affections,  dactylitis,  exostoses, 
etc. 

Quite  frequently,  indeed,  a  diffused  erythematous  or  macular  erup- 
tion appears  in  the  genitocrural  region,  usually  also  involving  the  but- 
tocks, and  with  but  few,  if  any,  associated  or  outlying  maculopapules 
or  papules;  and,  except  as  to  the  dusky  red  color,  resembling  erythema 
intertrigo.  Not  uncommonly  it  is  the  first  evidence  of  the  disease,  or 
that  which  leads  to  procuring  medical  advice.  As  a  rule,  however,  in- 
spection or  inquiry  will  show  several  of  the  associated  symptoms,  such 
as  the  fissures  or  papules  at  the  corners  of  the  mouth,  one  or  more 
mucous  patches  in  the  latter,  papules  at  the  anus,  and  possibly  lesions 
on  other  situations. 

These  two  manifestations, — macular  and  mixed  maculopapular, — 
according  to  my  experience,  are  those  most  frequently  observed  in  the 
hereditary  disease.  While  developing,  as  stated,  usually  in  the  first 
several  weeks,  two,  three,  or  more  months  sometimes  elapse  before  the 
outbreak,  although  the  later  the  appearance,  the  more,  it  seems  to  me, 
is  the  tendency  toward  a  predominance  of  the  papular  element.  Not 
infrequently  the  eruption  is  at  first  chiefly  macular,  the  macules  later 
developing  into  maculopapules  or  papules.  In  some  of  these  latter 
cases  the  papules  become  slightly  scaly,  although  rarely  to  such  a  degree 


SYPHILIS  817 

as  observed  in  the  papulosquamous  eruption  of  acquired  syphilis.  The 
papules  are  of  the  flat  variety,  and  not,  as  a  rule,  much  elevated,  and 
somewhat  variable  as  to  size,  although  usually  pea-  to  finger-nail-sized; 
the  acuminated  papules  are  rarely  seen  in  the  hereditary  disease. 

The  manifestations,  whether  predominantly  macular,  maculo-papular, 
or  papular,  are  somewhat  persistent,  and  new  lesions  may  continue 
to  appear  for  some  days  or  longer;  in  severe  cases,  and  especially  in  those 
whose  nutrition  is  impaired,  probably  through  visceral  complication  or 
other  causes,  as  neglect  or  poor  feeding,  the  general  health  fails,  a  mar- 
asmic  condition  develops,  some  of  the  lesions  may  show  ulcerative  tend- 
ency, and  the  child  gradually  sinks  and  finally  dies.  In  less  severe 
cases,  especially  if  well  nourished  and  carefully  looked  after,  the  mani- 
festations after  a  time  begin  to  fade,  and  with  or  without  a  few  relapsing 
exacerbations  the  disease  apparently  runs  its  course  and  the  patient 
recovers;  in  some  instances  to  have  later  other  signs  of  the  malady. 
Whether  without  proper  treatment  so  favorable  a  result  sometimes 
ensues  is  difficult  to  state,  inasmuch  as  such  cases  usually  receive  medical 
care.  Nevertheless  I  have  seen  several  instances  of  the  hereditary  dis- 
ease, in  connection  with  dispensary  practice,  presenting  one  or  the  other 
of  these  milder  manifestations,  in  which  apparent  recovery  followed 
in  spite  of  gross  carelessness  and  neglect  on  the  part  of  the  parent  in 
carrying  out  the  treatment  ordered. 

The  pustular  syphilodermata  are  seldom  met  with  as  a  hereditary 
manifestation,  although  some  of  the  vesicular,  vesicobullous,  and  bullous 
lesions  of  the  bullous  syphiloderm  may  become  purulent  and  develop 
into  more  or  less  perfectly  formed  pustules.  More  commonly  several 
or  more  pustules,  usually  flattened,  will  be  seen  about  the  mouth,  nose, 
and  genito-anal  region  in  association  with  the  maculopapular  or  papular 
syphilodermata.  When  they  occur  in  any  profusion,  a  grave  type  is 
usually  indicated.  The  vesicular  syphiloderm  in  hereditary  syphilis 
is  extremely  exceptional — but  has  been  noted  by  a  number  of  observers; 
usually,  however,  in  association  with  the  pustular  or  bullous  eruption.1 
The  tubercular  syphiloderm  is  rare  in  the  hereditary  disease,  although 
it  may  occur  as  early  as  the  sixth  month,  and  sometimes  later, — several 
or  more  years  after  birth, — but  at  this  period  usually  as  a  recur- 
rence. The  gumma  is,  as  a  rule,  not  met  with  in  the  first  months  or 
first  few  years,  but  generally  after  the  third  or  fourth  year.  It  is 
similar  in  its  characters  to  the  same  lesion  in  the  acquired  disease  in 
the  adult. 

The  diagnosis2  of  the  hereditary  syphilodermata  is  rarely  a  matter 
of  difficulty,  as  the  associated  symptoms  of  snuffles,  mucous  patches 
in  the  mouth,  moist  papules  or  flat  condylomata  around  the  anus,  the 

1  Grindon,  Jour.  Cutan.  Dis.  1910,  p.  284,  has   recently  reported   2  cases,  and 
briefly  reviews  the  subject. 

2  The  Spirochaeta  pallida  is  also  to  be  found  in  hereditary  syphilis;  Levaditi,  in  an 
interesting  paper  ("L'histologie  pathologique  de  la  syphilis  hereditaire  dans  ses  rapports 
avec  le  'spirochaete  pallida,'  "  Annales  mal.  ven.,  1906,  p.  22),  goes  over  the  ground, 
with  review  references  to  the  work  of  Hoffman,  Buschke  and  Fischer,  Bodin,  and 
others.     See  also  remarks  under  Etiology  and  Diagnosis  of  the  syphilodermata  in 
general. 

52 


8i8  NEW  GROWTHS 

frequently  accompanying  shriveled  or  "old-man  appearance,"  the  mar- 
asmic  tendency,  and  the  usually  polymorphous  character  of  the  eruption 
will  give  a  picture  more  or  less  characteristic.  At  least  two,  sometimes 
more,  of  these  associated  symptoms  will  generally  be  present,  together 
occasionally  with  dactylitis,  onychia,  keratitis,  exostoses,  etc.  The 
course  and  outlook  of  these  hereditary  cases  have  already  been  incidentally 
touched  upon.  The  prognosis  depends  upon  the  variety,  severity, 
general  condition  of  the  child,  the  probability  of  proper  nursing  or  feeding, 
and  the  careful  carrying  out  of  the  treatment.  In  breast-fed  children 
the  disease  is  much  less  fatal  than  in  those  artificially  nourished.  The 
result  is,  however,  always  somewhat  uncertain,  and  by  far  most  cases 
die.  As  a  general  rule,  the  more  distant  from  the  time  of  birth  the  mani- 
festations appear,  the  more  favorable  is  the  outcome.1  Occasionally 
destructive  action  takes  place  in  the  nose,  and  a  flattening  of  this  organ 
in  such  an  event  will  occur. 

Etiology. — Syphilis  is  acquired  through  heredity,  which  has  been 
sufficiently  touched  upon,  and  in  various  ways  by  direct  inoculation. 
The  usual  and,  of  course,  the  most  common  method  is  through  the  sexual 
act,  by  conveyance  of  the  syphilitic  poison  from  an  existing  chancre  or 
other  lesion  present  on  the  genitalia;  houses  of  prostitution  and  street 
prostitutes  are  its  principal  sources.  But,  as  already  referred  to  in  de- 
scribing the  initial  lesion,  extragenital  chancres  are  not  at  all  uncommon, 
and  are  the  result  of  accidental  and,  with  probably  but  few  exceptions, 
perfectly  innocent  inoculation,  as  by  the  act  of  kissing,  from  drinking- 
cups2  or  glasses,  or  the  common  communion-cup;  by  infected  razors, 
etc.,  in  barbershop,  tattooing;3  by  medical  men  also  from  operations  and 
other  professional  manipulations,  and  in  many  other  ways.  Knowing 
the  contagiousness  of  the  secretion  from  mucous  patches,  which  are  to 
be  found  quite  frequently  in  the  mouth,  the  wonder  is,  in  fact,  that 
the  innocent  and  unsuspecting  are  not  more  frequently  accidentally 

1  Hyde's  paper,  entitled  "What  Conditions   Influence  the  Course  of  Infantile 
Syphilis,"  Medical  News,  Dec.  4,  1897,  is  a  valuable  presentation,  on  pertinent  points, 
based  upon  his  own  observations  and  the  statistics  of  such  other  careful  observers  as 
Kassowitz,  Lancereaux,  Neumann,  Coutts,  Jullien,  Warner,  and  others.     It  shows  that 
in  1700  syphilitic  pregnancies  the  number  of  abortions  and  still-births  amounted  to 
579,  leaving  1121  born  alive,  of  whom  956  died  within  the  first  twelve  months;  of  the 
remaining  165  who  chanced  to  survive  a  year  nothing  is  further  known.     Of  41  preg- 
nancies in  25  syphilitic  mothers  under  his  own  observation,  there  were  31  abortions  and 
children  dead  at  birth  or  within  one  year.     Henoch  ( Vorlesungen  u'ber  Kinderkrank- 
heiten,  1889,  p.  105),  quoted  by  Hyde,  claims  that  all  infants  affected  with  hereditary 
syphilis  die  if  they  are  not  suckled  at  the  breast,  and  Widerhofer  ("Klinische  Vorle- 
sung,"  Wien.  med.  Zeitung,  1886),  quoted  by  the  same  writer,  puts  the  percentage  of 
such  deaths  in  children  artificially  reared  as  high  as  99  per  cent.     It  seems  to  me,  how- 
ever, that  it  is  not  at  all  improbable  that  in  some  of  those  cases  the  result  was  consid- 
erably influenced  by  improper  or  insufficient  feeding,  neglect  of  prompt  and  early  treat- 
ment due  to  parental  indifference  or  ignorance,  and  thus  affected  the  mortality  percent- 
age. 

2  Schamberg,  "An  Epidemic  of  Chancres  of  the  Lip  from  Kissing,"  Jour.  Amer. 
Med.  Assoc.,  Sept.,  2,  1911,  p.  783  (Q  cases);  Mclntosh,  "Syphilis,  Especially  in  Re- 
gard to  its  Communication  by  Drinking  Cups,  Kissing,  etc.";  The  Military  Surgeon, 
Feb.,  1913,  p.  184  (reviews  the  subject  briefly,  and  cites  personal  observations). 

3  Maury  and  Dulles,  "Tattooing  as  a  Means  of  Communicating  Syphilis"  (15 
cases),  Amer.  Jour.  Med.  Sci.,  January,  1878;  Barker,  "Outbreak  of  Syphilis  Following 
on  Tattooing,"  Brit.  Med.  Jour.,  1889,  i,  p.  985  (12  cases  with  several  cuts). 


SYPHILIS  819 

infected  through  the  common  drinking  vessel  and  in  other  similar  man- 
ner. There  is  an  all  too  common  belief  that  extragenital  chancres,1 
especially  about  the  mouth,  as  well  as  other  parts,  are  frequently  due  to 
unnatural  sexual  relation,  but  considering  the  chances  of  innocent  con- 
traction of  the  disease,  such  a  suspicion  is,  with  rare  exception,  an  ex- 
tremely unjust  one.  The  readiness  of  accidental  inoculation  is  shown 
by  the  examples  of  physicians  who,  in  the  course  of  professional  pursuit, 
through  digital  vaginal  examination,  operations,  and  in  other  ways,  con- 
tract a  finger  chancre.  Fifteen  to  twenty  such  instances  have  come  to 
my  own  notice.2  It  is,  too,  not  improbable,  indeed,  that  medical  men 
themselves  have  been  occasionally,  before  the  days  of  full  appreciation 
of  the  value  of  complete  asepsis,  the  unintentional  agents  of  conveying 
the  disease  to  others  through  infected  instruments  which  had  not  been 
properly  cared  for;  and  the  same  may  be  said  more  positively  of  dentists, 
who  have  to  do  with  a  cavity  in  which  contagious  material  is  often  pres- 
ent. Fortunately,  the  best  dentists  now  give  attention  to  the  necessity 
of  sterilizing  instruments  after  each  use,  but  there  are  still  many  who 
show  a  lack  of  even  common  cleanliness.  The  number  of  extragenital 
chancres  which  come  under  the  observation  of  those  engaged  in  certain 
lines  of  special  practice,  more  particularly  those  of  diseases  of  the  skin, 
venereal  diseases,  and  throat  diseases,  in  which  suspicion  often  points  to 
these  various  sources,  is  sufficiently  large  to  make  one  feel  strongly  on 
the  subject. 

Infected  persons  should  always  be  informed  of  the  danger  of  convey- 
ing it  to  others,  and  to  take  all  precautions  against  such  possible  mishap, 
and  this,  together  with  proper  treatment,  at  present  seems  the  only  method 
of  controlling  its  spread,  as  effective  legal  supervision  seems  both  impos- 
sible and  impracticable.  The  period  of  danger  of  contagion  is  not  a 
wholly  definite  one:  it  exists  through  the  active  stages  of  the  malady, 
and  therefore  during  the  first  one  or  two  years;  persisting,  but  its  viru- 
lence or  potency  probably  becoming  gradually  less,  in  some  instances 
up  to  the  third,  fourth,  and  even  fifth  year.  The  pathologic  secretion 
from  any  lesion  during  the  time  of  this  activity  is  capable  of  producing 
the  disease.  The  blood  of  such  an  individual  is  also  infecting,  and  while 
the  physiologic  secretions,  such  as  the  saliva,  milk,  sweat,  etc.,  are 
believed  to  be  generally  innocuous,  yet  the  possible  admixture  of  even 
insignificant  quantity  of  blood  or  discharge  from  mucous  patches  or 
other  lesion,  however  small  or  unrecognized,  renders  such  secretions 
dangerous,  and  this  fact  is  to  be  kept  in  mind.  Contagiousness  is,  how- 
ever, generally  considered  by  those  of  largest  opportunities  to  be  uncom- 
mon after  the  second  or  third  year,  but  there  are  sufficient  exceptions 
to  this  during  the  fourth  and  fifth  years  to  consider  still  the  possibility 

1  See  Bulkley's  most  admirable  monograph,  Syphilis  in  the  Innocent  (Syphilis 
Insontium),  New  York,  1894;  Knowles,  "Syphilis  Extragenitally  Acquired  in  Early 
Childhood,"  New  York  Med.  Jour.,  July  18,  1908  (with  bibliography). 

2  A.  Blaschko,  "Syphilis  als  Berufskrankheit  der  Aerzte,"  Berlin,  klin.  Wochenschr., 
No.  52,  Dec.,  1904;  D.  W.  Montgomery,  "The  Acquisition  of  Syphilis  Professionally 
by  Medical  Men,"  Jour.  Cutan.  Dis.,  April,  1905  (7  cases,  with  review  of  many  other 
reported  cases,  and  references);  Knowles,  "The  Relationship  of  Syphilis  to  Dentistry," 
The  Dental  Brief,  Nov.,  1909  (with  bibliography). 


82Q  NEW  GROWTHS 

of  danger.1  The  belief  that  the  tertiary  lesions  are  innocuous  in  this 
respect  is  not  so  absolutely  held  to-day  as  formerly,  as  instances  have 
been  noted  in  which  the  virulence  still  existed. 

While  the  various  facts  above  mentioned  are  now  common  knowl- 
edge, the  specific  infective  germ  had  long  been  eagerly  sought  for.2  The 
comparatively  recent  epoch-making  finding  is  that  of  the  Spirochaeta 
pallida  by  Schaudinn  and  E.  Hoffmann,3  whose  findings  have  been  since 
repeatedly  confirmed  by  themselves  and  numerous  other  investigators. 
That  this  organism  exists  in  primary  and  secondary  lesions  and  lymphatic 
glands  is,  therefore,  now  admitted,  and  its  pathogenic  importance  seems 
well  assured.  It  is  true  that  some  doubt  was  engendered  by  the  state- 
ments of  a  few  observers  that  they  had  also  found  the  organism  in  non- 
syphilitic  lesions,  but  inasmuch  as  there  are  other  spirochetes  resembling 
the  Spirochaeta  pallida,  these  statements  are,  as  is  now  known,  due  to 
errors  of  that  kind.  Now  that  Metchnikoff  and  Roux,4  followed  by  Las- 
sar  and  Neisser  and  others  have  shown  conclusively  that  syphilis  can  be 
transmitted  by  inoculation  to  chimpanzees  and  other  apes,  a  field  of 
investigation  is  opened  that  may  lead  to  a  definite  solution  of  some  of  the 
problems  connected  with  this  interesting  disease.  Indeed,  experiments 
already  made  along  this  line  go  to  prove  the  Spirochseta  pallida  the 

,  l  See  interesting  paper  by  Feulard,  "Duree  de  la  periode  contagieuse  de  la  syphilis," 
Trans.  Third  Internal.  Dermatolog.  Congress,  and  Annales,  1896,  p.  1025  (shows  that 
four  or  five  years  or  more  afterward  contagious  examples  have  been  noted — many  cited 
both  from  his  own  experience  and  that  of  others). 

2  Krzysztalowicz  and  Siedlecki,  Monatshefte,  1905,  vol.  xli,  p.  231,  gave  a  brief 
review  of  these  various  findings  to  date. 

3  Schaudinn  and  E.  Hoffmann,  Arbeiten  aus  dem  k.  Gesundheitsamte,  1905,  vol.  xxii, 
p.  527;  Deutsch.  med.  Wochenschr.,  May  4,  1905;  Berlin,  klin.  Wochenschr.,  May  29, 
1905;  ibid.,  July  10,  1905;  E.  Hoffmann,  ibid.,  1905,  No,  32;  E.  Hoffmann  and  Halle, 
Munch,  med.  Wochenschr.,  1906,  No.  31;  E.  Hoffmann  and  Beer,  Deutsch.  med.  Woch- 
enschr., 1906,  No.  22;  E.  Hoffmann,  Dermalolog.  Zeitschr.,  Nov.,  1909  (with  colored 
plates).     Among  the  many  contributions  on  the  subject  may  be  mentioned  the  admir- 
able review  papers  by  Shennan,  Scottish  Med.  and  Surg.  Jour.,  1905,  p.  457  (with  bibli- 
ography), and  Jour.  Cutan.  Dis.  (same  paper),  1905,  p.  457;  Fanoni,  Med.  News,  Oct.  7, 
1905,  and  New   York  Med.  Jour.,  Nov.  4,  1905;  Flexner,  Med.   News,  Dec.  9,  1905; 
Pfender,  Amer.  Med.,  Mar.  10,  1906  (with  bibliography);  Schultz,  "The  Present  Status 
of  Our  Knowledge  of  the  Parasitology  of  Syphilis,"  Jour.  Cutan.  Dis.,  1907,  p.  429; 
and  Harris,  Jour.  Amer.  Med.  Assoc.,  1909,  vol.  liii,  p.  757  (with  review,  and  numerous 
references). 

The  Spirochata  pallida,  now  classified  as  Treponema  pallidum,  is  an  extremely  deli- 
cate organism;  long,  very  thin,  and  filamentous,  of  a  spiral,  or  cork-screw  shape,  with 
pointed  ends  showing  a  hair-like  flagellum;  and  as  stated  by  some  writers,  with  a  nucleus, 
although  this  last  is  not  yet  absolutely  proved.  Its  length  varies  from  4  to  10  u;  its 
breadth  is  difficult  to  gauge,  being  at  most  about  0.25  fi;  the  turns  m  the  spiral  number 
six  to  fourteen,  averaging  eight  to  ten.  It  is  vigorously  motile,  and  progresses  by  rotat- 
ing on  its  long  axis,  and  when  at  rest  it  shows  undulatory  movements  in  its  whole  length, 
suggestive  of  the  play  of  a  vibratile  membrane.  It  exists  in  numbers  and  more  numer- 
ously in  the  deeper  parts  of  the  lesions;  is  very  weakly  retractile,  stains  with  difficulty, 
and  is  not  easily  seen,  requiring  very  high  power  of  the  microscope,  y'j  oil-immersion  ob- 
jective with  medium  to  No.  8  ocular.  They  have  been  found  in  primary  and  secondary 
syphilitic  lesions  and  the  lymphatic  glands,  and  in  almost  all  tissues  and  organs  in  hered- 
itary syphilis.  They  remain  alive  for  several  hours  in  physiologic  salt  solution,  and 
they  can  be  seen  in  smears  from  the  tissue  juice,  fixed  in  absolute  alcohol,  and  stained  by 
a  modification  of  Giemsa's  method;  Schaudinn  and  Hoffmann  employed  Giemsa's 
eosin-azure  solution. 

4  Metchnikoff  and  Roux,  Ann.  de  VInstitut  Pasteur,  Nov.  25, 1905;  Neisser,  Deutsch. 
med.  Wochenschr.,  1906,  Nos.  1-3;  Bowen,  Boston  Med.  and  Surg.  Jour.,  1905,  vol.  clii, 
p.  285,  gives  a  review  of  these  "experimental  inoculations";  Williams,  Jour.  Cutan. 
Dis.,  1907,  p.  350,  also  gives  a  good  review. 


SYPHILIS  821 


essential  factor  in  its  etiology.  We  have  yet  doubtless  much  to  learn 
about  the  life  history  of  this  organism.1 

Difference  of  opinion  exists  as  to  the  explanation  of  the  various  grades 
of  the  disease  as  shown  by  the  manifestations,  which  are  sometimes  slight 
or  even  almost  wanting,  or,  on  the  other  extreme,  malignant.  Some 
hold  that  it  is  chiefly  dependent  upon  the  difference  in  constitution, 
health,  or  resisting  power  of  the  individual;  others,  that  there  is  possible 
a  variation  in  the  degree  of  virulence  of  the  organism  itself.  The  former 
certainly  has  considerable  bearing,  and  the  latter  also,  judging  from  the 
observations  of  other  infectious  maladies,  must  likewise  be  considered 
as  not  unimportant. 

External  agents,  such  as  heat  and  cold,  etc.,  do  not  seem  to  be  pro- 
ductive of  any  direct  special  influence,  but  in  many  instances  of  tertiary 
cutaneous  manifestations  a  determining  etiologic  factor  of  import  is 
local  irritation  or  injury,  which  starts  the  syphilitic  pathologic  process. 

Pathology. — The  pathologic  anatomy  of  syphilitic  cutaneous 
lesions  has  been  studied  by  various  investigators,  among  whom  are 
Biesiadecki,  Auspitz,  Neumann,2  Kaposi,  Cornil,  Unna,  Crocker,  and 
Fordyce,  those  of  most  recent  date  being  by  Crocker,3  Unna,4  and 
Fordyce,5  and  whose  conclusions  in  the  main  coincide.  In  general 
it  may  be  said  that  the  syphilitic  deposit  is  essentially  a  new  growth, 
and  consists  of  round-cell  infiltration,  especially  about  the  vessels, 
generally  endothelial  proliferation,  and  in  the  papular,  tubercular,  and 
gummatous  lesions,  the  presence  usually  of  a  variable,  but,  as  a  rule, 
scanty,  number  of  giant-cells6  The  rete,  corium,  and  in  the  deep  lesions 
the  subcutaneous  connective  tissue  also,  are  involved  in  the  process, 
although  the  initial  changes  are  noted  in  the  upper  part  of  the  corium. 
It  differs  from  some  other  neoplastic  formations  by  the  absence  of  all 
tendency  to  organization,  the  retrogressive  steps  being  by  invo- 

1  Recent  valuable  papers  by  McDonagh,  "The  Life  Cycle  of  the  Organism  of  Syph- 
ilis," Brit.  Jour.  Derm.,  1912,  p.  381,  and  the  "Complete  Life  History  of  the  Organism 
of  Syphilis,"  ibid.,  1913,  p.  i  (both  papers  well  illustrated),  and  Ross,  Brit.  Med.  Jour., 
Dec.  14,  1912  (covering  the  same  ground  as  McDonagh),  may  throw  considerable  light 
upon  the  incubation  and  vagaries  of  the  disease.      These  investigators  conclude  that 
the  wellrknown  spirochaeta  5s  but  a  phase  in  the  rather  complicated  life  history  of 
a  sporozoal   parasite;  that  it  is,  in  fact,  the  adult  male  gamete  in  search  of  the 
quiescent  female  gamete,  with  which  to  unite  and  form  a  zygote.     According  to 
McDonagh  it  would  seem  that  an  infective  granule  enters  a  large  mononuclear  leukocyte 
and  increases   in  size  therein.     In  the  male  sexual  cycle  a  mass  of  spirochaetae  are 
eventually  formed  from  this,  which  are  finally  liberated,  whilst  in  the  female  cycle  a 
spheric  mass  is  eventually  evolved  which  becomes  also  free.     A  spirochaete  fertilizes 
this  mass  to  form  a  zygote.     Four  sporoblasts  then  form  in  the  zygote,  and  from  these 
numerous  sporozoites  develop.     The  cell  finally  bursts,  and  the  sporozoites  are  set 
free  to  start  again  the  sexual  cycle.     McDonagh  believes  that  these  several  stages 
in  the  development  of  the  organism  account  for  the  long  period  of  incubation  of  syphilis, 
and  that  the  infection  is  probably  conveyed  by  the  sporozoite.   He  thinks  the  organism 
can  be  assigned  to  the  order  sporozoa,  and  the  subclass  Telosporidia;  the  order  doubtless 
being  the  coccidiidea,  and  the  species  leukocytozoon,  and  hence  suggests  the  name  for 
the  parasite — "Leukocytozoon  Syphilis." 

2  Neumann,  Archiv,  1885,  p.  209  (with  many  excellent  plates  and  r£sum6  of  the 
investigations  of  others). 

3  Crocker,  Diseases  of  the  Skin,  third  ed.,  p.  845  et  seq. 

4  Unna,  Histopathology. 

8  Fordyce,  "The  Vessel  Changes  and  Other  Pathological  Features  of  Cutaneous 
Syphilis"  (with  illustrations),  Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlix,  p.  462. 
8  Fordyce,  "Giant  Cells  in  Syphilis,"  Interstate  Med.  Jour.,  xviii,  No.  i. 


822  NEW  GROWTHS 

lution  through  fatty  degeneration  and  absorption  or  by  necrosis  and 
consequent  ulceration.  The  ordinary  changes  are  not  so  well  shown 
in  the  macular  syphiloderm,  where,  in  fact,  the  changes  scarcely  go  be- 
yond hyperemia  with  insignificant  cell  infiltration,  and  are  practically 
limited  to  the  papillary  layer  of  the  corium;  often  tolerably  sharply  de- 
fined, and  sometimes  extending  a  little  more  deeply,  and  also,  when  more 
than  the  usual  effusion  takes  place,  upward  to  the  lowest  strata  of  the 
rete.  Sometimes  also,  according  to  Neumann,  the  changes  extend  still 
more  deeply,  and  cell  effusion  is  noted  around  the  glandular  structures 
as  well.  The  capillaries  and  other  minute  vessels  are  dilated,  and  both 
in  and  surrounding  them  is  found  cell  accumulation,  with  also  both  round 
and  spindle-shaped  cells  in  the  adventitia  of  the  larger  vessels.  A 
variable  number,  usually  large,  of  the  Spirochaeta  pallida  will,  on  careful 
examination,  and  more  especially  after  staining,  be  seen  in  this  and 
other  types  of  lesions,  being  more  numerous  in  the  deeper  parts. 

Renaut1  says  that  all  the  different  forms  of  syphilitic  lesions  are, 
anatomopathologically  considered,  structurally  the  same:  a  reactionary 
defensive  work  against  a  pathogenic  agent,  which,  at  a  certain  stage, 
gives  rise  to  an  endarteritis  of  a  special  kind,  slowly  obliterating,  and 
tending  from  the  first  to  excite  the  production  of  hypertrophy  of  the 
tissues  about  it. 

In  the  miliary  papular  or  follicular  syphilid  the  process  is  seated 
especially  around  and  about  the  hair-papilla,  and  also  in  the  tissues 
immediately  surrounding  and  slightly  below  the  follicle,  the  cell  infiltra- 
tion being  of  a  dense  character.  The  vessels  of  the  papilla  are  dilated, 
and  both  surrounded  and  filled  with  cells,  the  vessel-walls  exhibiting 
numerous  nuclei.  The  hair-sac,  especially  at  its  lower  part,  is  dilated 
and  ruptured  by  the  pressure  of  the  dense  cell  collection.  The  adjacent 
horny  layers  show  slight  changes,  the  rete  is  thickened,  and  the  corium 
more  or  less  replaced  or  obscured  by  the»cell  infiltration..  The  sebaceous 
glands  and  neighboring  sweat-glands  are  also  involved.  This  papule 
is  not  always,  however,  formed  about  the  hair-follicle,  as,  according  to 
Crocker's  investigations,  "it  is  also  formed  by  the  lifting-up  of  the  epi- 
dermis by  dense  cell  effusion,  in  the  center  of  which  a  sweat-duct  can 
sometimes  be  traced." 

The  flat  papule  may  be  said  to  represent  the  more  typical  condi- 
tions of  the  syphilodermata,  and  these  show  some  resemblance  to  lupus 
vulgaris.  There  is  marked  deposit  here,  and  found  seated  in  the  rete, 
all  layers  of  the  corium,  and  downward  in  the  subcutaneous  tissue, 
where  it  is  sharply  defined  beneath.  There  is  also  sharp  definition 
laterally.  The  cell  infiltration  is  in  places  more  or  less  dense,  and  in 
others  somewhat  disseminated,  but  it  is  greater  in  the  papillary  and  sub- 
jacent layers,  being  primarily  observed  about  the  vessels  and  their 
ramifications  of  the  superficial  and  deep  plexuses.  It  may  be  so  great 
in  amount  as  to  more  or  less  obliterate  the  normal  structures.  A  variable 
number  of  incompletely  formed,  and  a  few  typical,  giant-cells,  and  oc- 
casional epithelioid  cells,  are  commonly  also  to  be  noted.  The  new 

1  Renaut,  Rev.  prat.  d.  mal.  Cutan.,  Syph.  el  vener.,  Jan.,  1903 — abs.  in  Brit.  Jour. 
Derm.,  1903,  p.  271. 


SYPHILIS  823 

growth  in  the  papular  syphilodermata,  according  to  Unna,  is  composed 
mainly  of  variously  sized  plasma-cells.  The  sweat-ducts  and  coils  are 
frequently  involved  to  considerable  degree,  both  by  surrounding  cell 
infiltration  and  proliferation  of  the  lining  cells.  The  hair-follicle  in  this 
papular  form  usually  holds  its  shape  fairly  well.  In  the  process  of  in- 
volution the  first  steps  are  generally  noted  centrally,  absorption  taking 
place,  and  the  part  sinking  in  slightly,  and  exceptionally  absorption  may 
be  so  complete  in  this  part,  and  then  with  halting  or  relatively  slower 
retrogression  peripherally,  that  the  papules  present  a  ring-like  aspect. 
In  the  squamous  papular  lesion  the  epidermis  shows  considerable  involve- 
ment, the  horny  layers  exfoliating,  and  usually  with  a  moderately  or  con- 
siderably thickened  proliferating  rete.  The  moist  papule  may  extend 
more  deeply  than  the  ordinary  papule,  but  ordinarily  the  conditions  are 
essentially  or  closely  similar,  but  the  rete  is  usually  considerably  thick- 
ened and  the  papillae  show  variable  degrees  of  hypertrophy  and  elonga- 
tion from  slight  to  extreme  development. 

The  tubercle  and  gumma  are  not  only  clinically  to  be  looked  upon 
as  enlarged  papules,  but  also  anatomically,  the  process,  of  course,  being 
much  more  extensive,  and  going  more  widely  and  more  deeply  into  the 
tissues.  The  evolution  of  the  tubercle  is  much  less  rapid,  and  its  per- 
sistence more  prolonged,  and  atrophic  or  necrotic  changes  going  into 
ulceration  usually  follow.  In  gumma  the  infiltration  is  generally  wide- 
spread and  much  deeper,  although  it  remains  fairly  well  circumscribed. 
While  the  deposit  in  this  growth  may  ultimately  disappear  by  absorption, 
its  usual  course  is  that  of  necrosis  and  ulceration. 

The  pustular  syphilodermata  may,  in  great  measure,  be  viewed  as 
papular  processes,  plus  the  consequences  and  changes  produced  by 
local  pyogenic  cocci  invasion.  In  the  basal  or  more  or  less  persistent 
papular  portion  the  alterations  are  similar  to  those  found  in  papules. 
Like  the  latter,  therefore,  they  are  well  defined,  and  may  be  seated  in 
the  corium  or  the  subcutaneous  tissue.  According  to  Kaposi,  as  quoted 
by  Duhring,  "the  essential  features  of  the  pustule  consist  in  the  presence 
of  dimly  contoured,  highly  granular,  cloudy,  nucleated  cells,  and  free 
nuclei  within  the  uppermost  layers  of  the  corium,  papillary  layer,  and 
rete,  seated  in  a  succulent,  large-meshed,  serum-saturated  tissue  or  even 
in  open  spaces."  As  with  the  papules,  the  pustular  lesions  may  be 
connected  with  the  hair-follicles  or  be  seated  in  the  corium  independently 
of  this  structure  and  of  the  sebaceous  gland.  The  anatomic  conditions 
of  the  several  varieties  of  the  pustules  themselves  are  not  greatly  differ- 
ent from  those  of  similar  non-specific  lesions,  as  variola,  impetigo,  and 
ecthyma.  The  pus-chamber  is  to  be  found  between  the  epidermic  strata, 
often  with  the  eroded  rete  as  the  basal  portion,  or  the  corium  forming  the 
basal  boundary,  and  not  infrequently  the  suppurative  or  destructive 
action  extending  superficially  or  more  or  less  deeply  through  this  latter 
structure,  and  in  such  instances  followed  by  more  or  less  marked  and  per- 
manent scarring. 

The  dark  or  dusky  red  or  ham  color  commonly  noted  in  the  syph- 
ilodermata is  due  to  the  blood-coloring  matter  derived  from  the  wander- 
ing or  extravasated  red  corpuscles,  and  to  the  sluggish  character  of 


824  NEW  GROWTHS 

the  inflammatory  element.  The  whole  process  is,  in  fact,  usually  slow 
in  evolution  and  more  or  less  persistent,  and  this  sluggishness  is  still 
further  emphasized  by  Neumann's  observations  that  the  morbid  prod- 
ucts, chiefly  exudation  cells,  are  to  be  found  four  to  eight  months 
after  clinical  evidences  have  disappeared;  and  this,  as  Crocker  states, 
"lends  some  support  to  Hutchinson's  doctrine  'of  residues  of  the  early 
period  of  syphilis  being  the  starting-point  of  later  lesions.'  ' 

Diagnosis. — The  features  of  the  various  syphilodermata  have 
already  been  considered  in  connection  with  the  description  of  each  form, 
and  in  the  general  observations  concerning  the  special  characters  of  these 
eruptions;  a  study  and  clear  understanding  of  the  latter  will  go  far 
toward  the  prevention  of  errors  in  diagnosis.  The  general  characters, 
distribution,  color,  and  associated  concomitant  symptoms  in  the  early 
syphilodermata,  usually  with  the  history  of  the  initial  lesion,  are  the 
chief  valuable  differential  points.  The  finding  of  the  Spirochaeta  pallida 
would  be  a  determining  factor  in  a  doubtful  case.  Fortunately,  cases  of 
syphilis  are  rare  that  cannot  be  recognized  by  the  gross  clinical  symp- 
toms alone.  In  the  late  eruptions  the  limited  or  regional  character,  seg- 
mental,  circinate,  or  serpiginous  configuration,  together  with  the  color, 
and  commonly  an  ulcerative  tendency,  are  to  be  given  consideration. 

Seven  or  eight  years  ago  the  serum  reaction  diagnostic  test  for  syphilis 
— now  known  as  the  Wassermann  test — was  brought  forward  by  Wasser- 
mann,1  Neisser  and  Bruck,  and  the  method  and  its  value  later  further 
explained  and  confirmed  by  themselves  in  association  with  Schucht. 
A  positive  reaction,  it  was  alleged,  is  presumptive  evidence  of  syphilis, 
and  this  belief  has  now  been  accepted  by  many  others  (among  whom 
Fleishmann,  Butler,  Hoffmann,  Haldin  Davis,  Blumenthal,  Lesser, 
Levaditi,  Blaschko,  Noguchi,  Boas,  Howard  Fox,  Heidingsfeld,  Swift, 
and  others) .  It  is  agreed  that  it  furnishes  an  additional  means  of  aiding 
in  reaching  a  conclusive  diagnosis  in  doubtful  cases.  It  is  not  as  yet,  in 
my  opinion,  to  be  considered  as  in  itself  absolute — it  fails  of  positive 
reaction  in  a  fair  proportion  of  cases  (25  to  30  per  cent.)  of  primary  syphi- 
lis, in  about  5  to  10  per  cent,  of  secondary  cases,  and  about  12  to  15  per 
cent,  in  tertiary;2  and  a  positive  reaction  has  been  frequently  noted  in 
several  other  diseases,  more  especially  in  leprosy  (not  all  cases) ,  sleeping- 
sickness,  malaria,  hookworm  disease,  frambesia,  scarlet  fever,  etc. 
While  one  is  justified  in  looking  upon  a  single  positive  reaction  with  doubt, 
unless  corroborated  by  symptoms  suspiciously  syphilitic,  the  significance 
of  a  series  of  tests  made  at  intervals  and  giving  a  constantly  positive 
reaction  would  scarcely  be  questioned.  A  single  negative  test  is  prac- 

1  Wassermann,  Neisser  and  Bruck,  "Eine  serodiagnostiche  Reaktion  bei  Syphilis," 
Deutsche  med.  Wochenschr.,  May  10,  1906,  xxxii,  and  Wassermann,  Neisser,  Brucht,  and 
Schucht,  "Weitere  Mitteilungen  ueber  den  Nachweis  Specifisch-luetischer  Substanzen 
durch  Komplementverankerung,"  Zeitschr.  f.  Hyg.  u.  Infectionskrankheiten,  1906,  Iv, 
P-  453- 

2  Boas,  "Die  Wassermannsche  Reaktion  mit  besonderer  Beriicksichtigung  ihrer 
klinischen  Verwertbarkeit"  (Harold  Boas,  Berlin,  1911  (German  translation)),  claims 
with  the  quantitative  method  of  carrying  out  the  Wassermann  reactions  its  value  is 
much  increased;  he  uses  in  every  case  five  amounts  of  serum,  ranging  from  the  usual 
.2  to  .01  c.c.;  Fildes,  Brit.  Jour.  Derm.,  1911,  p.  13,  gives  a  survey  of  Boas'  experiences 
as  gleaned  from  his  book. 


SYPHILIS  825 

tically  of  no  value,  as  to  be  inferred  from  the  data  already  presented, 
which  emphasizes  what  is  well  known— that  it  fails  of  positive  reaction  in 
a  small  percentage  of  frankly  syphilitic  cases;  a  series  of  negative  reac- 
tions made  at  intervals  would,  however,  be  of  great  value.  To  be  at 
all  reliable,  however,  such  tests  should  be  made  by  a  trained  laboratory 
expert,  or  at  least  by  one  who  is  well  practised  in  the  somewhat  elaborate 
and  delicate  technic.  The  Noguchi1  simplification  and  modification 
of  the  Wassermann  test  is  also  considered  trustworthy,  but  the  predomi- 
nant opinion  favors  the  Wassermann  test.  Antisyphilitic  treatment 
sometimes  rapidly,  more  often  gradually,  changes  a  positive  reaction 
to  a  negative,  and  this  latter  may  continue  for  some  time  after  such  treat- 
ment has  been  discontinued;  sufficient  and  sufficiently  prolonged  treat- 
ment will  bring  about,  it  is  generally  believed,  a  permanency  in  the 
negative  reaction,  and  presumably  a  cure  of  the  disease.2 

Noguchi3  has  introduced  another  diagnostic  test — cutaneous  reac- 
tion test,  the  so-called  luetin*  reaction — similar  to  that  of  Von  Pirquet 

1  Noguchi,  "Eine,  fur  die  Praxis  gecignete,  leicht  ausfiihrbare  Methode  der  Serum- 
diagnose  bei  Syphilis,"  Munchen  Med.  Wochenschr.,  March  9, 1909,  and  "A  Rational  and 
Simple  System  of  Serodiagnosis  of  Syphilis,"  Jour.  Amer.  Med.  Assoc.,  Nov.  6, 19(59,  and 
Jour.  Exper.  Med.,  1909,  xi,  p.  392;  and  "Serum  Diagnosis  of  Syphilis  and  the  Butyric 
Acid  Test  for  Syphilis,"  Phila.,  J.  B.  Lippincott  Co.,  1910  (with  bibliography  of  200 
selected  articles). 

2  It  is  not  considered  necessary  to  go  over  the  details  of  the  Wassermann  test  here. 
It  requires  an  extensive  and  well-equipped  laboratory,  painstaking  and  skilled  technic, 
and  infinite  attention  and  delicacy  in  its  management — it  is,  in  short,  laboratory  work. 
It  was  built  up  upon  the  already  known  basic  principle  (Bordet-Gengou)  of  the  power  of 
the  serum  of  one  animal  to  dissolve  the  red  corpuscles  of  that  of  another  species — known 
as  hemolysis.     This  action  is  dependent  upon  the  three  substa.nces:  The  complement, 
always  present  in  any  blood-scram;  the  antibody  or  hemolytic  amboceptor,  resulting 
from  the  reaction  of  the  injected  animal  against  the  injected  red  blood-cells;  and  the  so- 
called  antigen,  in  this  instance  the  injected  blood-corpuscles.     The  union  of  the  three 
constitutes  the  hemolytic  system,  and  effects  the  solution  of  the  injected  red  corpuscles. 
It  has  been  found  that  syphilis,  as  well  as  certain  other  diseases  also,  produces  anti- 
bodies or  amboceptors  which  have  the  power  of  uniting  with  the  complement  of  the 
blood-serum  and  its  special  bacterial  antigen.     For  the  Wassermann  test  are  mixed  to- 
gether the  inactivated  serum  (serum  that  has  had  its  complement  destroyed  by  heating) 
of  the  suspected  patient,  fresh  serum  complement  from  a  guinea-pig,  and  the  antigen — 
extract  of  a  syphilitic  fetal  liver  or  other  organ.     If  the  patient  is  syphilitic,  the  ambo- 
ceptors use  up  all  the  available  complement,  and  therefore,  when  later  washed  sheep's 
red  corpuscles  and  rabbit  serum  amboceptors  are  added  there  is  no  solution  of  the  red 
corpuscles,  but  these  gradually  settle  to  the  bottom  of  the  tube;  on  the  contrary,  if  the 
patient  is  not  syphilitic,  the  complement  still  being  available,  hemolysis,  or  solution  of 
the  corpuscles,  takes  place.     It  has  been  found  that  other  substances,  such  as  extract 
of  normal  organs,  of  new  growths,  lecithin,  etc.,  may  be  used  as  the  antigen  with  the 
same  results.     Indeed,  Wassermann  himself  has  already  modified  the  technic  and  others 
have  made  further  changes,  some  quite  material,  as  in  the  Noguchi  test.     Out  of  it  all 
comes  the  hope  of  a  future  possibility — a  fairly  certain  diagnostic  method  for  obscure 
cases  of  great  value  and  of  simple  technic. 

3  Noguchi,  "A  Cutaneous  Reaction  in  Syphilis,"  Jour.  Exper.  Medicine,  1911,  xiv, 
p.  557;  "Method  for  Pure  Cultivation  of  the  Treponema'Pallidum  (Spirochaeta  Pallida)," 
Jour.  Exper.  Med.,  Aug.,  1911,  p.  557;  "Experimental  Research  in  Syphilis  with  Especial 
Reference  to  the  Spirochaeta  Pallida  (Treponema  Pallidum),"  Jour.  Amer.  Med.  Assoc., 
April  20,  1912,  p.  1163. 

4  Luetin  is  the  name  given  by  Noguchi  to  a  suspension  of  Spirochaetae  pallidae  that 
have  been  grown  in  pure  culture  and  then  destroyed  by  heat.     About  ^  c.c.  is  injected 
superficially  in  the  skin  of  one  arm,  and  an  equal  amount  of  the  control  (uninoculated 
culture-medium)  in  the  skin  of  the  other  arm.     The  reaction  usually  shows  itself  about 
the  end  of  twenty-four  hours,  and  reaches  its  height  in  two  or  three  days;  it  consists  of 
an  inflammatory  papule  or  nodule,  with,  in  most  instances,  a  bright  red  areola  of 
\  to  5  inch  or  more  in  diameter;  and  later  there  may  follow  a  phlegmonous  inflammation 


826  NEW  GROWTHS 

for  tuberculosis,  which  he  believes  will  be  of  considerable  value.  The 
experiences  of  Cohen,1  D.  O.  Robinson,2  Howard  Fox,3  Pusey,4  Engman, 
Winfield,  Pollitzer,  and  Gradwohl5  with  this  test  vary  to  some  extent, 
but  are  more  or  less  confirmatory.  As  its  action  depends  upon  an  es- 
tablished anaphylaxis,  which  usually  takes  considerable  time,  it  is  not, 
therefore,  at  all  dependable  in  the  early  stages  of  syphilis,  being  most 
reliable  in  the  tertiary  stage. 

Prognosis. — The  prognosis  as  to  the  syphilodermata,  the  dura- 
tion of  contagiousness  of  the  virus,  and  hereditary  syphilis  have  received 
more  or  less  consideration  in  connection  with  type  description  and 
etiology.  The  cutaneous  manifestations  of  the  secondary  stage,  except 
sometimes  the  palmar  and  plantar  papulosquamous  lesions,  all  disappear 
sooner  or  later  spontaneously,  but  much  more  rapidly  by  treatment. 
In  short,  if  the  patient  lives, — and  in  only  rare  instances  of  malignancy 
does  death  take  place  hi  the  secondary  period  of  syphilis, — the  eruption 
or  eruptions  and  relapses  of  this  period  are  self-limited,  even  though  the 
patient  be  neglected.  On  the  palms  and  soles,  in  the  form  mentioned, 
there  may  be  chronicity,  and  while  many  such  cases  yield  more  or  less 
promptly  to  proper  constitutional  and  local  measures,  some  are  extremely 
rebellious.  Moist  papules  are,  if  untreated,  sometimes  persistent,  but 
yield  rapidly  to  local  measures  and  also  to  constitutional  medication. 

The  late  syphilodermata  show  but  little  if  any  disposition  to  sponta- 
neous cure,  but,  as  a  rule,  respond  readily;  in  exceptional  instances,  more 
especially  in  the  tubercular  or  tuberculogummatous  form,  and  more 
particularly  about  the  nose,  and  in  the  flattened,  gummatous,  infiltrating 
variety,  the  improvement  is  often  slow,  and  the  final  cure  brought  about 
only  by  energetic  and  persistent  medication.  The  apparent  obstinacy 
in  some  of  these  cases  is  due  to  the  patient's  tolerance  of  the  specific 
drugs  employed,  especially  to  the  iodids.  My  own  observations  as  to 
these  rare  cases  have  shown  me  that  mercury  is  the  remedy  which  needs 
to  be  pushed,  the  potassium  iodid  even  in  large  doses  proving  ineffective, 
and,  if  this  is  done,  a  result  is  soon  obtained.  In  the  past  several  years 
arsenical  preparations,  especially  salvarsan,  have  proved  themselves  par- 
ticularly valuable  in  just  such  cases,  in  addition  to  their  usefulness  in 
other  manifestations  and  in  other  stages  of  the  disease.  Ordinarily,  as 
with  the  other  eruptions,  gummata  likewise  respond  rapidly  under  treat- 
ment, and  sometimes  disappear  without  ulceration,  even  after  consider- 
able softening  has  taken  place;  ulcerations  from  this  as  well  as  the  tuber- 
somewhat  furunculoid  in  aspect,  with  or  without  any  signs  of  suppuration,  and  some- 
times presenting  a  thin  scaliness.  After  several  days  to  a  week  the  reaction  has  usually 
largely  subsided,  gradually  disappearing  and  leaving  behind  for  some  time  slight  pig- 
mentation. In  some  instances  following  the  injection  systemic  symptoms  of  a  febrile 
character,  malaise  and  headache,  are  noted  for  a  day  or  two. 

1  Cohen,  "Noguchi's  Cutaneous  Luetin  Reaction  and  Its  Application  in  Ophthal- 
mology," Arch.  Ophthalmology,  1912,  xli,  p.  8. 

1  Daisy  Orleman  Robinson,  "Diagnostic  Value  of  the  Xoguchi  Luetin  Reaction 
in  Dermatology,"  Jour.  Cutan.  Dis.,  1912,  p.  410  (tried  it  also  in  22  other  skin  diseases 
— 108  cases — and  found  it  uniformly  negative). 

J  Howard  Fox.  "Experiences  with  Xoguchi's  Luetin  Reaction,"  ibid.,  p.  465. 

4  Pusey.  Engman.  Winfield,  Pollitzer  (discussion  on  Fox's  Paper),  ibid. 

5  Gradwohl,  New  York  Med.  Record,  May  25.  1912  (48  cases:  negative  in  primary 
syphilis,  often  negative  in  untreated  secondary  syphilis,  positive  in  all  tertiary  cases). 


SYPHILIS  827 

cular  or  other  types  show,  as  a  rule,  prompt  reparative  process.  In  rare 
instances  gangrenous  ulceration,  due  indirectly  to  syphilis  in  consequence 
of  resulting  endarteritis  obliterans,  without  preceding  formation  of  a 
gummatous  neoplasm,  is  observed,  and  which  shows  but  little  effect 
from  antisyphilitic  treatment.1  Mucous  patches  in  the  oral  cavity  may 
be  stubborn  if  smoking  is  continued  and  if  kept  up  by  irritation  from  a 
sharp  or  rough  tooth  or  by  irritating  drinks  or  foods;  but  with  attention 
as  to  these  points  will  generally  disappear  either  as  the  result  of  internal 
treatment  or  local  applications.  There  is  a  tendency  to  relapse  or  new 
spots,  especially  under  the  above  conditions,  and  particularly  from 
smoking.  With  smokers,  even  though  the  active  patches  themselves 
finally  go,  those  sometimes  present  just  within,  but  slightly  beyond,  the 
corners  of  the  mouth,  while  they  practically  disappear,  leave  behind  some- 
what milky-looking,  occasionally  slightly  thickened,  areas,  the  so-called 
smokers'  patches ;  these  are  probably  to  be  looked  upon  as  a  mild  phase 
of  leukoplakia,  and  not  necessarily  possessed  of  contagious  properties. 

The  mildness  or  severity  of  the  disease  cannot  always  be  foretold 
by  the  character  of  the  chancre  or  the  early  secondary  symptoms.  The 
pustular  syphilodermata  are  usually  significant  of  a  severe  type,  showing 
either  virulence  of  the  virus  or  impaired  resisting  power,  or  both.  The 
condition  of  the  general  health  has  often  a  material  influence  in  deter- 
mining the  grade  of  the  disease,  and  subjects  with  tuberculosis  or  such 
family  tendency  often  show  severe  manifestations.  The  belief  that  the 
infection  following  extragenital  chancres  is  always  more  severe  is  some- 
what general,  but  has  nothing  substantial  to  support  it,  and  extensive 
experience  will  soon  prove  that  the  infection,  as  regards  degree,  has  no 
relation  whatever  to  the  site  of  the  inoculation.  As  a  general  rule  it  can, 
I  believe,  be  said  that  mildness  of  the  early  secondary  symptoms  is  indica- 
tive of  a  mild  type  of  the  disease,  and  less  probability  to  late  manifesta- 
tions. This  probability  is  always  materially  lessened,  both  in  the  mild 
and  severe  cases,  by  proper  and  persistent  specific  medication.  Indeed, 
late  symptoms  are  to  be  considered  rather  exceptional  if  treatment  has 
been  thorough;  in  fact,  one  can  truthfully  say  that  the  most  important 
etiologic  factor  in  the  production  of  the  tertiary  syphilodermata  and 
other  syphilitic  manifestations  is  to  be  found  in  imperfect,  deficient, 
and  insufficiently  prolonged  treatment  in  the  early  periods  of  the  disease; 
and  almost  of  equal  importance  are  the  habits  and  mode  of  living  of  the 
patient  himself.2 

Treatment. — The  treatment  of  syphilis  as  regards  the  specific  con- 
stitutional remedies  is  at  the  present  day  clearly  understood,  but  concern- 
ing the  manner  or  method  there  is  still  some  diversity;  it  is  true  that 
the  new  remedy  salvarsan  has  to  a  material  extent  with  some  and  to  a 
moderate  extent  with  others  changed  the  plans  somewhat.  For  the  mi- 
nute details  and  various  plans  of  treating  the  initial  lesion  the  reader  is 

1  See  paper  by  Klotz,  "On  the  Occurrence  of  Ulcers  Resulting  from  Spontaneous 
Gangrene  of  the  Skin  During  the  Later  Stages  of  Syphilis,  and  their  Relation  to  Syph- 
ilis," New  York  Med.  Jour.,  Oct.  8,  1887  (with  references). 

1  Keyes,  Jr.,  "Some  Elements  in  the  Prognosis  of  Acquired  Syphilis,"  Jour.  Cuian. 
Dis.,  1910,  p.  449  (gives  an  interesting  survey  of  this  subject). 


828  NEW  GROWTHS 

referred  to  works  on  venereal  diseases.1  It  consists  practically  in  the 
maintenance  of  cleanliness.  This  can  be  accomplished  by  washing  the 
parts  with  tepid  water,  occasionally  using  soap,  two  or  more  times  daily, 
according  to  the  conditions,  and  the  use  of  a  bland  antiseptic  dusting- 
powder,  such  as  boric  acid,  of  boric  acid  with  2  to  5  per  cent,  admixture 
of  acetanilid,  iodol,  or  like  substance;  or,  sometimes,  the  application  of 
lint  wet  with  black  wash,  or  with  saturated  boric  acid  solution  containing 
2  or  3  minims  (0.135-0.2)  of  carbolic  acid  to  the  ounce  (32.).  As  soon 
as  there  is  no  longer  question  as  to  its  nature,  the  best  application,  if 
it  is  desired  to  hasten  its  disappearance,  as  more  especially  obtains  on 
extragenital  parts,  is  mercurial  plaster,  full  strength,  or,  if  irritating, 
with  one  or  more  parts  of  vaselin  or  other  ointment  base,  and  kept  con- 
stantly applied,  changing  twice  daily.  Ointments,  as  commonly  under- 
stood, however,  are  not  usually  satisfactory,  except  as  a  supplementary 
application,  spread  upon  lint,  in  those  discharging  cases  in  which  there 
is  more  or  less  gumminess,  which  glues  the  dry  dressing  too  firmly.  In 
women  the  same  plans  are  followed,  but  the  importance  of  cleanliness — 
frequent  washing — is  still  more  important,  conjoined  with  the  liberal 
general  use  to  the  parts  of  mild  antiseptic  lotions,  such  as  boric  acid, 
with  or  without  a  minute  quantity  of  corrosive  sublimate,  or  with  a 
weak  solution  of  potassium  permanganate.  The  parts  should  be  kept 
separated  with  pieces  of  lint.  When  administration  of  mercury  is  begun, 
it  will,  if  the  induration  is  still  present,  and  it  often  is  when  constitutional 
medication  is  instituted,  have  a  prompt  influence  in  promoting  its  ab- 
sorption. Caustic  agents  are  not  desirable  or  necessary. 

Constitutional  Treatment.— Before  taking  up  the  considera- 
tion of  the  specific  treatment  proper,  the  occasional  necessity  of  general 
tonic  remedies  and  the  value  of  hygienic  living  in  the  management  of 
the  disease  should  be  referred  to.  The  effect  of  freedom  from  excessive 
or  even  moderate  "drinking,"  good  food,  healthy  living,  and  reasonable 
exercise  cannot  be  overestimated,  and  are  essential  to  final  success  in  the 
severe  and  especially  malignant  cases,  and  of  more  or  less  material  help 
in  the  proper  handling  of  the  mild  types.  Smoking  is  also  detrimental, 
and  often  the  exciting  causative  factor  in  the  production  of  mucous 
patches  in  the  mouth.  While  in  spite  of  disregard  of  these  ordinary 
common-sense  measures  the  eventual  outcome  as  to  the  active  stages 
of  the  disease  is  usually  seemingly  favorable,  there  can  scarcely  be  a 
doubt  that  the  tissue-resisting  power  and  recuperative  force  are  fre- 
quently sufficiently  impaired  or  lessened  as  to  give  a  greater  probability 
of  recurrent  manifestations.  With,  however,  the  observance  of  such 
precautions  and  the  administration  of  the  specific  remedies,  most  cases 
go  on  successfully  to  satisfactory  end;  some  with  no  other  manifesta- 
tions than  the  macular  or  maculopapular,  or  possibly  papular,  syphilo- 

1  Metchnikoff  has  recently  claimed  that  rubbing  a  strong  calomel  ointment  (made 
up  of  \  calomel,  f  lanolin,  with  10  per  cent,  vaselin  added)  over  the  parts  exposed,  within 
the  first^  few  hours  after  exposure  will  destroy  the  causative  organisms  and  prevent 
inoculation.  In  the  past  few  years  several  observers  (Duhot,  Neisser,  Hallopeau,  and 
others)  have  reported  prompt  cure  or  abortion  of  the  disease  in  the  very  earliest  chancre 
stage  by  excision  of  the  chancre  and  "intensive"  systemic  treatment;  or  by  "intensive" 
remedial  treatment  both  of  the  initial  lesion  locally  and  systemically. 


SYPHILIS  829 

derm,  and  one  or  several  light,  concomitant,  secondary  symptoms,  with, 
in  others,  a  tendency  to  slight  recurrence  or  outcroppings.  In  some  the 
disease  is,  of  course,  more  troublesome,  and  with,  for  a  variable  time,  a 
persistent  tendency  to  manifestations.  In  other  cases  the  anemia  re- 
sulting, the  depraved  condition  of  the  health  engendered,  -and  other 
occasional  accidental,  non-specific  affections,  but  indirectly  due  to  the 
disease,  may  require  the  administration  of  iron,  cod-liver  oil,  strychnin, 
digestive  tonics,  and  other  indicated  remedies.  It  is  true  that  the  mild 
anemia  not  infrequently  encountered  will  often  disappear  upon  the  ad- 
ministration of  the  specifics, — mercury  and  arsenic, — which,  as  Keyes 
and  others  (especially  as  to  the  former  remedy)  have  pointed  out,  have 
a  direct  influence  in  increasing  the  number  of  red  corpuscles. 

The  proper  time  for  the  specific  constitutional  treatment  had, 
up  to  a  few  years  ago,  been  generally  taught  to  be  when  the  earliest 
secondary  symptoms  put  in  an  appearance,  when  there  no  longer  re- 
mains the  least  question  as  to  syphilitic  infection.  The  main  reason 
for  believing  the  earlier  administration  of  the  specific  drug  injudicious 
is  that  there  may  possibly  be  an  element  of  doubt  as  to  the  nature 
of  the  inoculative  lesion,  which,  though  it  may  present  the  characters 
of  the  initial  sore  of  syphilis,  yet  the  induration  which  distinguishes 
it  may  be  the  result  of  accident  or  meddlesome  applications,  and  simply 
be  a  chancroid  or  patch  of  herpes  or  other  simple  irritation  which  has 
been  thus  transformed;  under  such  circumstances  the  patient  would 
forever  be  under  the  impression  of  having  syphilis,  believing  the  con- 
stitutional treatment  had  kept  the  secondary  symptoms  in  abeyance, 
which  it  frequently  does  in  true  infection  when  its  administration  is  begun 
during  the  early  chancre  stage.  Another  reason  is  that  if  administered 
early,  the  patient  may  establish  more  or  less  of  a  tolerance  for  it,  and 
thus,  when  prompt  effect  against  the  appearance  of  severe  symptoms 
which  may  arise  is  desired,  action,  owing  to  this  fact,  cannot  be  so  quickly 
obtained.  Of  the  two  reasons,  the  former  is  the  only  one  to  be  con- 
sidered, the  other  having  no  rational  basis;  and  now  that  any  doubt  as 
to  the  character  of  the  lesions  can  be  cleared  up  by  examinations  for 
the  spirochaeta,  even  that  reason  no  longer  holds.  The  time  to  begin 
specific  treatment,  therefore,  is  as  soon  as  the  fact  of  the  disease  is 
established — in  short,  as  early  as  possible. 

There  are  three  drugs  which  are  now  considered  to  have  more  or  less 
specific  influence  in  the  management  of  the  disease — mercury,  potassium 
or  sodium  iodid,  and  arsenic  in  its  new  combinations.  The  first  two, 
now  long  in  use,  will  be  considered  first,  and  the  arsenical  preparation 
later.  Both  mercury  and  arsenic  are  antagonistic  to  the  syphilis  organ- 
ism and  its  products,  and  both  tend  more  or  less  rapidly  to  change  a  posi- 
tive Wassermann  reaction  into  a  negative  one.  Of  the  first  two  named, 
mercury  is  fully  entitled  to  be  looked  upon  as  the  specific  one,  and  the 
one  that  has  long  been  depended  upon  during  the  active  or  secondary 
stage  of  the  malady ;  and  also  to  constitute  a  necessary  part  of  the  treat- 
ment of  the  later  or  tertiary  symptoms;  although  in  the  latter,  whether 
appearing  precociously  or  at  the  usual  period,  the  value  of  potassium 
iodid  is  not  to  be  underrated.  While  there  is  but  little,  if  any,  difference 


830 


GROWTHS 


of  opinion  as  to  the  value  of  mercury,  especially  in  the  early  stages, 
there  is  a  divergence  as  to  the  special  ,f  orm  of  the  drug  to  be  employed, 
and,  to  a  less  extent,  as  to  the  method  of  its  administration.  The  former, 
if  the  matter  is  judiciously  investigated,  is  probably  almost  wholly  the 
result  of  training  and  prejudice,  for  in  reality  any  of  the  mercurial  drugs 
capable  of  invoking  physiologic  action  will  prove  of  antidotal  power 
against  the  disease.  The  choice  is  necessarily  somewhat  influenced  by 
the  plan  of  administration  selected.  The  several  methods  of  adminis- 
tration are  by  the  mouth,  inunction,  and  subcutaneous  or  intramuscular 
injection,  each  having  its  advocates,  although  by  far  the  most  usual 
plan  with  the  rank  and  file  of  the  profession  is  by  the  one  first  named. 
Whatever  be  the  method  of  administration,  the  producton  of  ptyalism, 
sponginess  and  bleeding  of  the  gums,  and  other  toxic  effects  of  mercury 
are  to  be  avoided.  As  measures  against  such  accidents,  the  dosage  is  to 
be  carefully  supervised,  and  thorough  cleanliness  of  the  teeth  is  to  be 
maintained,  and  frequent  rinsing  of  the  mouth  with  a  potassium  chlorate 
and  tincture  of  myrrh  wash  practised.  Indeed,  if  cleanliness  of  these 
parts  is  neglected,  tartar  and  food  allowed  to  collect  and  decay  in  the 
dental  interspaces,  tenderness  and  actual  soreness  and  sponginess  will 
result  from  smaller  doses,  —  a  decided  detriment  in  those  urgent  or  severe 
cases  where  the  fullest  dose  of  the  drug  that  can  be  satisfactorily  borne  is 
desirable. 

Administration  by  the  mouth  is,  for  ordinary  purposes,  a  satisfac- 
tory method  in  average  cases,  and  is  the  one  most  convenient  to 
both  patient  and  physician,  and  this  will  be  first  referred  to.  It  is  a 
method  that  the  patient  will  usually  be  willing  to  follow  up  over  suf- 
ficiently long  periods  to  be  permanently  effective.  There  is  much  more 
diversity  in  this  method  as  to  the  particular  mercurial  to  be  employed 
than  with  the  subcutaneous  plan  —  as  regards  inunction  there  is  naturally 
not  much  choice.  My  own  preference,  as,  indeed,  that  of  Taylor, 
White  and  Martin,  Hyde  and  Montgomery,  as  well  as  many  French 
physicians,  is  for  the  protiodid  of  mercury,  and  this  is  possibly  in  more 
general  use  than  other  preparations.  It  is  to  be  given  in  dosage  of  f  to  f 
of  a  grain  (0.008-0.05),  in  pill,  capsule,  or  triturate  form  after  each  meal, 
and  if  it  should,  as  it  occasionally  does,  especially  in  the  larger  dosage, 
give  rise  to  abdominal  pain,  griping,  or  diarrhea,  a  small  quantity  of 
opium,  on  an  average  about  -^  of  a  grain  (0.0055),  can  be  added  to  each 
pill.  Opium  is,  however,  to  be  avoided  if  possible,  and  a  good  plan  in 
these  cases  is  to  prescribe  the  protiodid  alone  and  give,  if  necessary,  an 
occasional  dose  of  paregoric;  or  two  prescriptions  for  the  tablets  or  pills 
can  be  given,  one  without  opium  and  one  with,  the  latter  only  to  be 
taken  when  the  pain  or  griping  demands  it.  Probably  the  most  usual 
dose  of  the  protiodid  is  f  of  a  grain  (0.016),  and  it  is  only  occasionally 
that  troublesome  pain  is  produced.  Women  stand  less,  as  a  rule,  than 
men.  Unless  the  case  is  urgent,  the  beginning  dose  should  not  exceed 
this  latter  quantity;  this  can  be  continued  for  four  or  five  days,  and,  if 
an  evident  impression  is  made,  can  remain  the  same.  Should,  however, 
no  effect  be  observed,  and  particularly  if  new  lesions  are  appearing,  the 
dose  is  to  be  increased  every  two  days  by  yV  to  £  of  a  grain  (0.004-0.008) 


SYPHILIS  831 

until  some  influence  is  perceived,  when  the  same  dosage  can  be  main- 
tained. Or,  if  no  benefit  is  noted,  it  is  increased  until  evidences  of 
physiologic  action  present;  the  dose  is  then  to  be  lessened  slightly, 
and  continued  at  the  reduced  quantity.  Occasionally  the  physio- 
logic action  shows  itself  somewhat  suddenly,  and  not  infrequently 
in  quite  a  pronounced  manner,  and  in  such  instances  it  is  wise  to 
discontinue  entirely  for  one  or  two  days,  and  then  resume  at  the  smaller 
dosage. 

In  severe  and  urgent  cases  of  the  disease  it  is  well  to  begin  with  a 
larger  dose, — |  to  \  of  a  grain  (0.024-0.035), — and  increase  daily  by 
the  addition  of  TV  to  |  of  a  grain  (0.004-0.008)  to  each  dose  until  slight 
physiologic  effect  is  produced,  and  then  reducing  somewhat.  The 
proof  of  such  action  is  to  be  found,  first  of  all,  as  well  known,  in  the  con- 
dition of  the  gums,  such  as  slight  soreness  with  swelling  or  sponginess, 
especially  adjoining  the  teeth,  and  a  disposition  to  bleed  easily;  and  even 
before  any  evidences  are  visible  there  is  a  tenderness  noticeable  upon  the 
patient  shutting  the  teeth  together  rapidly  and  with  some  force,  and  also 
fetor  of  the  breath  and  a  metallic  taste;  with  these  there  is  not  infre- 
quently slight,  but  scarcely  noticeable,  increase  and  possibly  thickness 
of  salivary  secretion.  It  should  not  be  pushed  beyond  the  production 
of  such  evident  physiologic,  or,  as  might  be  termed,  mildly  toxic,  action, 
nor  this  far  if  it  can  be  avoided  unless  a  prompt  effect  is,  for  reasons, 
especially  desirable.  Under  the  administration  of  the  mercurial  the 
syphilitic  eruption  and  other  symptoms  gradually  abate,  and,  after  a 
variable  time,  pass  away;  the  anemia  frequently  noted  gradually,  and 
often  rapidly,  lessens,  the  patient  usually  increases  in  weight,  and  the 
mental  depression  often  present  gives  way,  and  in  most  instances  the 
patient's  general  health,  in  most  cases  impaired  by  the  disease,  seems 
re-established.  The  disappearance  of  the  manifestations  of  the  secon- 
dary stage  does  not  mean  necessarily,  however,  that  the  malady  is 
at  end,  for,  especially  if  treatment  is  discontinued,  there  may  be 
relapses  and  other  symptoms  later  in  the  disease.  The  duration  of 
administration  should  therefore  be  much  longer,  as  will  be  later 
especially  referred  to. 

In  cases  in  which  the  protiodid  gives  rise  to  pain  and  griping,  and  in 
which  the  addition  of  an  opiate  is  undesirable,  gray  powder — mercury 
with  chalk  (hydrargyrum  cum  creta) — can  be  substituted.  This  prepa- 
ration is,  in  fact,  preferred  over  all  others  by  some  observers,  notably 
Hutchinson,  and  is  also  favored  by  Duhring  and  Crocker.  The  dose  is 

1  to  3  grains  (0.065-0.2)  or  more  after  each  meal,  according  to  circum- 
stances and  the  tolerance  of  the  patient,  the  larger  dosage  often  requiring 
the  occasional  administration  of  paregoric  or  the  addition  of  i  or  2  grains 
(0.065-0.133)  of  Dover's  powder  to  each  dose  of  the  gray  powder  in  order 
to  control  the  resulting  diarrhea.    Other  preparations  which  have  support 
and  which  may  likewise  be  prescribed  with  satisfactory  effects  are  calomel, 
blue  mass,  corrosive  sublimate,  and  red  iodid — calomel  in  dose  of  i  to 

2  grains  (0.065-0.133);  blue  mass,  i  to  3  grains  (0.065-0.2);  corrosive 
sublimate  or  red  iodid,  ^T  to  f  grain  (0.0027-0.008),  after  each  meal.     In 
the  use  of  calomel  or  blue  mass  an  addition  of  opiate  is  usually  necessary 


332 


GROWTH'S 


to  restrain  the  laxative  action  and  to  relieve  the  pain  sometimes  pro- 
duced. Corrosive  sublimate  and  the  red  iodid  are  rarely  used  in  the 
secondary  stage  of  the  disease,  but  are  the  favorite  preparations  in  the 
late  stage,  conjointly  with  potassium  iodid;  in  the  largest  dosage  indi- 
cated they  sometimes  give  rise  to  gastric  and  intestinal  irritation  and 
diarrhea. 

The  inunction  method  of  administering  mercury,  which  found  its 
greatest  support  under  Sigmund,  of  Vienna,  and  very  largely  employed  by 
Zeissl,  Neumann,  Mracek,  Kaposi,  and  others  of  that  school,  as  well  as  by 
other  German  physicians,  is  now  one  of  the  recognized  methods.  It  has 
long  been  an  accepted  plan  in  some  cases  in  English,  French,  and  Ameri- 
can practice.  It  permits  more  readily  of  the  conjoint  administration  of 
tonics  and  potassium  iodid  by  the  mouth,  if  such  should  be  indicated. 
It  is  an  extremely  valuable  method,  and  one  that  can  be  satisfactorily 
employed  in  urgent  cases.  It  is  the  plan  to  be  adopted  in  those  instances 
of  obstinate  syphilis  occasionally  encountered,  and  in  which  mercury 
by  the  mouth  is  often  without  material  influence,  or  cannot,  owing  to  gas- 
tric irritation  or  other  reasons,  be  pushed  to  a  dosage  sufficient  to  bring 
about  a  result;  or  in  which  it  may  seem  preferable  to  the  mercurial  (and 
arsenical)  injection  method.  Such  cases  are  not  common,  but  they  are  now 
and  then  met  with,  as  well  as,  moreover,  instances  where  the  patient  is 
exceedingly  tolerant  of  the  drug,  not  susceptible  to  ordinary  mouth  doses, 
and  in  which  a  result  is  obtained  only  by  inunctions  freely  employed.  Of 
this  latter  kind,  I  have  met  with  3  extreme  examples  of  tertiary  eruptions 
in  which  a  cure  was  obtainable  only  by  overwhelming  doses  —  the  drug 
being  administered  both  by  the  mouth  and  inunction,  with  a  disappear- 
ance of  the  lesions  and  absolutely  no  sign  of  toxic  action.  Doubtless 
the  injection  method  would  have  been  equally  prompt  and  satisfactory. 
There  is  a  common  belief  that  this  method  requires  care  as  to  the  avoid- 
ance of  taking  cold,  and  the  exercise  of  some  judgment  as  to  proper  diet 
and  other  hygienic  observances,  but  no  more  than  with  other  methods 
of  administration.  The  mercurial  preparations  which  have  been  em- 
ployed for  this  plan  are  the  blue  ointment  (unguentum  hydrargyri)  and 
the  oleate  of  mercury;  the  latter,  which  was  urged  as  a  clean  substitute 
for  the  blue  ointment,  proved,  however,  inefficient  and  unreliable,  and 
is  no  longer  in  use,  the  blue  ointment  now  being  solely  employed.  It 
should  be  freshly  prepared,  as  it  is  quite  probable  that  the  local  irritation 
it  not  infrequently  produces  is  in  many  instances  due  to  rancidity  of  the 
base  and  not  necessarily  always  to  the  incorporated  drug. 

The  amount  of  ointment  required  for  one  inunction  is,  on  the  average, 
about  i  dram  (4.),  although  it  is  safer  to  begin  with  not  over  30  or  40 
grains  (2-2.6$),  the  effect  watched  as  to  evidences  of  physiologic  or 
toxic  action,  and  the  dose  thus  properly  regulated.  As  a  rule,  except 
in  those  extremely  susceptible  to  the  drug,  it  can  be  safely  increased 
up  to  i  dram  (4.),  and  in  some  cases  more.  An  inunction  is  made  once 
daily,  intermitting  if  circumstances  indicate;  in  private  patients  treated 
at  home  the  inunction  is  most  conveniently  made  at  night.  A  general 
warm  bath  should  precede;  during  the  bath  the  part  which  is  to  receive 
the  medication  should  be  thoroughly  washed,  soap  being  used  to  remove 


SYPHILIS  833 

the  skin  oiliness,  so  as  to  render  absorption  more  complete.  If  a  general 
bath  is  convenient  or  impossible,  the  part  itself  can  be  washed  with  soap 
and  water.  After  rubbing  dry  the  ointment  is  to  be  rubbed  in,  and 
this  is  done  best  by  a  nurse  or  professional  rubber,  although  in  most 
cases  the  private  patient  does  it  himself.  The  rubbing  should  be  gentle 
but  firm,  and  should  last  twenty  to  thirty  minutes.  Taylor  states  that 
after  the  general  bath  or  local  washing  a  2  to  3  per  cent,  carbolic  acid 
solution  should  be  applied  to  the  part, 'as,  "by  strict  attention  to  the 
aseptic  condition  of  the  skin,  dermal  inflammatory,  complications  can 
almost  always  be  avoided."  In  order  to  lessen  the  chances  of  such  acci- 
dent the  rubbing  should  never  be  upon  the  same  part  consecutively. 
The  regions  usually  selected  are  where  the  skin  is  softer  and  thinner 
and  less  likely  to  be  hairy,  as  the  sides  of  the  chest,  inner  aspects  of  the 
arms,  and  thighs;  other  parts  in  extremely  sensitive  skins  can  also  be 
added,  as  the  anterolateral  surfaces  of  the  abdomen,  the  lower  part 
of  the  leg,  the  soles,  etc.  This  gives  six  or  more  regions,  and  one  should 
follow  after  the  other,  thus  giving  an  interval  of  at  least  five  days  before 
the  inunction  is  again  made  on  the  same  part.  The  palm,  fortunately, 
by  which  the  rubbing  is  done,  is  not  very  readily  irritated.  The  inunc- 
tion treatment  should  be  continued  as  in  the  mouth  method  until 
symptoms  have  disappeared,  and  repeated  later  on,  or  give  place 
to  another  plan,  as  will  be  subsequently  referred  to.  Old  under- 
wear of  suitable  thickness  for  the  season  of  the  year  should  be  worn. 
The  chief  objections  to  this  plan  of  treatment,  in  addition  to  the 
possible  skin  irritation,  are  the  soiling  of  the  wearing  apparel  next  to 
the  skin  and  the  feeling  of  messiness  engendered,  and  the  trouble  of 
its  application. 

Subcutaneous  and  intramuscular  injections  constitute  another  method 
of  the  introduction  of  mercury,  the  general  trial  or  introduction  of  which 
was  due  to  Lewin,  and  which  is  more  or  less  practised  at  the  present 
day  by  some  syphilographers  as  a  practically  exclusive  plan,  by  others 
as  occasional,  and  by  still  others,  and  by  much  the  larger  number,  only 
for  particularly  rebellious  cases.  It  cannot  be  gainsaid  that  it  is  usually 
slightly  more  rapid  in  its  action  than  mouth  administration,  but  not 
materially  superior,  in  this  respect,  to  inunctions.  Its  dosage,  at  least 
as  regards  soluble  mercurials,  can  be  accurately  gauged,  and  the  patient 
is  kept  more  under  direct  control.  Its  painfulness  is  variable,  from  trifling 
and  of  short  duration  to  somewhat  severe  and  prolonged;  the  fact  that 
it  necessitates  the  frequent  personal  attention  of  the  physician;  and  the 
occasional  painful  induration  and  exceptional  abscess  formation  result- 
ing— are  the  disadvantages.  It  is  a  method  that  is  much  in  vogue, 
and  increasingly  so  at  the  present  day,  and  one  to  employ  especially 
when  circumstances,  either  as  to  the  patient  or  the  gravity  of  the 
disease,  demand  prompt  and  effective  action,  and  when  the  same  cannot 
be  secured  by  mouth  administration  or  inunctions;  more  especially  when 
objection  is  made  to  the  latter  on  the  score  of  possible  betrayal  of  the 
existence  of  the  disease  or  when  the  eruption  is  of  extensive  and  especially 
pustular  character,  making  inunctions  impracticable.1  The  method  is 
1  It  is  now  quite  frequently  preceded  by  one  or  two  salvarsan  injections. 
53 


834  NEW  GROWTHS 

not  entirely  without  risk1  when  the  insoluble  preparations  are  employed, 
although  those  who  make  use  of  these  as  routine  practice  consider 
the  risk  so  slight  as  scarcely  to  be  considered;  with  the  soluble  prepara- 
tions the  possibility  of  serious  accident  is  practically  nil,  probably  no 
greater,  at  least,  than  with  the  hypodermic  injection  of  any  other  soluble 
drug. 

Of  the  several  soluble  mercurial  preparations  urged  from  time  to 
tune  for  this  method — corrosive  sublimate,  succinamid,  albuminate, 
carbolate,  peptonate,  bicyanid,  iodo-tannate,  benzoate,  and  a  few 
others .  the  one  which  has  the  most  support  and  in  general  use  is  corro- 
sive sublimate;  the  dosage  of  this  is  TV  to  f  grain  (0.005-0.024),  \  grain 
(0.008)  being  an  average  dose.  It  is  dissolved  in  sterilized  water, 
so  that  20  minims  (1.35)  will  represent  \  grain  (0.008)  of  the  drug. 
In  fact,  as  great  a  dilution  as  convenient  to  inject,  within  reason- 
able limits,  is  best,  as  least  likely  to  be  disturbing.  It  is  considered 
an  advantage  by  some  to  add  a  minute  quantity  of  sodium  chlorid, 
tartaric  acid,  or  sodium  chlorid  and  ammonium  chlorid  conjointly,  to 
such  a  solution,  and  others  add  a  small  portion  of  glycerin;  upon  the 
whole,  however,  the  plain  solution  is  in  common  use.  A  rubber  syringe 
and  good  steel  needle  should  be  employed,  and  the  injection  made  deeply 
and  carefully  into  the  subcutaneous  tissue;  if  only  into  the  derma,  slough- 
ing is  apt  to  result.  Injecting  directly  into  a  blood-vessel  or  vein  should 
be  guarded  against.  The  points  most  commonly  selected  for  the  injec- 
tion are  the  gluteal  region,  just  behind  the  great  trochanter  and  the  sub- 
scapular  regions.  It  is,  however,  often  made  on  other  parts,  where 
some  depth  is  possible.  Great  care  should  be  taken  that  the  solution, 
needle,  syringe,  and  skin  at  the  point  of  injection  are  thoroughly  aseptic. 
It  is  well  to  have  a  number  of  needles,  and  if  small  items  of  expense  are 
not  to  be  considered,  a  good  plan  is  to  use  a  fresh  one  for  each  injection. 
The  frequency  and  dose  of  the  injection  depend  upon  the  effect  upon 
the  eruption  or  other  symptoms,  and  upon  the  physiologic  or  toxic  evi- 
dence of  the  drug;  once  daily  or  every  second  day  constitutes  the  average. 

Of  the  insoluble  mercurial  salts,  which  are  always  injected  deeply 
in  the  tissues — intramuscular  injections — gray  oil  and  calomel  are  the 
favorite  preparations.  Other  insoluble  salts  of  mercury  which  have  also 
been  extolled  are  the  yellow  oxid,  black  oxid,  cinnabar,  tannate,  thymol 
acetate,  salicylate,  and  several  others.  The  insoluble  preparation  under- 
goes gradual  absorption,  and  the  action  is  continuous  for  several  days 
or  longer.  Calomel  is  administered  in  suspension  in  a  mucilaginous 
vehicle,  in  glycerin  and  water,  or  in  liquid  vaselin,  about  i  grain  (0.065) 
at  an  injection,  every  three  or  four  days,  or  a  somewhat  larger  quantity 
at  longer  intervals.  Gray  oil  (oleum  cinereum)  is  most  frequently  pre- 

1  Lasserre  ("Le  Passif  des  injections  mercurielles,"  Annales.  1908,  pp.  215,  289,  655, 
and  707)  goes  over  the  entire  subject  of  the  subcutaneous  and  intramuscular  mercurial 
injections,  both  as  to  the  soluble  and  insoluble  salts;  gives  brief  citations  of  the  pub- 
lished instances  of  grave  and  fatal  accidents;  publishes  the  communicated  opinions 
and  experiences  of  well-known  men  of  most  countries.  He  shows  that  there  have  been 
70  fatal  accidents  and  no  serious  accidents.  Gray  oil  and  calomel  were  responsible 
for  38  of  the  deaths.  There  were  but  comparatively  few  deaths  or  serious  accidents 
from  the  soluble  preparations.  A  complete  bibliography  is  added  to  this  excellent 
paper. 


SYPHILIS  835 

scribed,  of  which  an  injection  of  10  to  40  grains  (0.65-2.65),  an  equivalent 
of  5  to  20  grains  (0.33-1.33)  of  metallic  mercury,  is  made  weekly;  gray 
oil  is  made  according  to  various  formulas,  probably  most  commonly  with 
lanolin  and  liquid  vaselin. 

Fumigation,  or  mercurial  vapor-baths,  is  a  method  of  introducing 
mercury  in  the  treatment  of  syphilis  that  was  at  one  time  quite  fre- 
quently employed,  but  it  is  not  much  resorted  to  at  the  present  day. 
A  special  vaporizing  lamp,  both  for  water  and  the  mercury,  obtainable 
in  the  instrument  shops,  is  necessary;  and  an  impermeable  enveloping 
garment  or  one  or  two  ordinary  bed-coverings  or  blankets,  to  be  closely 
adjusted  around  the  neck  to  prevent  damaging  inhalation  of  the  fumes. 
Calomel  and  cinnabar  are  the  salts  commonly  employed — the  former  in 
average  quantity  of  i  dram  (4.),  and  of  the  latter  the  same  or  a  slightly 
larger  amount.  The  vapor-bath,  if  the  sole  plan  of  treatment,  is  given 
every  two  or  three  days  at  first,  and  then  daily  or  every  other  day,  ac- 
cording to  circumstances.  It  is  best  given  in  the  evening,  and  not  less 
than  two  hours  after  eating;  the  duration  should  be  about  twenty  to 
thirty  minutes,  and  the  patient  can  then,  after  cooling  off  some,  retire 
enveloped  in  the  garment  employed  during  the  bath,  if  it  is  not  too 
moist.  In  a  prolonged  bath  of  this  kind  too  much  steam  vapor  is  not  to 
be  used,  as  the  patient  is  often  thereby  weakened.  The  continuance 
and  duration  of  this  active  plan  of  treatment,  as  with  others,  depend 
upon  the  obstinacy  of  the  eruption  and  other  symptoms. 

Potassium  iodid,  or  its  equivalent  salt  of  sodium,  is  an  extremely 
valuable  remedy  in  the  later  stages  of  syphilis,  but  it  is  rarely  needed  in 
the  secondary  or  active  stages  of  the  disease,  in  which  mercury  is  with 
rare  exceptions  fully  adequate  to  bring  about  a  favorable  result.  It  is 
often  stated  that  the  iodid  should  be  given  in  secondary  syphilis  and  take 
the  place  of  mercury,  when  this  latter  is  contra-indicated  or  not  well 
borne,  but  such  instances,  judging  from  dermatologic  observation, 
are  exceedingly  rare  and  almost  unknown,  for  while  one  plan  of  mercurial 
treatment  might  be  found  damaging  to  digestion,  for  instance,  in 
mouth  administration,  another  method  can  readily  be  substituted.  It 
has  also  been  alleged  that  mercury  is  not  well  borne  in  some  cases  of 
malignant  syphilis,  and  therefore  it  is  often  advisable  to  suspend  its  use, 
but  even  in  such  instances,  if  properly  and  judiciously  administered, 
along  with  the  conjoint  treatment  by  iron,  strychnin,  minute  doses  of 
arsenic,  cod-liver  oil,  and  other  remedies,  as  may  be  indicated,  its  omission 
or  discontinuance  is  usually  unnecessary.  Profound  anemia,  which  is 
often  the  troublesome  symptom  in  these  cases,  needs  more  than  mercury 
to  promote  the  rebound  or  even  to  stop  the  downward  trend,  and  it  is, 
I  believe,  the  failure  to  recognize  this  fact  or  an  unsuitable  method  of 
administration  that  has  given  rise  to  the  view  that  the  mercury  may  be 
doing  harm.  It  is  true,  however,  that  in  extremely  rare  instances  the 
temporary  discontinuance  of  this  drug  may  be  deemed  wise,  or  at  least 
tried,  and  to  the  treatment,  consisting  of  tonics  and  nutrients,  small  or 
moderate  doses  of  the  iodids  be  for  a  time  given  in  its  place.  A  compara- 
tively few  physicians  are,  however,  inclined  to  give  the  iodids  a  more 
prominent  place  in  the  active  stages,  although,  with  rare  exceptions,  all 


836  NEW  GROWTHS 

of  large  experience  have  recourse  to  them  at  this  period  only  when  preco- 
cious tertiary  symptoms  present,  such  as  persistent  rheumatic  pains, 
periostitis,  gummata,  destructive  ulceration,  troublesome  cephalalgia, 
and  othei  evidences  of  more  or  less  serious  involvement  of  the  nervous 
system.1 

Its  conjoint  administration  in  moderate  dosage  is  sometimes  adopted 
toward  the  end  of  the  first  year  by  some  as  a  routine  method,  but,  as 
a  rule,  mercury  is  to  be  the  recourse  throughout,  if  tertiary  or  other 
serious  manifestations  do  not  suggest  its  earlier  use.  It  is  especially 
in  the  later  manifestations,  such  as  the  tubercular  and  gummatous  and 
other  tertiary  evidences,  that  the  iodid  is  extremely  valuable,  and  under 
the  administration  of  which  symptoms  often  disappear  in  a  comparatively 
short  time  as  if  by  magic.  But  while  it  has  this  power,  it  does  not,  in  the 
judgment  of  many,  including  myself,  seem  to  have  the  same  influence 
in  preventing  recurrences,  or,  in  short,  of  extinguishing  the  syphilitic 
poison,  as  does  mercury,  and  the  latter,  therefore,  is  almost  invariably 
associated,  constituting  the  well-known  "mixed  treatment."  Corrosive 
sublimate  and  the  red  iodid  of  mercury  are  the  mercurials  used  most 
frequently  with  potassium  iodid,  the  latter,  I  believe,  deserving  the  pref- 
erence. The  two  drugs  are  commonly  ordered  conjointly  in  mixture, 
with  mint-water,  cinnamon-water,  compound  tincture  of  cardamom, 
gentian,  wine  of  coca,  or  the  compound  syrup  of  sarsaparilla  as  the  vehicle. 
This  last  has  long  been  a  favorite,  owing  to  the  erroneous  or  scantily 
founded  belief  that  it  has  itself  some  influence,  but  its  syrupy  character 
has  often  seemed  to  me  to  be  responsible  for  the  nausea  and  gastric 
uneasiness  attributed  to  the  iodid,  although  the  latter  is  in  many  instances 
the  exciting  cause.  I  have  found  that  the  sodium  iodid  is  much  less 
likely  to  disagree  than  the  potassium  salt,  and  for  that  reason  frequently 
prescribe  it  in  preference,  although  in  the  same  dosage  it  is  not  quite 
so  efficient  as  the  potassium  salt.  With  the  other  iodid  salts — ammonium 
iodid,  rubidium  iodid,  strontium  iodid,  and  lithium  iodid — occasionally 
suggested  as  substitutes  for  the  potassium  and  sodium  salts  I  have  had 
no  experience,  although  it  is  generally  admitted  that  they  are  not  com- 
parable to  the  two  in  common  use.  Not  infrequently  the  iodid  is  pre- 
scribed as  a  saturated  aqueous  solution,  i  minim  being  equivalent  to  i 
grain  (0.065),  and  the  dose  can  thus  be  conveniently  increased  drop  by 
drop  if  necessary;  it  is  taken  diluted  with  water  or  milk,  and  the  mercurial, 
if  advised  also,  separately  in  pill,  solution,  or  by  inunction.  When 
separately  administered  as  pill  or  tablet,  the  mercurial  can,  as  in  the  ear- 
lier stages  of  the  disease,  be  prescribed  as  the  protiodid,  although  for  this 
plan  also  the  biniodid  or  corrosive  sublimate  is  frequently  preferred, 
especially  the  former,  as  less  liable  to  give  rise  to  gastric  or  intestinal 
irritation  or  to  the  other  toxic  symptoms. 

The  dose  of  the  iodid  of  potassium  or  sodium  required  is  variable 
—in  some  cases  not  requiring  urgency  it  is,  as  a  rule,  not  necessary 
to  exceed  10  grains  (0.65)  three  times  daily,  and  frequently  5-grain  doses 
(0.33)  will  suffice;  and,  indeed,  in  some  cases  of  the  late  tubercular  syphilid 

1With  some  physicians  salvarsan  has  largely  supplanted  the  iodids  in  such 
instances. 


SYPHILIS  837 

the  eruption  will  rapidly  disappear  under  smaller  dosage,  as  i  or  2  grains 
three  or  four  times  daily,  a  fact  to  which  Hartzell1  has  recently  called 
attention.  As  a  rule,  however,  the  drug  must  be  given  in  moderate 
doses,  and  very  often  the  quantity  is  gradually  increased  up  to  20  or  30 
grains  (1.33-2.)  or  more  at  the  dose,  and  occasionally  the  total  daily 
amount  reached  before  improvement  sets  in  will  be  6  to  8  drams  (24.- 
32.)  or  more,  as  sometimes  observed,  and  as  I  myself  have  noted  in  occa- 
sional instances.2  These  large  doses  are,  however,  only  rarely  necessary 
in  the  management  of  cutaneous  lesions,  being  sometimes  required  if  the 
destruction  is  rapid  and  threatening,  or  if  indicated  by  grave  concomitant 
symptoms.  In  such  instances  the  beginning  dose  should  be  moderately 
large — 20  to  30  grains — and  rapidly  increased.  In  exceptional  instances, 
however,  it  is  found  that  the  case  does  not  yield  so  readily  to  the  increase 
of  the  iodids  as  it  will  to  increase  in  the  mercurial,  and  it  is  in  such  that 
the  iodid  of  potassium  or  sodium  can  be  given  by  the  mouth  and  the 
mercury  advantageously  by  inunction.  In  rare  instances  of  the  late 
tubercular  and  gummatous  manifestations  the  iodid,  even  when  increased 
to  extremely  large  doses,  fails  utterly  to  remove  the  eruption,  but,  for- 
tunately, such  cases  are  so  exceptional  that  the  value  of  the  so-called 
"therapeutic  test"  in  doubtful  cases  of  suspected  late  syphilitic  eruptions 
is  not  materially  lessened.  In  such  instances  the  discontinuance  of  the 
drug  is  advisable;  the  institution  of  vigorous  mercurial  treatment,  espe- 
cially by  inunction  or  hypodermic  injections,  will  usually  have  a  prompt 
effect;  or  recourse  may  be  had  to  salvarsan  injections. 

Sometimes  even  moderate  doses  of  the  iodid  salt  give  rise  to  such 
distressing  symptoms  of  iodism  that  it  cannot  be  increased,  and  occa- 
sionally must  be  discontinued.  One  or  two  drops  of  belladonna  tincture 
with  each  dose  will  sometimes  lessen  the  severity  of  such  symptoms,  and 
administration  of  small  doses  of  arsenic  or  potassium  bitartrate  occa- 
sionally seems  to  exert  some  control.  The  belief  that  the  iodid  eruption 
— iodid  acne,  for  instance — and  other  symptoms  of  iodism  do  not  arise 
when  the  drug  is  administered  for  syphilis,  and  that  if  they  do,  it  indicates 
an  erroneous  diagnosis,  is  absolutely  without  basis,  as  such  symptoms 
arise  just  as  often  in  a  given  number  of  syphilis  cases  as  in  the  same 
number  of  cases  of  other  diseases  for  which  it  may  be  administered,  as 
shown  by  J.  William  White,3  myself,4  and  others. 

Other  alleged  specific  remedies  for  syphilis  lauded  from  time  to  time, 
more  commonly  proprietary  in  character,  such  as  the  various  vegetable 
remedies,  which  need  not  be  enumerated,  gold  chlorid,  opium,  decoctions, 
etc.,  have  made  no  permanent  impression,  and  their  supposed  effects 

1  Hartzell,  "Some  Practical  Points  in  the  Treatment  of  Late  Cutaneous  Syphilis," 
Therapeutic  Gazette,  May  16,  1898. 

2  Stelwagon,  "A  Case  of  Late  Cutaneous  Syphilis,  Illustrating«the  Occasional  Neces- 
sity of  Large  Doses  of  Potassium  Iodid,"  Philadelphia  Med.  News,  June  27,  1885. 

3  J.  William  White,  "Contributions  to  the  Discussion  of  the  Diagnostic  Value  of  the 
Tolerance  of  the  Iodids  in  Syphilis,"  Therapeutic  Gazette,  March  15,  1889  (presenting 
communicated  opinions  from  a  number  of  eminent  syphilographers  and  neurologists); 
and  "Valeur  diagnostique  de  la  tolerance  des  iodures  dans  la  syphilis,"  Union  Medicare, 
1889,  pp.  628  and  639. 

4  Stelwagon,  "On  the  Alleged  Tolerance  of  the  Iodids  in  Late  Syphilis,"  Therapeutic 
Gazette,  Oct.  15,  1889. 


838 


NEW  GROWTHS 


have  mostly  been  based  upon  their  use  in  the  secondary  stage  of  the  dis- 
ease, when  nature  alone  is,  in  reality,  when  properly  guided  or  supported 
by  suitable  hygiene,  often  amply  sufficient  to  bring  the  eruption  and  other 
symptoms  to  a  favorable  termination. 

Arsenical  Preparations. — Arsenic  has  claimed  much  attention  re- 
cently in  the  treatment  of  syphilis,  and  if  the  experiences  so  far  with 
its  use  continue  to  be  further  verified  and  the  effects  prove  lasting,  it 
will  be  given  probably  an  equal — possibly  a  superior — position  to  that 
so  long  and  satisfactorily  occupied  by  mercury..  While  several  arsenical 
preparations,  such  as  sodium  cacodylate,  atoxyl,  arsacetin,  soamin,  and 
hectine,1  have  been  introduced,  the  Ehrlich-Hata  preparation,  known 
as  "salvarsan" 2  or  popularly  as  "606,"  has  met  with  the  greatest  ac- 
claim, and  seems  to  have  established  a  reputation  for  curative  power 
as  to  make  it  the  arsenical  remedy  of  choice.  The  leading  German  and 
Austrian  dermatologists  and  syphilographers  have  given  it  the  most 
thorough  and  extensive  trials,  and  it  seems  to  be  accepted  by  them  as  a 
peculiarly  specific  remedy  for  the  disease.  The  French  have  been  rather 
lukewarm  in  its  praise,  some,  among  whom  particularly  Hallopeau,  giving 
a  preference  for  hectine.  England  and  America  have  been  more  conser- 
vative than  the  Germans,  but  have,  nevertheless,  leaned  toward  sustain- 
ing the  German  enthusiasm.  Among  ourselves  it  has  gained  rather 
general  use,  and  has  been  accorded  high  value  by  those  who  have  given 
it  extensive  trial,  most  prominent  among  the  careful  and  exact  observers 
may  be  mentioned  Fordyce,  who  has  employed  it  largely,  and  is  warm  in 
its  praise.  Salvarsan  seems  to  have  its  most  pronounced  influence  in 
the  primary  stage,  and  quite  decided  in  the  late  stages;  it  has  a  remarkable 
action  in  dissipating  mucous  and  ulcerative  lesions;  and  in  chronic  de- 
structive lesions  it  acts  with  greater  rapidity,  as  a  rule,  than  mercury 
and  potassium  iodid,  and  acts  in  some  cases  in  which  the  latter  remedies 
have  failed.  The  hope  that  a  single  large  dose  would  prove  destructive 
to  the  spirochaetae  and  annihilate  the  disease  has  long  been  abandoned; 
and  recurrences  have  been  sufficiently  frequent  after  its  use  to  make 
us  somewhat  more  conservative  in  estimating  its  true  value.  It  has 
been  claimed  by  several  observers  that  excision  of  the  initial  lesion 
at  the  earliest  possible  moment,  together  with  a  full  dose  of  salvarsan, 
repeated  two  or  three  times  at  intervals  of  five  to  ten  days  has  succeeded 
in  aborting  the  disease.  There  has  been  a  trend  in  the  past  year  or  so 
to  give  salvarsan  in  the  earliest  stages  of  the  disease,  to  the  extent  of 
several  moderate  doses,  and  then  to  follow  this  up  with  a  mercurial 
course  as  formerly.  It  is  also  considered  by  many  the  remedy  of  choice 
either  in  early  or  late  syphilis  of  malignant  type.  The  most  common 
dose  of  salvarsan  is  5  to  9  grains  (0.33-0.6)  given  in  properly  prepared 
solution  made  just  before  administration,  intramuscularly  or  intraven- 
ously ;  the  former  in  the  same  regions  (buttocks)  as  mercury  is  similarly 
given,  and  in  the  arm  vein  intravenously.  Neosalvarsan,  another  prod- 
uct of  the  Ehrlich  laboratory,  has  been  brought  forward  as  a  substitute 
for  or  an  improvement  on  salvarsan,  chiefly  on  the  basis  of  its  much 

1  The  chemical  name  being  sodium  benzo-sulphonpara-amino-phenyl-arsenate. 
•  The  chemical  name  being  paradiamidodioxyarsenobenzol  dihydrochlorid. 


SYPHILIS 


839 


easier  preparation  in  solution  for  administration;  it  is  somewhat  weaker 
than  salvarsan  and  should  be  given  in  slightly  larger  dosage — about  one- 
tenth  to  one-eighth  more.  Salvarsan  has  been  tried  experimentally 
(Kolmer  and  Schamberg)1  by  the  mouth,  but  with  slight  therapeutic 
effect.  The  intramuscular  method  gives  rise  to  considerable  pain, 
sometimes  sufficient  to  call  for  hypodermic  injections  of  morphia,  and 
may  be  followed  with  fever  and  a  possibility  of  local  sloughing.  The 
intravenous  method  is  more  comfortable  for  the  patient,  quicker  in  its 
action,  but  requires  some  technical  skill  in  order  to  avoid  any  possible 
grave  accidents;  there  is  less  reaction;  general  symptoms  of  chilliness 
and  fever,  with  rise  of  temperature  often  persisting  for  several  hours, 
but,  as  a  rule,  not  lasting  more  than  a  day  or  so.  Those  who  depend 
upon  salvarsan  completely,  usually  repeat  this  dose  once  in  one  to  two 
weeks  till  3  to  5  doses  are  administered,  or  till  the  Wassermann  reaction 
becomes  permanently  negative.  It  would  seem  for  the  average  case, 
when  seen  for  the  first  time  after  the  chancre  has  well  developed  and  too 
late  to  attempt  to  abort  the  disease,  that  for  the  present  the  mercurial 
treatment  would  be  the  one  of  a  choice,  unless  extremely  urgent  symptoms 
should  show  themselves;  in  such  event  or,  as  many  practice,  in  average 
cases,  first  a  dose  of  salvarsan,  and  subquently  the  continued  or  inter- 
mittent mercurial  treatment.  If  the  case  comes  within  a  short  time  of 
the  first  sign  of  the  initial  lesion,  excision  should  be  practised,  and  a  full 
dose  of  salvarsan  administered;  if  no  untoward  arsenical  symptoms 
present  the  dose  of  salvarsan  is  repeated  in  several  days — it  is  alleged 
that  in  some  instances  the  disease  has  been  aborted  in  this  way. 

Of  the  other  arsenical  preparations  "  Hectine"  has  probably  had  the 
most  commendation.  Hallopeau2  and  other  French  observers  give  it 
high  value,  stating  that  in  a  large  number  of  cases  administered  early  in 
the  primary  stage  it  has  repeatedly  aborted  the  disease;  the  injections 
are  given  daily  in  3-grain  (0.2)  doses  dissolved  in  sterilized  water;  and 
are  given  mostly  in  and  about  the  chancre,  and  using,  when  necessary, 
novocain  to  relieve  the  pain.  This  treatment  is  continued  for  thirty 
days;  the  Wassermann  reaction  becomes  negative,  it  is  stated,  and  re- 
mains so.  Sodium  cacodylate,  in  i^-  to  5-grain  (0.1-0.33)  dose  in  solu- 
tion hypodermically,  every  two  to  three  days,  has  also  been  given  credit 
(Murphy,  Spivak,  and  others)3  for  favorable  action  in  syphilis,  but  it  is 
much  inferior  to  the  other  arsenical  preparations  named,  but  safer. 

1  Kolmer  and  Schamberg  ("Experimental  Studies  on  the  Administration  of  Sal- 
varsan by  Mouth  to  Animals  and  Man,"  Jour.  Exper.  Med.  1912,  xv,  No.  5)  found  that 
doses  of  salvarsan  in  doses  of  high  as  7^  to  9  grains  (0.5-0.6)  could  be  given  to  man  by 
the  mouth,  without  disturbing  symptoms,  with,  however,  but  comparatively  slight 
therapeutic  influence  on  the  syphilitic  manifestations;  in  cats  and  rabbits  doses  ap- 
proximating those  given  to  human  subjects  failed  to  produce  toxic  effects,  either 
symptomatically  or  in  visceral  examinations  following  autopsy. 

2  Hallopeau,  Annales  des  Maladies  Vener.,  Nov.  1911,  p.  848. 

3  Murpny,  Jour.  Amer.  Med.  Assoc.,  Sept.  24,  1910,  p.   1113;  Spivak,  New  York 
Med.  Jour.,  March  2.  1912,  tried  sodium  cacodylate  in  43  cases  with  the  conclusions: 
— it  has  a  decided  effect  upon  the  initial  lesion;  not  so  much  upon  the  secondaries,  but 
some  effect  on  the  adenopathy,  and  a  decided  effect  on  mucous  patches  and  condy- 
lomata;  very  little  effect   in  tertiary  lesions.      He  gave  3  grains  (0.2)  daily  in  fresh 
solution,  and  states  that   the  "  human  system  can  take  100  grains  (6.66)  in   three 
weeks  without  arsenical  poisoning." 


840 


NEW  GROWTHS 


Atoxyl,  one  of  the  first  arsenical  compounds  to  be  used,  had  unques- 
tionably, as  Neisser  and  others  have  shown,  considerable  specific  power 
over  the  disease,  but  the  serious  accidents,  especially  optic  atrophy  and 
permanent  blindness,  which  sometimes  followed  its  use,  has  practically 
led  to  its  abandonment. 

There  have  been  fatal  results  from  the  use  of  salvarsan,  and  doubt- 
less would  be  from  other  arsenical  preparations  if  given  in  large  dosage. 
The  number  of  fatalities  and  serious  accidents  has  not  been  large  when 
one  considers  the  thousands  of  times  it  has  now  been  administered;  it 
should  never  be  given  to  those  with  serious  cardiac  or  other  vascular 
disease,  to  those  with  pronounced  kidney  disorders,  to  those  with  grave 
cerebral  or  other  nervous  disease,  or  to  those  with  middle-ear  or  eye 
disease— if  independent  of  syphilis;  nor  to  the  profoundly  cachectic 
and  weak. 

Doubtless  remedies  having  diaphoretic  and  diuretic  properties  and 
promotive  of  proper  action  of  the  bowels  do  have  some  influence  in 
hastening  the  elimination  of  the  syphilitic  virus,  but  such  are  often 
attainable  by  the  observance  of  ordinary  rules  of  hygiene.  In  this  way 
balneotherapy — warm  or  hot  baths — is  doubtless  of  some  service.1  It 
is  not  necessary  that  patients  go  to  "hot  springs"  for  bathing  purposes, 
for  tub-  and  vapor-baths  at  home  will  answer  the  same  end,  provided 
patients  will  give  the  same  attention  to  diet,  temperate  living,  etc., 
as  they  willingly  follow  at  the  "springs" ;  and,  if  they  do  so,  then  the  state- 
ment made  by  Taylor,  "take  away  the  mercurial  ointment  and  iodid  of 
potassium  from  any  thermal  spring,  and  its  business  will  soon  close  up 
for  want  of  patronage,"  is  a  simple,  but  strong,  expression  of  the  truth. 
There  are,  however,  patients  who  are  not  docile  at  home,  who  eat  too 
much,  "drink"  too  much,  and  smoke  too  much,  and  who  do  not  follow  up 
carefully  the  advice  given,  and  for  such  the  thermal  spring,  with  its  strict 
regimen,  moral  living,  and  the  incidental  change  of  scene,  and  the  usually 
rigorous  treatment,  is  a  resort  sometimes  to  be  professionally  advised. 

The  serum  treatment  is  still  in  the  experimental  stage. 

Duration  of  Treatment. — The  active  treatment  of  syphilis,  if 
with  mercurials,  is  continued  for  a  few  months  after  all  the  symptoms 
have  disappeared;  and  then  usually  at  intervals  of  one  or  two  months 
repeated  for  a  few  months,  and  so  on  for  at  least  eighteen  months  to  two 
years,  the  treatment  in  the  second  year  being  somewhat  less  in  dosage. 
Should  at  any  time  fresh  evidences  of  syphilis  show  themselves,  the  treat- 
ment is  naturally  to  be  actively  energetic  again.  I  have  been  accus- 
tomed to  advise  my  patients  to  resume  treatment  for  six  weeks  to  two 
months  in  each  of  the  following  two  to  three  years.  So  far  as  my  own  ex- 
perience goes,  now  covering  a  number  of  years,  the  results  have  been, 
with  very  few  exceptions,  permanently  satisfactory.  If  the  preliminary 
treatment  is  with  one  or  two  doses  of  salvarsan,  followed  by  mercurials — 
the  plan  largely  practised  just  at  the  present  time — the  duration  should 
be  almost  the  same  as  detailed  above.  Those  who  follow  the  salvarsan 

1  Interesting  papers  on  the  subject  are  contributed  by  Bogart,  Brooklyn  Med.  Jour., 
Dec.,  1895,  and  Neisser,  Berlin,  klin.  Wochenschr.,  1897,  No.  16;  and  Baum,  Medicine, 
1896,  p.  253. 


SYPHILIS  841 

treatment  exclusively,  usually  base  its  continuance  or  repetition  purely 
upon  symptoms  and  the  serum  reaction  test,  as  referred  to  again  a  few 
paragraphs  further  on.  In  fact,  there  is  a  disposition  to  depend  upon  the 
Wassermann  test  indications,  whatever  the  plan  of  treatment,  for  con- 
tinuance or  discontinuance,  but  for  the  present  the  patient  should  still 
have  the  benefit  of  a  prolonged  period  of  treatment — it  means,  in  my 
opinion,  greater  safety. 

Probably  sufficient  has  been  said  as  to  the  treatment  of  tertiary 
manifestations  in  discussing  the  iodid  salts.  The  cases  coming  der- 
matologically  under  observation  are  chiefly  those  of  limited  tubercular 
eruptions  or  gummatous  lesions,  sometimes  several  to  five,  ten,  or  more 
years  after  the  disease  was  contracted.  The  treatment  of  these  and  other 
tertiary  or  late  manifestations  consists  in  the  conjoint  administration 
of  the  iodid  and  the  bichlorid  or  biniodid  of  mercury,  5  or  more  grains 
(0.33)  of  the  former  and  -^  (0.002)  to  T-J  (0.006)  or  more  of  the  mercurial, 
in  any  suitable  vehicle  three  times  daily;  if  rebellious,  increasing  the  dose 
of  the  potassium  or  sodium  iodid  salt,  if  well  borne,  up  to  2  drams  (8.), 
and  then  if,  as  exceptionally  occurs,  there  is  no  result,  giving  the  patient 
an  active  mercurial  course,  either  by  stomach,  inunction,  or  hypodermic 
injection.  The  inunction  plan  often  acts  very  satisfactorily  in  such 
cases.  A  dose  of  salvarsan  usually  acts  quickly  in  these  cases,  and 
should  certainly  be  prescribed  in  serious  and  rapidly  destructive  cases 
which  are  rebellious  to  the  iodid  and  mercurials.  The  treatment  in 
these  late  manifestations  is  to  be  continued  actively  for  one  or  two 
months  after  the  disappearance  of  the  symptoms;  the  iodid  is  then 
omitted,  and  the  usual  daily  dose  of  the  mercurial  continued  for  six 
weeks  to  two  months,  and  again  resumed  once  or  twice  at  intervals 
of  three  or  four  months.  If  the  symptoms  had  been  of  an  urgent  char- 
acter, the  subsequent  employing  of  one  or  two  short  courses  by  inunction 
at  the  above  intervals  is  to  be  advised. 

Duration  of  Treatment  Based  upon  the  Serum  Test. — Whatever 
may  have  been  the  plan  of  treatment  pursued,  or  whatever  may  have 
been  the  stage  of  the  disease,  the  Wassermann  test  or  its  modification, 
the  Noguchi  test,  is  at  the  present  time  largely  depended  upon  for  the 
continuance  or  renewal  of  active  treatment.  Therefore,  after  patients 
have  been  thought  sufficiently  treated  and  free  of  all  manifestations  for 
several  or  more  months,  a  series  of  such  tests,  more  especially  the  Was- 
sermann test,  should  be  made  at  intervals  of  one  or  two  weeks;  and  if 
found  constantly  negative  it  is  thought,  by  many  observers,  presumptive 
evidence  that  the  disease  is  at  end.  Such  a  series  of  tests  should  not, 
however,  be  made  till  treatment  has  been  discontinued  for  at  least 
several  weeks,  as  it  is  well  known  that  the  antisyphilitic  remedies  have 
the  power,  even  in  the  active  stages  of  the  disease,  of  suppressing  the 
positive  reaction  for  the  time.  Should  the  reactions  show  positive 
active  treatment  is  to  be  again  resumed.  While  I  do  not  question  the 
value  and  significance  of  the  serum  test,  nevertheless  I  should  not  as  yet 
be  willing  to  deprive  my  patients  of  the  additional  safety  of  a  prolonged 
period  of  mercurial  treatment,  as  heretofore  extending,  with  intervals  of 
interruption,  over  two  or  three  years. 


842 


NEW  GROWTHS 


External  Treatment. — In  the  majority  of  cases  of  the  secondary 
cutaneous  manifestations  no  local  applications  are  called  for,  but  in 
severe  types  of  the  papular  eruption,  and  also  in  the  pustular  syph- 
ilodermata,  baths  of  corrosive  sublimate,  \  to  3  or  4  drams  (2-12. 
or  1 6.)  to  30  gallons  of  warm  water,  can  be  employed,  the  patient  re- 
maining in  the  bath  for  five  to  fifteen  minutes.  When  the  surface 
shows  a  good  number  of  abraded  lesions,  absorption  is  likely  to  take 
place,  and  the  smaller  quantities  should  be  used.  This  bath  method 
was  formerly  occasionally  employed  as  a  plan  of  treatment  for  the  in- 
troduction of  mercury,  but  it  was  found,  except  under  the  condition 
just  noted,  that  absorption  practically  did  not  take  place,  or  at  least 
was  uncertain.  As  the  patient  is  at  the  same  time  taking  the  remedy 
by  the  mouth  or  by  one  of  the  other  methods,  the  possibility  of  such  ab- 
sorption is,  however,  to  be  kept  in  mind,  so  as  to  guard  against  toxic 
action.  A  much  better  plan  of  medicating  the  general  surface  is  by  the 
mercurial  vapor-bath,  but  this  is  not  always  practicable.  Very  often 
the  surface  in  such  cases  can  with  advantage  be  sponged  with  a  saturated 
solution  of  boric  acid,  containing  i  to  2  drams  (4--8.)  of  carbolic  acid  to 
the  pint,  with  or  without  the  addition  of  2  to  4  grains  (0.135-0.265)  of 
corrosive  sublimate.  Or  this  lotion  can  be  applied  to  the  covered  surface, 
and  an  ointment  applied  to  the  lesions  on  exposed  regions,  such  as  one  of 
ammoniated  mercury,  20  to  60  grains  (1.35-4.)  to  the  ounce  (32.);  one 
of  oleate  of  mercury,  5  to  10  per  cent,  strength;  mercurial  plaster,  full 
strength  or  weakened  with  lard  or  petrolatum;  blue  ointment,  full 
strength  or  weakened;  a  2  to  20  per  cent,  ointment  of  iodol;  resorcin,  20 
to  60  grams  (1.35-4)  to  the  ounce  (32.).  The  selected  ointment  is  gently 
rubbed  on  the  spots  twice  daily,  or  it  may  be,  when  possible,  as  when  in 
the  house,  applied  spread  upon  lint  as  a  plaster.  The  base  used  can  be 
made  of  equal  parts  of  lard  and  petrolatum,  with  some  stiffening,  as 
cerate  or  wax,  if  it  is  to  be  applied  as  a  plaster.  For  exposed  situations, 
the  most  elegant,  as  well  as  most  cleanly,  is  the  ointment  containing 
ammoniated  mercury,  and  this  often  acts  satisfactorily,  but  in  the  event 
of  its  making  no  positive  impression,  one  of  the  others  can  be  tried.  In 
the  larger  pustular  lesions,  especially  when  exhibiting  an  ulcerative 
tendency  of  the  base,  the  crust  can  be  softened  and  removed,  the  surface 
cleansed  with  mild  antiseptic  lotions,  such  as  the  above,  and  an  ointment 
spread  upon  lint  and  applied,  changing  once  or  twice  daily,  according  to 
circumstances. 

In  the  late  or  limited  syphilodermata,  the  same  applications  are, 
when  necessary,  resorted  to,  the  ammoniated  mercury  ointment,  the 
oleate  of  mercury,  the  blue  ointment,  and  the  mercurial  plaster,  full 
strength  or  weakened,  are  the  most  satisfactory.  The  ulcerating  lesions 
can  be  cleansed  first,  an  antiseptic  lotion  dabbed  on,  and  an  ointment 
applied  as  a  plaster.  One  of  the  above  lotions  can  be  employed,  or, 
and  especially  in  offensive  ulcerations,  one  slightly  modified  can  be  sub- 
stituted, containing  2  to  6  grains  (0.135-0.4)  of  corrosive  sublimate,  10 
to  20  grains  (0.65-1.35)  of  carbolic  acid,  4  drams  (16.)  of  alcohol,  ^  to  i 
dram  (2. -4.)  of  glycerin,  and  water  to  make  4  ounces  (128.).  Occasional 
cleansing  with  a  weak  hydrogen  peroxid  solution  is  often  of  advantage. 


SYPHILIS  843 

lodol  may  also  be  applied  to  ulcers  as  a  dusting-powder,  usually  mixed 
with  one  to  several  parts  of  boric  acid  or  zinc  oxid.  In  sluggish  ulcera- 
tions  the  healing  process  can  often  be  advantageously  started,  as  Zeisler1 
has  especially  emphasized,  by  a  light  cauterization  with  silver  nitrate, 
and  in  rebellious  cases,  if  necessary,  by  a  preliminary  curetting.  The 
palmar  and  plantar  syphiloderm,  occasionally  observed  both  in  the  late 
secondary  and  later  periods,  is  treated  by  the  various  ointments  already 
referred  to,  but  when  there  is  much  thickening  this  is  first  to  be  removed 
by  the  continuous  application,  for  one  or  two  days  or  longer,  of  a  10  to 
25  per  cent,  salicylic  acid  plaster;  frequently  it  is  necessary  to  repeat 
this  from  time  to  time;  vigorous  constitutional  treatment  conjoined  with 
active  local  measures  is  usually  required  in  these  cases.2 

To  the  papules,  often  moist  and  fissured,  sometimes  found  at  the 
angles  of  the  mouth  in  the  secondary  period,  one  of  the  several  oint- 
ments can  be  gently  rubbed  or  smeared  on  two  or  three  times  daily,  or 
they  can  be  painted  over,  once  or  twice  at  one  time,  with  tincture  of 
benzoin  containing  |  to  i  grain  (0.018-0.065)  °f  corrosive  sublimate  to 
2  drams  (8.),  and  repeated  night  and  morning.  Moist  papules  on  other 
regions,  as  about  the  anus  and  genitalia,  often  disappear  upon  the  institu- 
tion of  rigorous  cleanliness,  washing  the  parts  twice  or  more  daily  with 
tepid  water  and  small  quantity  of  soap,  rinsing,  and  tapping  dry  with 
absorbent  cotton,  and  dusting  on  the  iodol-boric  acid  powder  noted 
above,  or  a  powder  of  one  or  two  parts  calomel  to  the  ounce  (32.)  of 
boric  acid  or  zinc  oxid  powder;  or  in  obstinate  lesions  pure  calomel 
powder  alone  can  be  applied.  In  the  latter  cases  the  preliminary  use 
of  one  of  the  mild  lotions  already  named  can  be  advantageously  used 
before  the  powder  is  applied.  Ointments  such  as  named  are  sometimes 
advised,  but,  as  a  rule,  they  are  not  well  borne,  and  the  above  dry  methods 
are  much  superior,  and  along  with  the  constitutional  treatment  suffice. 
Very  obstinate  lesions  can  be  occasionally  painted  with  a  5  to  10  per  cent, 
solution  of  silver  nitrate.  These  same  plans  are  alike  applicable  to  the 
hypertrophic  warty  and  vegetating  papules.  For  the  mucous  patches 
in  the  mouth  absolute  cleanliness  of  this  cavity  and  of  the  teeth  is  a 
measure  of  usefulness.  For  this  purpose  frequent  cleansing  with  the 
ordinary  potassium  chlorate  and  tincture  of  myrrh  or  similar  mouth- 
washes  or  gargles  can  be  employed.  Any  roughened  teeth  are  to  be 
smoothed  down,  and  smoking  prohibited,  as  well  as  the  ingestion  of  very 
hot  or  acid  or  other  foods  which  seem  to  irritate.  Sometimes,  under 
such  measures,  and  as  the  result  of  constitutional  medication,  the  mucous 
patch  will  disappear.  In  all  cases,  however,  their  disappearance  can  be 
promoted  by  touching  with  the  silver  nitrate  stick,  and  if  no  change  is 
observed  in  two  or  three  days,  the  application  is  to  be  repeated.  In 
sensitive  subjects  or  slight  cases  a  5  to  10  per  cent,  solution  will  answer 
the  purpose.  In  other  cases  touching  carefully  with  a  minute  quantity 
of  lactic  acid,  nitric  acid,  or  acid  nitrate  of  mercury  is  sometimes  neces- 
sary, rinsing  the  mouth  afterward. 

Zeisler,  "The  Importance  of  Local  Treatment  in  Syphilis,"  Jour.  Amer.  Med. 
Assoc.,  Mar.  16,  1889  (with  references). 

2Stelwagon,  "Observations  Concerning  Some  Palmar  Eruptions,"  Jour.  Cutan. 
Dis.,  Jan.,  1905  (illustrated). 


844  NEW 

The  nail  affections — onychia,  paronychia — sometimes  observed 
require,  in  addition  to  the  active  constitutional  treatment,  rigorous 
cleanliness,  and  the  application  of  mild  antiseptic  lotions,  such  as  already 
named,  and  the  enveloping  of  the  part  in  a  mild  mercurial  ointment, 
redressing  twice  daily;  when  loose,  the  nail  is  to  be  removed.  Falling 
of  the  hair  is  managed  in  the  same  manner  as  described  in  other  cases 
independent  of  this  malady  (see  Alopecia) ;  the  hair  usually  regrows  as 
the  general  constitutional  disease  abates. 

Treatment  of  Hereditary  Syphilis. — The  constitutional  treatment 
of  hereditary  syphilis  is  essentially  that  of  the  acquired  disease  in  adults, 
with  modifications  as  to  dosage  and  method.  It  is  understood  that  if 
opportunity  is  afforded  in  a  suspected  syphilitic  pregnancy  that  the 
mother  should  be  vigorously  treated  with  mercurials  during  this  period, 
as  in  this  way  a  healthy  or  seemingly  healthy  birth  will  result,  or  the 
child  will  exhibit  the  disease  in  a  milder  phase.  In  a  child  born  of  syph- 
ilitic parents  and  not  showing  specific  symptoms  treatment  should  not 
be  instituted  until  evidence  of  inherited  disease  appears,  as  it  may  have 
wholly  escaped  infection;  to  this,  however,  the  exception  should  be  made 
with  children  born  during  a  recent  syphilis  in  the  mother,  especially  if 
it  has  been  untreated.  The  condition  of  the  general  nutrition  should 
be  carefully  looked  after,  however,  so  if  the  disease  does  exist,  there  will 
be  a  better  chance  to  subdue  its  symptoms  when  they  present.  In  fact, 
the  nourishment  of  the  child  in  all  cases  of  inherited  syphilis,  whether 
the  evidences  are  present  at  birth  or  show  themselves  later,  is  of  greatest 
importance.  The  best  method  of  introducing  mercury  in  these  cases  is 
by  inunction,  but  the  ordinary  mercurial  ointment  should  be  weakened 
with  2  or  3  parts  of  vaselin  or  cold  cream,  according  to  the  age  of  the 
child;  about  \  to  i  dram  (2.~4.)  of  this  is  spread  upon  a  binder  on  the  part 
which  goes  over  the  abdomen.  The  surface  should  have  a  preliminary 
washing  with  a  mild  soap  and  water,  and,  to  lessen  the  chances  of  irrita- 
tion, Taylor  advises  the  application  of  a  lotion  of  boric  acid,  after  which 
the  ointment  is  bound  on.  From  time  to  time,  in  order  to  avoid  irritation, 
the  ointment  can  be  applied  to  the  back  instead  of  anteriorly.  The 
dressing  is  to  remain  on  twenty-four  hours,  the  motions  of  the  child 
serving  to  rub  it  in;  the  binder  is  then  removed,  and  the  washing,  etc., 
gone  through  with  again,  fresh  ointment  gently  rubbed  in,  and  the  same 
binder  applied,  and  so  the  treatment  is  continued,  a  fresh  binder  being 
substituted  every  few  days.  In  spite  of  precautions  and  care,  however, 
the  parts  often  become  irritated,  and  this  plan  must  give  way,  temporarily 
at  least,  to  inunctions  gently  rubbed  on  other  parts,  as  with  the  adult. 
Under  the  mild  lotions  and  dusting-powders,  such  as  are  employed  in 
erythema  intertrigo  and  acute  eczema,  the  irritation  soon  subsides. 

In  some  cases  of  extreme  sensitiveness  of  the  skin  the  inunction 
method  becomes  impracticable,  and  in  such  instances,  and  in  others 
where  seemingly  preferable,  treatment  by  the  mouth  can  be  tried.  The 
most  satisfactory  preparation  for  this  purpose  is  the  gray  powder,  which 
can  be  administered  as  a  powder  with  sugar  of  milk  in  dosage  of  yV  to 
i  grain  (0.006-0.065)  three  times  daily  after  nursing,  the  dose  depending 
upon  the  age  and  effect,  the  larger  doses  not  infrequently  proving  too 


ORIENTAL   SORE  845 

laxative.  Jacobi  and  others  prescribe  in  preference  minute  doses  of 
calomel,  about  ^V  of  a  grain  (0.0032)  three  or  four  times  daily.  The 
drug  is  also  sometimes  prescribed  as  corrosive  sublimate  in  solution,  \ 
grain  (0.033)  to  6  ounces  (192.)  of  water,  of  which  the  dose  is  one  or  two 
teaspoonfuls.  In  some  cases  the  laxative  effect  of  the  mercurial  is  to  be 
counteracted  by  the  administration  of  compound  chalk  powder  or  other 
mild  astringent.  Treatment  by  corrosive  sublimate  baths  (10  to  30 
grains  (0.65-2.)  to  a  bath  of  8  or  10  gallons)  is  at  times  a  serviceable 
method  much  more  frequently  employed  formerly  than  at  the  present 
day.  It  is  not,  however,  so  certain  a  plan  as  those  already  mentioned. 
The  bath  should  be  warm  and  the  patient  remain  in  for  five  to  ten 
minutes.  Potassium  iodid  is  sometimes  prescribed  in  place  of  the  mer- 
curial, but  if  deemed  advisable,  their  conjoint  administration  is  preferable ; 
the  dose  of  the  iodid  ordinarily  varying  from  J  of  a  grain  to  2  or  3  grains 
(0.017-0.2)  three  times  daily.  Older  children  can  tolerate  larger  doses. 
In  addition  to  the  specific  treatment,  cod-liver  oil  and  the  iron  prepara- 
tions are  sometimes  demanded ;  of  the  latter,  the  syrup  of  the  iodid  being 
the  most  feasible.  The  duration  of  active  medication  depends  upon  the 
continued  presence  of  symptoms  or  recurring  evidences  of  the  disease; 
the  patient  should  be  under  observation  and  more  or  less  treatment  for 
a  prolonged  period,  as  advised  in  the  acquired  disease  in  adults.  Hor- 
wjtz  advises  that  the  child  undergo  four  to  six  weeks'  treatment  every 
year  until  it  reaches  the  age  of  puberty. 

The  external  treatment  of  the  lesions  of  hereditary  syphilis  is  prac- 
tically the  same  as  in  the  adult  already  described.  The  erythematous 
or  erythematomacular  condition  sometimes  observed  about  the  genito- 
crural  region  and  the  buttocks  requires,  as  a  rule,  no  special  application, 
but  mild  dusting-powder  or  lotions  can  be  prescribed  with  advantage, 
and  especially  in  cases  which  may  be  complicated  with  a  true  erythema 
or  eczema  intertrigo.  The  blebs  of  the  bullous  syphilid,  if  distended, 
should  be  opened,  the  contents  pressed  gently  out,  and  the  parts  cleansed 
and  dressed  with  a  dusting-powder  of  boric  acid  and  zinc  oxid.  Mouth 
lesions  and  moist  papules  about  the  anus  and  genitalia  usually  require 
attention,  similar  to  that  in  adults. 

ORIENTAL  SORE1 

Synonyms.— Delhi  boil;  Delhi  sore;  Oriental  boil;  Kandahar  sore;  Pendjeh  sore; 
Natal  sore;  Aleppo  boil;  Biskra  button;  Gassa  button;  Puru;  etc.  Fr.,  Bouton  d'Alep; 
Clou  de  Biskra;  Ger.  Orientbeule;  Beule  von  Aleppo. 

Definition. — A  specific  granuloma  of  the  skin,  endemic  within 
certain  limited  areas  in  warm  countries;  characterized  primarily  by  a 

1  Valuable  literature:  Murray,  Trans.  Epidemiologicd  Soc.,  London,  1882-83,  vol.  ii, 
p.  90  (with  illustrations);  Altounyan,  Jour.  Cutan.  Dis.,  1885,  pp.  161  and  173;  Riehl, 
Archill,  1886,  p.  805;  Hirsch,  Handbook  of  Geographic  and  Historic  Pathology,  Syden- 
ham  Soc.  ed.,  1886,  vol.  iii,  pp.  668-683,  with  bibliography  almost  complete  to  1884; 
Riehl  and  Paltauf,  Archiv,  1886,  vol.  xiii,  p.  805,  etiology  and  anatomy,  with  review  of 
previous  investigations;  Leloir  and  Vidal,  Traite  descrip.  des  mal.  de  la  peau,  first  and 
second  parts,  1890,  1891;  Matas,  Morrow's  System,  vol.  iii,  (Dermatology),  p.  708; 
Auchg  and  Le  Dantec,  Archiv  Clin.  de  Bordeaux,  Oct.,  1894— abs.  Brit.  Jour.  Derm., 
1895,  p.  98  (bacteriologic,  with  review  of  other  findings);  Unna,  Histopathology  (with 


846 


NEW  GKOWTHS 


papule,  gradually  enlarging  by  peripheral  and  subjacent  infiltration, 
with  scaling  or  crusting,  and  which  usually,  sometimes  with  an  inter- 
vening furunculoid  stage,  slowly  breaks  down  and  develops  into  an 
indolent  ulcer. 

It  is  difficult  to  give  an  inclusive  definition  of  this  malady,  if  all 
the  various  cases  reported  and  described  as  such  are  true  examples 
of  it.  The  differences  can  only  be  explained  on  the  assumption  of  the 
influence  of  environment,  nutrition,  hygienic  conditions,  and  individual 
resisting  power.  Errors  in  diagnosis  are  doubtless  responsible  for  some 
of  the  discrepancies. 

Symptoms  and  Character.— There  is  a  quiescent  inoculation 
period  of  from  three  days  to  one  or  more  months.  The  lesion  appears 
as  an  itchy  red  papule.  It  gradually  increases  to  the  size  of  a  pea  or 
small  grape,  usually  flattened,  becoming  hard  and  more  vascular.  It 
tends  to  become  scaly,  more  especially  in  the  central  portion  where  it 
later  generally  shows  a  crust  formation  with  sometimes  slight  depression. 

If  the  crust  falls  off  or  is  scratched 
off,  a  shallow  erosion  or  ulcer  is  dis- 
closed. From  the  central  necrotic 
portion  there  may  be  some  serous 
oozing,  changing  to  a  seropurulent 
character.  It  is  chiefly  of  this 
that  the  crust  is  composed.  It 
may  continue  in  this  manner,  and 
after  a  long  while,  commonly  some 
months,  with  usually  an  interven- 
ing ulcer  formation,  gradually  heal 
and  disappear;  or  it  may  become 
distinctly  furunculoid,  gradually 
break  down,  discharge,  and  de- 
Fig.  2o2.-0riental  sore  (courtesy  of  Dr.  vel°P  into  an  ^cer.  While  a 
W.  B.  Adams).  rather  distinct,  sharply  cut,  indo- 

lent ulcer  is  a  common  termination, 

which  finally  heals  and  leaves  a  pronounced  scar,  the  growth  may  con- 
tinue as  a  scaly  or  crusted  nodule,  and  eventually  disappear  by  desicca- 
tion, exfoliation,  and  absorption,  with  insignificant  scar  or  atrophic 
mark.  It  is  not  unusual  for  the  "sore"  to  consist  primarily  of  two,  three, 
or  more  closely  aggregated  papules,  which,  as  they  grow,  become  solidly 
crowded  or  coalescent;  the  further  development  being  as  already  de- 

pathologic  references);  J.  H.  Wright,  Jour.  Med.  Research,  1903,  p.  472;  and  Jour. 
Cutan.  Dis.,  1904,  p.  i  (bacteriologic,  with  illustrations);  Cox,  Indian  Med.  Gaz.,  1904, 
p.  56  (clinical);  Marzinowsky  and  Bogrow,  Virchow's  Archivf.  Path.  Anat.,  1904,  vol. 
clxxviii,  p.  112  (etiology);  Mesnil,  Nicolle,  and  Remlinger,  Compt.  rend.  Soc.  de  Biol., 
1904,  Iviii,  p.  167  (bacteriologic);  James,  Scientific  Memoirs  by  Officers  of  the  Medical 
and  Sanitary  Department  of  the  Government  of  India,  Calcutta,  1905,  New  Series,  No. 
13  (chiefly  bacteriologic);  Malmejac,  Echo  med.  du  Nord,  1905,  p.  103  (treatment); 
Strong,  Philippine  Jour.  Sci.,  Manila,  1906,  p.  91  (a  good  resume  of  bacteriologic  find- 
ings with  references);  Billet,  Butt,  de  la  Soc.  de  Path.  Exot.,  Paris,  1909,  vol.  ii,  No.  2 
(patient,  a  soldier,  with  five  sores,  who  had  returned  from  Biskra) ;  Darling  and  Connor, 
Jour.  Amer.  Med.  Assoc.,  1911,  April  20,  p.  1257  (case  in  Canal  Zone — 3d  case  to  date — 
history  of  fly  bite);  and  Darling,  "Oriental  Sore,"  Jour.  Cutan.  Dis.,  1911,  p.  617  (gives 
a  good  historic  review);  Howard  Fox,  Correspondence,  ibid,  1912,  p.  206  (with 
pertinent  excerpts  from  letter  from  W.  B.  Adams,  of  Beirut,  and  four  excellent  photo 
cuts,  two  of  which  are  here  reproduced). 


ORIENTAL    SORE 


847 


scribed,  although  occasionally  in  this  coalescent  "sore"  there  is,  as  less 
frequently,  also,  in  the  single  lesion  sore,  a  tendency  to  fungoidal  granu- 
lations. On  an  average  a  fully  developed  Oriental  sore  is  an  inch  or  so 
in  diameter.  While  there  is  often  but  one,  there  may  be  several  or  more 
distinct  and  sometimes  quite  widely  separated  formations.  An  Oriental 
sore,  when  developed,  is  of  a  dull  red  color,  is  usually  of  sluggish  nature 
throughout  its  course,  unless  constantly  knocked,  irritated,  or  having 
added  an  active  pyogenic  factor,  when  it  may  become  much  more  in- 
flammatory, and  quite  tender  and  painful.  The  favorite  regions  are 
the  face,  hands  and  forearms,  and  legs,  but  no  part  is  exempt. 

The  ulcer,  as  remarked,  is  usually  rather  sharply  cut,  frequently 
oblong  and  irregular  in  shape,  with  commonly  some  elevation  and  in- 
filtration of  the  surrounding  border;  the  latter  may  or  may  not  be  un- 
dermined. It  may  discharge  but  slightly,  so  that  it  is  continually 


Fig.  203. — Oriental  sore,  a  larger, 
spreading,  patch,  with  smaller  lession 
on  forehead  (courtesy  of  Dr.  W.  B. 
Adams  and  Dr.  Howard  Fox). 


Fig.  204.-^-Oriental  sore,  a  larger 
and  older  lesion  (courtesy  of  Dr.  W.  B. 
Adams  and  Dr.  Howard  Fox). 


covered  with  an  adherent  dry  scab;  or  it  is  forever  discharging  abund- 
antly a  pale  yellow,  watery  pus,  which  adds  to  the  discomfort  of  the 
patient.  After  attaining  a  variable  size  the  ulcer  may  remain  stationary 
for  some  time  before  the  reparative  process  begins.  In  some  cases, 
however,  the  ulcer  continues  to  extend,  and  may  finally  involve  an  area 
of  several  inches  or  more,  and  persist;  such  instances  doubtless  furnishing 
some  of  the  examples  of  so-called  "endemic  ulcer,"  "tropical  ulcer,"  etc. 
As  a  rule,  however,  after  a  variable  period,  of  from  two  or  three  months  to 
a  year  or  more,  healing,  sometimes  more  or  less  interrupted,  sets  in; 
and  this  may  be  effected  under  the  crust.  In  some  cases  the  ulcer  is  still 
extending  peripherally  whilst  healing  is  progressing  centrally.  As 
intimated,  the  character  of  the  scar  varies;  it  may  be  slight  or  almost 
nil  in  some  instances,  whilst  in  others,  more  particularly  when  about 
the  face  and  joints,  be  extremely  pronounced  and  disfiguring,  and  if 
contraction  occurs  can  give  rise  to  considerable  deformity.  In  fact, 


848  NEW  GROWTHS 

the  character,  features,  course,  and  cicatrix  of  the  malady  show  wide 
variations.1  There  is  no  systemic  involvement,  but  occasionally  the 
usual  accidental  complications  of  such  ulcerative  processes  are  noted, 
such  as  lymphangitis,  erysipelas,  and  the  like. 

Ktiology  and  Pathology. — The  disease  is  limited  to  certain 
tropical  countries,  as  the  various  names  imply,  but  it  is  occasionally 
met  with  elsewhere  in  travelers  or  immigrants  from  infected  districts, 
one  such  instance  coming  under  my  own  notice.  The  malady  is  conta- 
gious, inoculable,  and  auto-inoculable ;  it  is  doubtless  due  to  inoculation 
through  the  media  of  infected  laundry  and  other  clothing  and  water, 
breaks  in  the  continuity  of  the  skin  being  predisposing.  Insects  are 
also  probable  carriers  of  the  infection.  It  is  thought  that  a  poor  condition 
of  the  general  health  makes  one  more  liable.  In  fact,  some  writers  have 
considered  the  malady  of  malarial  origin.  It  is  much  more  prevalent 
in  the  autumn  months.  No  age  is  exempt,  but  it  is  much  more  common 
in  childhood  and  adolescence  and  it  is  rare  after  forty-five.  It  is  met 
with  in  both  sexes  and  in  those  of  all  nationalities.  One  attack  seemingly 
furnishes  comparative  immunity. 

The  lesion  is  admittedly  the  result  of  infection  by  some  micro-organ- 
ism, and  a  number  of  investigators  (among  whom  Laveran,  Duclaux, 
Heydenreich,  Riehl  and  Paltauf,  Leloir,  Chantemesse,  Wright,  James, 
Strong,  and  others)  have  been  sanguine  as  to  the  import  of  their  indi- 
vidual findings — variously,  micrococci,  streptococci,  staphylococci,  and 
protozoa,  or  protozoa-like  organisms  resembling  the  Leishman-Donovan 
bodies  of  tropical  splenomegaly.  These  last  (Wright,  James,  confirmed 
by  Mesnil,  Nicolle,  and  Remlinger),  also  bear  similarity  to  the  organisms 
found  by  Cunningham,  Firth,  Marzinowsky,  and  Bogrow.2  The  evi- 
dence now  seems  pretty  conclusive  that  the  actual  cause  is  a  protozoon 
— named  Leishmania  tropica3 — gaining  access  through  the  intermediary 
of  insects. 

1  A  few  examples  of  this  variation,  especially  as  to  its  clinical  characters:  James  (loc. 
cit.)  says  "the  appearances  of  some  true  Oriental  or  Delhi  sores  are  by  no  means  as  char- 
acteristic as  one  would  expect  from  the  description  given  in  books,  and  I  found  that  civil 
surgeons  whose  experience  of  the  disease  was  considerable,  were  often  unwilling  to  ex- 
press a  definite  opinion  as  to  whether  a  given  sore  was  really  an  Oriental  sore  or  whether 
it  was  an  example  of  the  ordinary  chronic  ulcers  so  common  among  natives  of  India. 
When  I  say  that  the  first  examples  of  an  Oriental  sore  seen  by  me  in  Delhi  appeared,  at 
a  superficial  examination,  to  be  more  like  a  ringworm  than  anything  else,  and  that  I  at 
first  considered  another  Oriental  sore  to  be  an  ordinary  'shoe-bite,'  it  will  be  apparent 
that  I  have  felt  a  similar  difficulty  in  diagnosis."     Sir  Malcolm  Morris  (Derm.  Soc'y, 
Trans.,  Brit.  Jour.  Derm.,  1902,  p.  130,  case  demonstration  of  officer  in  India  medical 
service  with  Delhi  boils  on  the  arms),  stated:  "The  lesions  were  in  no  sense  of  the  word 
boils,  but  rather  resembled  the  verrucous  forms  of  lupus  of  the  extremities.     Each 
lesion  was  about  as  large  as  a  shilling,  and  showed  a  raised,  reddish,  infiltrated  swelling 
of  fairly  firm  consistence,  over  which  the  epidermis  was  thickened  and  warty.     There 
were  no  signs  of  ulceration  or  necrosis,  which  the  patient,  who  was  very  familiar  with 
the  disease,  averred  to  be  a  later  stage  of  the  process." 

2  Strong  (loc.  cit.)  believes  the  organisms  found  by  him  to  be  a  form  of  blastomyces, 
and  that  they  seem  similar  to  the  bodies  which  have  been  found  in  ulceration  of  the 
skin  occurring  in  horses  in  the  tropics  suffering  from  blastomycetic  infection,  and  that 
these  two  diseases  are  probably  identical  or  closely  related  species. 

3  Nicolle  and  Manceaux,  Annales  de  I'Institut  Pasteur,  Paris,  September  25,  1910, 
xxiv,  have  succeeded  in  cultivating  the  protozoon  which  they  believe  is  responsible  for 
Oriental  sore,  and  in  reproducing  the  lesion  in  dogs  and  monkeys  after  a  period  of  in- 
cubation ranging  from  16  to  166  days.     They  find  many  points  of  resemblance  between 


ORIENTAL   SORE  849 

Microscopic  examinations  of  the  tissue  of  Oriental  sore  show  that 
it  is  a  reaction  of  the  skin  against  some  virus  of  low  virulence  which  has 
produced  granulation  changes  in  the  corium  beneath  and  around  the  ulcer 
(Macleod).  The  deposit  of  a  tumor-like  formation  of  granulomatous 
tissue  is  the  first  and  essential  condition;  the  new  tissue  infiltrate  destroys 
and  replaces  all  the  structures  of  the  true  skin,  and  pressing  upon  the 
epidermis  causes  it  to  atrophy  and  disappear,  so  that  an  ulcer  results 
(James).  In  a  number  of  sections  examined  by  Elliot,  he  found  the 
disease  confined  to  the  epidermis  and  corium  extending  through  to  the 
subcutaneous  tissue,  with  a  distinct  line  of  separation  between  the  dis- 
eased portion  and  the  surrounding  tissue;  the  area  of  disease  seemed 
composed  almost  entirely  of  small,  round,  inflammatory  or  formative 
cells  and  epithelial  elements,  and  with  no  evidence  of  the  disease  begin- 
ning in  the  glandular  structures.  Riehl  found  giant-cells  present  quite 
frequently.  Unna  looks  upon  it  as  a  chronic  serofibrinous  inflam- 
mation of  the  whole  cutis  leading  to  central  necrosis,  softening,  and 
ulceration. 

Diagnosis. — Its  origin  in  and  limitation  to  endemic  districts,  its 
site,  its  beginning  as  an  itchy  papule,  its  growth  into  a  desquamating 
and  crusted  nodule,  usually  followed  by  ulceration,  considered  together 
with  its  slow  development  and  non-involvement  of  the  general  health, 
are  sufficiently  characteristic  for  many  of  the  cases.  One  could  readily 
imagine,  however,  how,  especially  in  its  early  beginning,  it  might  be 
mistaken  for  several  other  affections,  such  as  ecthyma,  the  primary  lesion 
or  patch  of  frambesia,  lupus,  and  other  scrofulodermata,  syphilis,  and 
the  like. 

Prognosis  and  Treatment — Recovery  always  takes  place, 
usually  after  some  months;  but  how  much  is  due  to  the  treatment 
or  to  the  natural  course  of  the  disease  is  difficult  to  say.  Cleanliness 
is  all-important,  and  this,  together  with  protection  and  possibly  mild 
soothing  applications,  is  about  all  that  many  advise.  By  some,  com- 
plete excision,  cauterization,  and  the  actual  cautery  (Murray)  are  vari- 
ously recommended  for  discrete  lesions;  the  milder  antiseptics  are  sub- 
sequently used.  Painting  the  beginning  lesions  with  iodin  tincture 
is  commended  (Hickman,  Altounyan),  and  also  mercurial  applications 
(Brocq,  Vidal,  Bard).  Gaucher  and  Bernard  obtained  rapid  results 
from  daily  spraying  (ten  minutes)  with  boiled  water,  and  the  constant 
application  of  compresses  of  the  same;  Malmejac  strongly  commends  a 
somewhat  similar  treatment:  forcible  spraying  (150  to  200  c.c.)  of  the 
sore  with  boiled  distilled  water  at  a  high  temperature  twice  daily  for 

Oriental  sore  and  kala-azar;  recovery  from  the  latter  protects  the  dog  against  infection 
from  the  virus  of  Oriental  sore  and  affords  a  partial  protection  to  the  monkey.  The 
evidence  on  hand  suggests  that  the  dog  is  the  natural  reservoir  for  the  virus  of  Orien- 
tal sore.  This  animal  thus  seems  to  be  the  agent  involved  in  the  etiology  of  the 
Leishmanioses.  Wenyon,  ("Parasitology,"  vol.  iv,  1911 — abs.  in  Brit.  Jour.  Derm., 
1912,  p.  166),  concludes  from  his  investigations  (in  Bagdad,  etc.)  that  the  incubation 
period  is  about  two  weeks  and  that  the  typical  parasite — Leishmania  tropica — can  be 
found  except  in  the  final  healing  stage;  house  flies  collected  from  open  sores  nearly 
always  show  the  parasites  in  the  gut;  and  mosquitos  fed  upon  the  sore  are  also  found 
to  take  up  the  parasite;  doubtless  flies  and  mosquitos  act  as  carriers  of  the  disease 
and  probably  transmit  it. 
54 


NEW  GROWTHS 

eight  days,  and  then  once  daily,  and  compresses  of  dry  aseptic  gauze. 
Large  doses  of  quinin  and  arsenic  are  said  (Besnier,  Rankin)  to  have  a 
favorable  influence  in  promoting  the  healing  of  the  ulcers.1 

FRAMBESIA2 

Synonyms.— Yaws;  Frambcesia  tropica;  Pian;  Bouba;  Polypapilloma  tropicum; 
Tonga;  Amboyna  button;  Parangi;  Fr.,  Pian;  Ger.,  Beerschwamm. 

Definition. — An  endemic,  highly  contagious  disease  with  or 
without  constitutional  disturbances,  characterized  primarily  by  an 
eruption  of  papules  which  develop  into  more  or  less  exuding  raspberry 
or  cauliflower-like  nodules  or  patches. 

1  Row,  Brit.  Med.  Jour.,  March,  9,  1912,  p.  540,  states  that  rapid  healing  in  three 
cases  seemed  to  result  from  vaccine  treatment — vaccine  being  made  from  cultures  from 
an  experimental  lesion  in  a  monkey. 

2  Literature:  J.  Numa  Rat,   Yaws:  Its  Nature  and  Treatment,  London,  1891  (with 
bibliography  to  1887);  review  and  resume  of  the  same  by  Malcolm  Morris,  in  Brit. 
Jour.  Derm.,  1892,  p.  63;  Beaven  Rake,  "Postmortem  Appearances  in  Cases  of  Yaws," 
ibid.,  1892,  p.  371;  Breda,  "Beitrag  zum  klinischen  und  bacteriologischen  Studium  der 
brasilianischen  Frambcesia  oder  Boubas,"  Archiv,  1895,  vol.  xxxiii,  p.  3  (2  colored  plates 
of  the  disease,  and  2  plates  with  histologic  cuts;  unsuccessful  experimental  animal 
inoculations;  literature  references);  Pierez,  "Frambcesia,"  Trans.  First  Pan- American 
Med.  Cong.,  Washington,  1895,  part  ii,  p.  1764  (an  elaborate  paper);  Daniels,  "The 
Non-Identity  of  Yaw  and  Syphilis,"  Brit.  Jour.  Derm.,  1896,  p.  426;  Powell,  "Yaws 
in  India,"  ibid.,  p.  457  (a  clear  presentation  of  the  subject  in  all  its  aspects);  Hirsch, 
Handbook  of  Geographic  and  Historic  Pathology,  Syd.  Soc.  ed.,  vol.  ii,  p.  no  (with 
bibliography);  Dyer's  paper  in  Morrow's  System,  vol.  iii.  (Dermatology),  p.  687,  gives 
a  good  account  with  bibliography;   Scheube,  Die  Krankheiten  der  warmen  Lander, 
2d  edit.,  1900;  Kynsey,  Brit.  Med.  Jour.,  1901,  ii,  p.  802  (differentiation  from  syphilis). 
Nicholls,  Gov't  Rep.  on  Yaws  in  West  Indies,  1894  (with  colored  illustrations),  condensed 
critical  report  of  this  by  Wallbridge  and  Daniels,  in  New  Sydenham  Soc'y  vol.  for 
1897;  Manson's  Tropical  Diseases,  3d  edit.,  1903;  Dalziel,  Jour.  Trap.  Med.,  1904,  p. 
288  (occurrence  and  probable  origin  in  South  China);  R.  Koch,  Archiv,  1902,  vol.  lix, 
p.  5  (with  case  illustrations);  J.  Numa  Rat,  Jour.  Trap.  Med.  1904,  p.  86  (its  introduc- 
tion in  Auguilla  in  1902),  and  Select  Colonial  Med.  Reports,  1904,  p.  177,  and  Jour.  Trap. 
Med.  1904,  p.  317  (alkaline  treatment);  Modder,  ibid.,  p.  213  (bacteriology  and  alkaline 
treatment);  Dalziel,  ibid.,  p.  288  (in  South  China);  Pernet,  ibid.,  1905,  p.  262  (De 
Rochas'  views,  and  histologic  note);   Woolley,  Amer.  Med.  1904,  vol.  viii,  p.  242; 
Graham,  Brit.  Med.  Jour.,  1905,  ii,  p.  1275;  Jeanselme,  ibid.,  p.  1276,  and  La  Pratique 
Dermatologique,  vol.  iii,  p.  868  (in  French  Indo-China);  De  Boissere,  Jour.   Trap. 
Med.,  1904,  p.  179  (tertiary  manifestations);   Henggeler,  Monatshefte,  1905,  vol.  xl,  p. 
235  (a  comprehensive  paper,  with  6  case  illustrations,  a  good  review  and  bibliography 
Wellman,  Jour.    Trop.  Med.,  1905,  p.  345   (spirochaetae  findings);  Castellani,  Brit. 
Med.  Jour.,  1905,  ii,  p.  1330  (spirochaetae  findings  and  also  oval  chromatin-containing 
bodies),  and  also  in  ibid.,  pp.  1280,  1330,  and  1438;  and  Jour.  Trop.  Med.,  1906,  p.  i 
(differentiation  from  syphilis);  Macleod,  ibid.,  ii,  p.  1266;  McCarthy,  Indian  Med. 
Gaz.,  1906,  p.  53  (in  lower  Chindivin  District,  Upper  Burma);  Gimlette,  Jour.  Trop. 
Med.,  1906,  pp.  149,  175,  and  186  (The  Pura  of  the  Malay  Peninsula);  Neisser,  Baer- 
mann,  and  Halberstaedter,  Munch,  med.  Wochenschr.,  July  10,  1906  (experimental 
inoculation  in  apes);  Breda,  Giorn.  ital.,  1006,  p.  98;  Castellani,  "Frambcesia  Tropica," 
Jour.  Cutan.  Dis.,  1908,  p.  151,  gives  an  admirable  exposition  and  review,  with  14 
excellent  illustrations;  Howard,  "Tertiary  Yaws,"  Jour.  Trop.  Med.,  July  i,  1908,  p. 
197  (observations  based  upon  nine  years'  residence  in  central  Africa,  in  the  country 
bordering  on  the  southern  half  of  Lake  Nyassa);  Ashburn  and  Craig,  "Observations 
upon  Treponema  Pertenuis  (Castellani)  of  Yaws  and  the  Experimental  Production 
of  the  Disease  in  Monkeys,"  Philippine  Jour.  ofSci.,  Oct.,  1907,  p.  441  (with  excellent 
photomicrograph  and  extensive  bibliography);  "Contribuicao  ao  Estudo  da  Bouba," 
by  O.  Silia  Aranjo,  Rio  de  Janeiro,   Rodriques   Co.,   1911;  C.  J.  White   and  E.  E. 
Tyzzer,  "A  Case  of  Frambcesia,"  Jour.  Cutan.  Dis.,  March,  1911,  p.  138  (patient, 
Porto  Rican  sailor,  lesions  with  somewhat  horny  verrucous  covering;  spirochaetae  found 
corresponding  to  Castellani's  spirochseta  pertenuis;  reproduction  of  disease  in  a  monkey; 
case,  spirochaetas,  and  histologic  cuts). 


FRAMBESIA  85 1 

Symptoms. — There  is  usually  a  prodromic  stage,  or  stage  of 
incubation,  dating  from  the  time  of  inoculation  to  that  of  the  appear- 
ance of  the  inoculation  lesion.  While  during  this  period  such  symptoms 
as  malaise,  slight  fever,  anorexia,  hyperidrosis,  vertigo,  and  rheumatic 
pains,  etc.,  with  pallor  of  the  skin,  may  be  present  and  even  quite  pro- 
nounced, especially  in  young  children,  they  are  often  wholly  wanting. 
At  this  time  or  somewhat  later,  but  as  a  rule  before  the  papular  eruption 
develops,  furfuraceous  whitish,  usually  pruriginous  patches  appear  on 
the  trunk  and  limbs;  these  may  coalesce  and  cover  large  portions  of  the 
body.  Some  of  these  desquamating  patches  may  disappear  early,  and 
leave  the  skin  lusterless  and  rough;  others  may  remain,  and  sometimes 
new  ones  appear,  throughout  the  whole  course  of  the  disease  (Castellani). 


Fig.  205. — Frambesia  (courtesy  of  Dr.  O.  Henggeler). 

It  is  upon  these  patches  that  many  writers  state  the  elements  of  the  erup- 
tion appear.  On  the  other  hand,  Henggeler  has  not  observed  these 
prodromal  changes  in  the  skin  at  all.  The  period  of  incubation  varies 
much,  from  ten  days  to  several  weeks  or  longer;1  and  is  followed  by  the 
so-called  primary  stage,  characterized  by  the  development  of  a  papule 
at  the  point  of  inoculation.  This  appears  as  a  hard  papule,  usually 
itchy  in  character,  which  gradually  enlarges  and  presents  upon  its  sum- 
mit a  depressed  yellow  spot  of  inspissated  secretion;  this  latter  tends  to 
spread  until  the  whole  papule  is  absorbed  by  the  ulceration  and  crusted 
over  (MacCarthy);  it  quite  frequently  becomes  rapidly  papillomatous. 
Instead  of  a  papule  the  beginning  lesion  may  be  a  pustule  (Henggeler). 

1  In  the  experiments  by  Neisser,  Baermann,  and  Halberstaedter  (loc.  tit.)  upon  apes 
the  period  of  incubation  varies  from  thirteen  to  ninety-six  days. 


852 


NEW  GROWTHS 


The  primary  lesion  is  generally  extragenital,  and  may  occur  on  any  part, 
probably  most  commonly  on  the  extremities  in  adults  and  on  the  hands 
and  face  in  children;  and  in  infants  who  contract  it  from  an  affected 
mother,  in  the  corners  of  the  mouth — the  breast  in  women  being  a  not 
uncommon  site.  The  inoculation  lesion,  or  beginning  lesion,  may  also 
present  and  continue  as  a  nodule  or  tubercle,  desquamating  and  disap- 
pearing by  absorption;  also  as  a  kerion-like  formation;  and  sometimes 
as  a  papillomatous  growth,  similar  to  the  typical  lesion  of  yaws,  to  which 
the  name  of  "mother  yaw"  is  sometimes  given.  It  is  quite  variable  in 
size,  from  a  fourth  to  an  inch  or  more  in  diameter.  Some  observers 
have,  however,  doubted  the  existence  of  an  inoculation  lesion,  looking 
upon  this  so-called  formation  as  simply  a  part  or  an  early  lesion  of  the 
general  eruption. 

With  care  and  treatment  this  initial  or  primary  lesion  is  commonly 
of  but  a  few  weeks'  duration;  but  if  uncared  for  may,  especially  if  it 
had  developed  into  an  ulcer,  last  for  several  months.  Following  this 
or  during  its  development,  and  sometimes  almost  synchronously  with 
its  first  appearance  the  papular  eruption  of  yaws  is  noted — the  so-called 
secondary  stage  of  the  disease.  This  consists  of  a  variable  number 
(sometimes  scanty,  but  usually  numerous)  of  papules  or  tubercles  of 
but  little  more  than  millet-seed  size,  and  commonly  appearing,  primarily 
at  least,  on  the  favorite  localities — the  face,  especially  about  the  lips,  the 
neck,  arms,  and  genitalia;  and  being,  as  a  rule,  least  abundant  on  the 
trunk.  It  may  be  limited  and  regional;  on  the  other  hand,  it  may  be 
extensive  and  general,  and  when  so,  and  especially  if  occurring  late, 
it  indicates  a  protracted  attack  (Manson).  The  advent  of  this  eruptive 
stage  is  quite  frequently  signalized  by  a  recrudescence  of  the  systemic 
symptoms,  but  which  subside,  or  measurably  so,  when  the  eruption  is 
well  out.  Pains  in  the  limbs,  sometimes  quite  severe,  may  persist  for 
some  time  (Henggeler).  The  lesions,  while  small  at  first,  soon  grow  rap- 
idly larger,  are  usually  conic  in  shape,  the  summits  becoming  yellowish 
in  color,  and  often  exhibiting  a  central  depression,  so  that  some  at  this 
time  may  suggest  a  rough  resemblance  to  beginning  variola  pustules 
(R.  Koch).  From  these  papules  the  typical  eruption  of  yaws  develops; 
for  along  with  the  development  of  this  yellowish  summit  the  lesions 
become  somewhat  broader  based,  some  of  them  much  larger,  and  crust 
over.  Many  may,  however,  disappear,  some  before  and  some  after  this 
stage  is  reached.  On  removing  the  crust,  which  may  fall  off  sponta- 
neously, the  surface  is  noted  to  be  papillomatous,  with  a  raspberry  aspect, 
and  discharging  an  offensive,  dark  yellow,  acid  fluid.  Rat  says  the 
appearance  is  much  less  like  a  raspberry  than  it  is  like  the  top  of  a  pickled 
cauliflower.  Several  or  more  of  these  lesions  may  coalesce  and  form  large 
areas  of  similar  character,  crusting  and  discharging;  and  this  tendency 
to  coalescence,  according  to  de  Rochas,  is  much  more  common  or  more 
pronounced  in  children  than  in  adults.  In  some  cases  fissuring  is  to  be 
noted  in  some  of  the  nodules  and  patches.  After  a  time  the  lesions  gradu- 
ally flatten  down,  change  to  a  yellowish  or  whitish  color,  and  eventually 
disappear,  leaving  a  spot  characterized  in  negroes  by  increased,  and  in 
the  white  by  lessened,  pigment.  The  larger  lesions  and  confluent  areas 


FRAMBESIA 


853 


sometimes  break  down  and  ulcerate,  finally  healing  and  leaving  scars. 
Some  of  the  confluent  groups  may  tend  to  clear  up  centrally,  and  a  patch 
is  then  seen  with  a  ring-like  edge  (ringworm  yaws).  In  some  of  the 
patches  a  process  of  hyperkeratosis  sets  in;  they  become  of  much  harder 
consistency,  and,  especially  those  on  the  feet,  may  be  covered  with 
numerous  hard,  verruca-like,  small  protuberances. 

The  disease  may,  after  thus  lasting  for  several  weeks  to  several  months, 
gradually  come  to  an  end,  favorable  changes  taking  place  and  recovery 
ensuing.  In  others  there  are  fresh  outcroppings  from  time  to  time  of 
the  papular  eruption,  with  not  infrequently  a  recrudescence  of  the  sys- 
temic symptoms,  and  with  the  development  of  some  or  all  of  the  new 


Fig.  206. — Frambesia  (courtesy  of  Dr.  O.  Henggeler). 

papules  into  the  characteristic  "yaws."  Occasionally  some  of  these 
latter  break  down  into  ulcers.  It  is,  therefore,  not  uncommon  to  see 
all  varieties  of  lesions  in  the  same  case:  furfuraceous  patches,  variously 
sized  papules,  variously  sized  "yaws,"  and  in  extreme  and  broken-down 
cases  sometimes  a  few  or  many  ulcers  as  well.  Distinct  glandular  en- 
largement has  been  noted  by  some  observers  and  not  noted  or  denied 
by  others.  The  mucous  surfaces  are  hardly  ever  affected,  unless  about 
the  lips,  around  the  angles  of  the  mouth,  and  in  the  nostrils,  where  the 
yaws  often  form  clusters  (Manson). 

In   chronic  cases,   especially  in  broken-down  adults,   the  "yaws," 
more  particularly  the  confluent  areas,  may  undergo  disintegration  and 


854 


GROWTHS 


destructive  ulcerations,  bearing  some  resemblance  to  the  gummatous 
ulcerations  of  syphilis;  and  some  of  these  may  persist  long  after  the 
general  and  ordinary  lesions  have  disappeared;  furnishing  in  some  in- 
stances doubtless  cases  of  so-called  "endemic  ulcers,"  and  "tropical 
ulcers." 

There  is  much  difference  of  opinion  as  to  a  tertiary  stage  of  yaws, 
with  lesions  and  symptoms  akin  or  somewhat  akin  to  those  noted  in 
tertiary  syphilis;  most  observers  deny  its  occurrence  and  claim  in  such 
instances  that  there  has  been  either  a  mistake  in  diagnosis  or  that  there 
has  been  a  coincident  or  subsequent  syphilitic  infection;  nevertheless 
a  limited  number,  among  whom  De  Boissiere  and  Montagu1  have  de- 
scribed tertiary  manifestations  consisting  of  ulcers,  bone  pains,  throat 
ulcerations,  lupoid  ulcerations  of  the  face  and  nose,  gummata,  enlarge- 
ment of  the  tibia,  synovitis,  dactylitis  and  "soki"  (small  granuloma  on 
the  sole,  occasionally  on  the  hand  (De  Boissiere)),  bearing  resemblance 
to  the  late  manifestations  of  syphilis,  and  encountered  months  or  even 
years  after  the  primary  invasion. 

The  subjective  symptoms  in  yaws  consist  of  a  variable  degree  of 
pruritus,  and  occasionally  some  spontaneous  pain  and  tenderness;  but, 
as  a  rule,  the  yaw  itself  is  not  at  all  sensitive,  and  the  tumor  may  be 
touched  with  acid  even  with  impunity  (Manson). 

Etiology  and  Pathology.—  The  disease  is  limited  to  tropical 
countries,  being  endemic  in  certain  regions;  it  is  seen  chiefly  in  the 
black  races,  and  in  both  sexes  and  at  all  ages,  but  is  most  common  in 
children.2  It  is  contagious  and  inoculable,  and  as  in  most  diseases 
of  this  class  it  is  seen  most  frequently  in  those  in  poor  health  and  living 
unhygienically.  One  attack  is,  as  a  rule,  protective.  The  point  of  in- 
oculation is  almost  always  extragenital,  and  quite  frequently  on  exposed 
parts.  It  is  conveyed  by  direct  contact  with  the  secretion  from  a  yaws 
lesion,  by  the  contact  of  clothing,  mats,  or  other  agencies  in  a  house 
infected  with  the  disease,  from  the  dust  in  a  village  infected,  and  through 
the  bites  of  flies  and  other  insects  (McCarthy).  The  malady  is  un- 
questionably due  to  a  micro-organism,  but  there  has  been  as  yet  no  uni- 
formly definite  finding.  Breda  found  a  bacillus,  Pierez,  Nicholls,  Watts, 
Modder,3  and  also  Powell  found  cocci,  and  the  last,  as  well  as  Haffkine, 
found  an  yeast,  but  further  confirmatory  observations  and  experimental 
investigations  as  to  these  have  not  been  as  yet  forthcoming.  Castellani 
has  found  a  spirochaete  present  in  the  lesions,  which  he  believes  to  be 
the  cause  of  the  disease  ;  to  this  organism  he  has  given  the  name  of  Spiro- 
chaeta  pertenuis.  While  it  closely  resembles  the  spirochaeta  of  syphilis, 
it  is  considered  by  him,  as  well  as  by  Blanchard,  Mesnil,  and  others,  as 
morphologically  different;  Ashburn  and  Craig  also  confirm  its  etiologic 
importance,  and  while  considering  it  distinct,  could  not  distinguish  it 
morphologically  from  the  Spirochaeta  pallida.  Other  observers,  among 

1  Montagu,  "Tertiary  Yaws,"  Jour.  Trap.  Med.,  June,  1910,  p.  161. 

2  McCarthy  states  that  in  a  series  of  cases  113  were  between  one  and  five,  106 
between  five  and  ten,  54  between  ten  and  fifteen,  21  between  fifteen  and  twenty,  43 
between  twenty  and  thirty,  35  between  thirty  and  forty,  and  59  over  forty  years. 

3  Modder  (loc.  cit.)  grew  and  cultivated  a  micrococcus  in  acid  media;  growth  ceased 
in  alkaline  media. 


FRAMBESIA 


855 


whom  is  Macleod,  have  either  failed  to  discover  any  microbic  factor,  or 
have  considered  those  seen  as  the  usual  accidental  contaminations  to  be 
found  in  such  formations.1 

There  seems  no  question,  from  an  impartial  study  of  the  disease 
and  its  literature,  that  it  is  one  sui  generis,  and  this  view  is  held  by  the 
various  prominent  writers  cited  in  the  text  and  in  the  literature  refer- 
ences given.  There  still  remain,  however,  a  few  observers,  among  whom 
the  most  prominent  are  Hutchinson  and  Scheube,  who  believe  it  to  be 
syphilis  modified  by  unknown  conditions.  Castellani  does  not  consider 
that  the  finding  of  spirochaetae  has  any  such  import.  The  experiments 
by  Neisser,  Baermann,  and  Halberstadter  in  apes  prove,  moreover,  that 
syphilis  does  not  protect  from  yaws,  nor  yaws  from  syphilis;  and  this  is 
fully  in  accord  with  the  clinically  observed  facts. 

The  anatomy  of  the  yaws  lesion  has  been  studied  by  Charlouis, 
Pontoppidan,  Rat,  Breda,  Jeanselme,  Macleod,  Fernet,  and  others. 
The  findings  indicate,  as  suggested  by  the  clinical  picture,  that  yaws 
belongs  to  the  infective  granulomata,  and  are  very  similar,  in  the  main, 
to  those  of  lupus  vulgaris,  except  that  there  are  no  giant-cells  (Breda). 
There  is  (Macleod)  marked  cellular  infiltration  of  the  corium,  involving 
all  its  parts  except  probably  hair-follicles,  sebaceous  glands,  and  coil- 
glands;  and  marked  proliferation  and  downgrowth  of  the  interpapillary 
processes  so  great  in  the  older  lesions  as  to  resemble  condyloma  acumina- 
tum.  Some  observers  believe  (Rat,  Fernet),  that  the  peculiar  frambe- 
sial  character  of  the  lesion  is  probably  merely  the  result  of  secondary 
microbial  infection  from  without. 

Diagnosis. — The  disease  is  to  be  distinguished  chiefly  from  syph- 
ilis, with  which  it  is  most  likely  to  be  confounded — by  the  absence  of  in- 
duration of  the  inoculative  lesion,  of  distinct  or  pronounced  glandular  en- 
largement (not  always  reliable) ,  and  of  the  usual  associated  lesions  of  the 
mucous  membrane  of  that  disease.  Daniels  states  that  there  is  no  resem- 
blance to  primary  or  secondary  syphilis  and  that  it  shows  none  of  the  asso- 
ciated lesions  of  that  disease.  It  would  certainly  seem  that  the  uniformly 
prevailing  peculiar  frambesial  or  fungoidal  character  of  the  eruption, 
developed  out  of  pre-existing  papules,  nodular  lesions  or  patches,  with 
an  acid  secretion,  and  covered  with  a  crust  is  quite  different  from  any 
eruption  of  syphilis;  in  the  latter  disease  a  frambesiform  character  may 
be  an  accidental  condition  in  some  lesions,  but  never  a  distinct  charac- 
teristic of  the  eruption  as  a  whole.  To  the  trained  eye,  the  histologic 
differences  would  be  of  value  in  the  differentiation.2  The  Wassermann 

1  Robertson  ("Frambcesia  Tropica"),  Trans,  of  Eighth  Session  Australasian  Med. 
Cong.,  1908,  made  examination  of  films  prepared  from  the  pus  on  the  papules  of  30 
cases  of  yaws,  and  got  the  following  results:  Staphylococcus  albus  and  aureus,  and 
streptococci  in  large  numbers,  and  bacilli  with  square  ends  containing  spores,  and  large 
cocci  in  pairs,  in  all  the  films;  and  the  Spirochaeta  pertenuis  of  Castellani  in  12  of  the 
30  cases  examined.     Divisional  forms  of  the  Spirochaeta  pertenuis  in  16  cases. 

2  Macleod  (Brit.  Med.  Jour.,  1901,  Sept.  21,  and  Practical  Handbood  of  the  Pathology 
of  the  Skin,  p.  200)  gives  the  following  summary  of  the  histologic  points  which  differ- 
entiate it  from  the  other  infective  granulomata:  It  is  distinguished  from  (i)  actino- 
mycosis  and  rhinoscleroma  by  the  absence  of  their  specific  micro-organisms.     (2)  From 
the  lepromata  by  the  absence  of  Hansen's  bacillus.     (3)  From  mycosis  fungoides  by  the 
absence  of  "fragmentation"  of  the  infiltrating  cells,  and  of  degenerative  changes  with 
the  formation  of  products  of  degeneration  in  the  collagen  and  elastin;  by  the  presence 


856  NEW  GROWTHS 

test  so  frequently  employed  as  a  differential  factor  in  suspected  syphilis 
is  of  no  differential  value  here  inasmuch  as  frambcesia  cases  usually 
also  give  a  positive  reaction. 

Prognosis  and  Treatment. — In  mild  and  limited  cases  in  sub- 
jects in  good  general  health,  the  disease  is  at  an  end  in  six  to  eight  weeks; 
but  in  average  cases  the  duration  varies  in  children  from  three  to  six 
months  and  in  adults  six  to  twelve  months,  and  occasionally,  with  re- 
lapses, it  may  continue  much  longer.  Europeans  do  not,  according  to 
Graham,  recover  as  quickly  as  natives.  In  those  debilitated  by  ill- 
health  and  dissipation,  especially  if  cleanliness  and  other  hygienic  con- 
ditions are  neglected,  septic  poisoning  may  ensue  and  death  result. 
The  ulcers  occurring  in  some  cases  may  exceptionally  be  persistent 
and  rebellious  to  ordinary  treatment. 

There  seems  to  be  considerable  unanimity  as  regards  the  curative 
value  of  mercury  and  the  iodids,  along  with  other  remedies  which  may  be 
indicated  by  the  patient's  general  health.  Alkaline  treatment  has  also 
had  a  few  advocates,  Modder  especially  commending  it.  Strong,1 
Cockin,2  Alston3  and  Rost4  had  rapidly  successful  results  from  salvarsan. 
Of  importance,  as  may  be  inferred,  are  improved  hygienic  conditions, 
and  good  nutritious  food.  The  external  treatment  consists  in  cleanliness 
and  the  free  use  of  antiseptic  lotions,  such  as  of  boric  acid  and  corrosive 
sublimate,  and  mercurial  ointments.  Stimulation  or  mild  cauterization 
of  the  more  obstinate  lesions  or  patches  is  sometimes  advisable.  Per- 
sistent ulcers,  when  not  responding  to  the  usual  remedies,  may  require 
erasion  with  the  curet. 

Thorough  disinfection  of  clothing,  room,  and  house  is  of  essential 
importance  in  limiting  the  spread  of  the  disease. 

of  the  epidermal  changes  peculiar  to  yaws.  (4)  From  tuberculosis,  apart  from  the 
tubercle  bacillus,  by  the  absence  of  the  characteristic  architecture  with  its  giant-cells, 
daughter  plasma-cells,  more  marked  disintegration  of  the  fibrous  stroma,  and  complete 
disappearance  of  the  blood-vessels.  (5)  From  syphilis  by  the  following  details,  which, 
considered  collectively,  strongly  suggest  that  yaws  and  syphilis  are  different  histologic 
entities:  (a)  Cellular  infiltration:  plasma-cells  not  so  definitely  arranged  in  rows  or 
clustered  round  the  blood-vessels  as  in  syphilis;  no  large  multinuclear  cells  (chorio- 
plaques),  or  true  giant-cells,  or  intracellular  hya'ine  degeneration  noted  in  yaws,  (b) 
Fibrous  stroma:  rarefaction  of  the  collagen  more  marked  than  in  syphilis,  but  no  organ- 
ization or  colloid  degeneration  found,  such  as  occurs  in  syphilitic  gummata.  (c) 
Blood-vessels:  no  distinct  proliferative  changes  in  the  vessel-walls  or  endothelium,  as 
frequently  occur  in  syphilis,  (d)  Epidermis:  marked  proliferation  and  downgrowth 
of  the  epithelium,  with  great  thickening  of  the  horny  layer  (due  to  hyperkeratosis  or 
parakeratosis)  are  characteristic  features  of  yaws,  while  they  are  unusual  in  syphilis. 

Strong,  Miinchen  Med.  Wockenschr.,  1911,  Ixviii,  No.  8,  p.  398,  and  Philippine 
Jour.  Sci.,  vol.  v,  No.  4. 

2  Cockin,  Jour.  Trop.  Med.,  Sept.  16,  1912,  p.  277  (used  it  successfully  in  22  cases 
at  the  Yaws  Hospital  St.  George's,  Grenada,  W.  I.). 

3  Alston,  Brit.  Med.  Jour.,  Feb.  18,  and  March  18,  1911,  pp.  360  and  618;  abs.  in 
Jour.  Cutan.  Dis.,  1911,  p.  515  (had  good  results  from  salvarsan  and  also  favorable 
influence  with  the  serum  from  the  salvarsan  treated  cases). 

4  Rost,  Munich,  Med.  Wochenschr.,  April,  1912,  p.  924  (has  had,  in  the  West 
Indies,  almost  uniform  success  with  intramuscular  injection  of  oily  emulsion  of  salvar- 
san— in  most  instances  a  cure  resulting  from  one  dose). 


GANGOSA 

GANGOSA1 

Synonyms. — Rhinopharyngitis  Mutilans. 


857 


This  peculiar  and  rare  malady  known  as  gangosa  (Spanish  word, 
meaning  muffled  voice)  has  recently  been  studied  by  Leys,  Rat,  Stitt, 
Mink  and  McLean,  Fordyce  and  Arnold,  Branch,  Musgrave  and  Mar- 
shall, Geiger,  and  others.  It  is  an  acute  or  chronic  destructive  ulcera- 
tive  process,  involving,  primarily,  the  soft  and  hard  palate  and  neigh- 
boring pharyngeal  and  laryngeal  parts;  and,  later,  the  nasal  cavity,  nose, 
and  contiguous  cutaneous  and  other  tissues,  sometimes  to  the  extent 
of  from  a  portion  to  almost  the  whole  face.  According  to  Leys  and  Mink 
and  McLean,  in  the  very  beginning,  if  the  case  is  seen  early  enough,  a 
superficial  ulcer  is  found  on  the  back  of  the  pharynx,  on  a  posterior  faucial 
pillar,  or  on  the  free  edge  of  the  palate,  covered  with  a  thin,  dirty,  brown- 
ish-gray pellicle  of  slough;  this  Leys  believes  to  be  probably  the  initial 
lesion  of  the  malady.  In  extreme  instances  the  destruction  is  great, 
both  of  soft  and  bony  structures,  and  the  resulting  ulcerative  and  cica- 
tricial  disfigurement  striking  and  repulsive.  In  its  rough  clinical  aspects 
it  has  some  features  suggestive  of  syphilis,  tuberculosis,  framboesia, 
rhinoscleroma,  and  an  unchecked  Vincent's  angina;  and  less  markedly 
of  actinomycosis  and  blastomycosis.  As  a  rule,  there  are  no  constitu- 
tional symptoms,  except  at  its  very  onset,  when,  with  symptoms  pointing 
to  a  tonsillitis,  pharyngitis,  or  laryngitis  of  mild  degree,  there  may  be  a 
slight  rise  in  temperature  (Mink  and  McLean).2 

Its  course  is  slowly  or  rapidly  progressive,  the  active  stage  lasting 
from  one  to  several  years  or  longer ;  a  stage  of  relative  or  complete  quies- 
cence then  ensues,  which  may  persist,  or  which  may  at  any  time  give 
way  to  another  period  of  variable  activity.  The  malady  has  its  greatest 
prevalence  in  Guam,  affecting  2  per  cent.  (Mink  and  McLean)  or  more 
(Arnold)  of  the  native  population;  but  cases  or  suggestive  cases  have 
also  been  reported  from  the  Ladrone  and  Caroline  Islands,  Fiji,  British 
Guiana,  Jamaica,  Italy,  Dominica,  Nevis,  Philippine  Islands,  and  Pan- 
ama. It  is  most  common  in  the  pure  blood  natives;  infrequent  in  those 
of  mixed  white  and  native  blood,  and  Stitt's  case3  is  the  only  one  that 
has  been  observed  in  the  white  race.  Fordyce's  case  was  in  a  negro 

1  Recent  literature:  Breda,  "Framboesia  brasiliana  o  Bouba,"  Giorn.  ital,  1900,  p. 
489;  Leys,  "Report  on  the  U.  S.  Naval  Station,  Island  of  Guam,  Report  of  Surgeon- 
General  U.  S.  Navy,  1905,  p.  91,  and  Rhinopharyngitis  mutilans,"  Jour.  Trap.  Med., 
Feb.  15,  1906,  p.  47;  Fordyce  and  Arnold,  "A  Case  of  Tropical  Ulceration,"  Jour. 
Culan.  Dis.,  1906,  p.  i  (with  case  and  histologic  plates  and  references);  Rat,  "Rhino- 
pharyngeal  Lesions  in  Yaws,"  Jour.  Trap.  Med.,  May  i,  1906,  p.  135  (correspondence); 
Mink  and  McLean,  "Gangosa,"  Jour.  Amer.  Med.  Assoc.,  1906,  vol.  xlvii,  p.  1166 
(illustrations  of  cases  and  tabulation  of  cases);  and,  "Gangosa  with  Additional  Notes," 
Jour.  Cutan.  Dis.,  1907,  p.  503  (review  and  illustrations  of  cases  and  references); 
Branch,  "Rhinopharyngitis  Mutilans,"  Jour.    Trop.  Med.,  May   15,   1906,  p.   156; 
Musgrave  and  Marshall,  "Gangosa  in  the  Philippine  Islands,"  Philippine  Jour,  of 
Science,  2,  1907,  p.  387;  Stitt,  "A  Case  of  Gangosa  in  a  White  Man,"  U.  S.  Naval 
Med.  Bull.,  July,  1907,  p.  96;  Geiger,  "A  Preliminary  Report  on  Gangosa  and  Allied 
Diseases  in  Guam,"  U.  S.  Naval  Med.  Bull.,  Jan.,  1908,  p.  i. 

2  Mink  and  McLean  refer  to  a  fulminating  type  of  the  disease,  exceptionally  seen  in 
young  children,  with  symptoms  suggestive  of  malignant  diphtheria,  and  terminating 
fatally  within  a  few  days. 

3  This  was  a  U.  S.  Marine,  who  had  been  in  Guam  for  several  years,  an  intimate 
associate  with  families  in  which  were  gangosa  cases. 


858 


NEW  GROWTHS 


from  Panama.  It  is  exceptional  in  the  very  young  or  very  old;  in  80 
cases,  38  appeared  during  the  second  decade,  23  in  the  third,  and  13  in 
the  fourth  (Mink  and  McLean).  The  disease  is  considered  to  be  con- 
tagious, but  as  yet  there  is  no  unanimity  as  to  the  organism  to  which  it 
is  due.1  There  seems  good  reason  for  the  generally  accepted  belief  that 
it  is  in  no  way  related  to  syphilis  or  to  any  other  of  the  diseases  above 
named,  to  which  it  may  bear  resemblance;  but  that  it  is  a  distinct  entity.2 
The  pathologic  histology  has  been  studied  by  Fordyce,  Musgrave  and 
Marshall,  and  Geiger,  with  some  differences  as  to  their  findings,  although 
indicating,  on  the  whole,  that  the  process  is  of  a  granulomatous  nature; 


Fig.  207. — Gangosa  (courtesy  of  Dr.  J.  A.    Fig.  208. — Gangosa,  extreme  case  (courtesy 
Fordyce).  of  Drs.  O.  J.  Mink  and  N.  T.  McLean). 

the  histologic  picture,  according  to  Fordyce,  showing  most  resemblance 
to  that  of  tuberculosis.3 

Prognosis  and  Treatment.— The  disease  never  kills  per  se 
(Mink  and  McLean),  but  unless  halted  or  kept  in  check  by  treatment 
it  may  continue  its  ravages  indefinitely.  Segregation,  hygienic  condi- 
tions, nutritious  food,  tonics,  and  antiseptic  applications  are  the  control 
measures  usually  resorted  to;  and  of  the  antiseptic  and  deodorant  appli- 

1  Geiger  describes  and  pictures  a  bacillus  (which  he  names  Bacillus  gangosse)  found 
in  all  his  active  cases  scarcely,  if  at  all,  distinguishable  from  the  Bacillus  diphtheriae. 

2  Rat  (loc.  cit.)  states  that  he  was  (Treatise  on  Yaws,  1901)  of  the  opinion  that  these 
rhinopharyngeal  symptoms  were  later  manifestations  of  yaws,  but  adds  that  in  the 
cases  he  saw  the  bone  structure  was  not  attacked;  Branch  (loc.  cit.)  believes  the  con- 
dition syphilitic,  but  offers  no  proof  to  sustain  this;  on  the  contrary,  the  observations  of 
other  writers  and  the  available  clinical  and  other  facts  and  therapeutic  tests  seem  con- 
clusively against  such  an  assumption. 

3  Fordyce's  investigations  (loc.  cit.)  as  to  its  possible  tuberculous  nature,  including 
experimental  inoculations  in  guinea-pigs,  were  all  negative.     In  a  case,  thoroughly  in- 
vestigated by  Musgrave  and  Marshall  (loc.  cit.),  dying  of  bronchopneumonia,  the  local 
histologic  conditions  were  negative;  they  found,  however,  tuberculous  nodules  in  the 
cervical  lymphatic  gland,  in  the  lungs,  spleen,  and  pancreas. 


VERRUCA   PERUANA  859 

cations,  potassium  permanganate,  in  i  per  cent,  solution,  seems  to  be  the 
favorite.  Should  a  case  come  under  observation  at  its  very  beginning, 
then  any  coated  plaque  or  ulcer  in  the  throat  or  contiguous  parts  should 
be  actively  cauterized  (Leys).  Mink  and  McLean  commend  the  tincture 
of  iodin  as  an  efficient  destructive  application  for  the  infected  areas. 
It  is  not  impossible  that  benefit  might  accrue  from  the  x-ray  and  other 
forms  of  light  treatment. 

VERRUCA  PERUANA 

Synonyms. — Peruvian  warts;  Carrion's  disease;  Oroya  fever;  Fr.,  La  Verruga; 
Maladie  de  Carrion. 

Definition. — A  specific,  inoculable  affection,  endemic  in  some 
valleys  of  the  Western  Andes,  in  Peru,  and  characterized  by  a  prodromal 
febrile  period  and  subsequent  outbreak  of  peculiar,  pin-head-  to  pea- 
sized  or  larger,  reddish,  rounded,  granulomatous,  wart-like  elevations.1 

Symptoms. — The  prodromic  period,  which  may  persist  for  weeks 
or  several  months  before  the  cutaneous  outbreak,  is  characterized  by 
irregular  fever  of  malarial  or  typhoid  type,  with  rheumatic  joint  and 
muscular  symptoms  and  more  or  less  profound  anemia.  Upon  the 
advent  of  the  eruptive  phenomena  these  symptoms  abate  or  vanish, 
or  remissions  may  be  noted.  The  eruption  usually  first  show  itself  on 
the  face  and  limbs  and  begins  as  small  reddish  spots  or  incompletely 
formed  vesicles,  which  soon  become  pin-head-  to  small  pea-sized  or  larger, 
conic,  rounded,  soft,  or  elastic  elevations,  which  may  be  sessile  or  pedun- 
culated.  They  are  somewhat  variable  as  to  size,  in  moderate  numbers 
or  abundant,  and  may  be  somewhat  painful  or  tender  to  the  touch. 
They  are  often  crowded  together  in  small  bunches.  They  are  bright 
red  in  color,  later  becoming  dark  red.  The  thinned  epidermal  covering 
often  cracks,  and  in  some  instances  considerable  hemorrhage  may  ensue, 
and  sometimes  to  a  dangerous  degree,  the  usual  anemic  condition  of 
the  patient  becoming  thereby  more  pronounced.  The  lesions  may 
be  small  and  remain  small,  and  gradually  dry  up  and  disappear.  When 
crowded  together,  they  seem  almost  confluent,  irritated,  and  abraded, 
crusting  over,  and  discharging  from  time  to  time  some  sanious  pus.  While, 
as  a  rule,  the  lesions  are  on  the  skin,  they  may  be  on  the  mucous  mem- 
branes, and  even  on  the  serous  membranes,  or  there  may  be  some  sub- 
cutaneous lesions,  especially  about  the  joints.  These  latter  lesions  feel 
at  first  like  small,  movable  bodies,  and  gradually  disappear,  or  may  in- 

1  An  admirable  and  exhaustive  paper  by  Matas  on  this  disease  to  be  found  in  Mor- 
row's System,  vol.  iii  (Dermatology),  p.  694;  also  in  Sydenham  Soc.  edit,  of  Hirsch's 
Handbook  of  Geographic  and  Historic  Pathology,  vol.  ii,  p.  no;  Escomel,  Annales, 
1902,  p.  961;  Elder,  Jour.  Trap.  Med.,  1906,  p.  213;  Jadassohn  and  Seiffert,  Zeitschr. 
f.  Hyg.  und  Infectionskrankheiten,  1910,  Ixvi,  p.  249  (case  report;  patient  Swiss,  moun- 
tain guide — occurred  after  a  visit  to  Peru;  experimental  transmission  to  apes;  colored 
illustrations  of  disease  in  the  patient,  and  in  an  ape);  Darling,  Jour.  Amer.  Med. 
Assoc.,  Dec.,  23,  1911,  p.  2071  (more  especially  as  regards  suspected  organisms — with 
references  to  findings  of  Barton,  Galli-Valerio,  Basset-Smith,  Mayer,  Laveran  and 
Carini,  etc.);  Giltner,  ibid.,  Dec.  23,  1911,  p.  2074  (with  review);  Barton,  "De- 
scription de  elementos  endo  globulares  hallados  de  fiebre  verrucosa,"  Cron.  Med., 
1909,  xxvi,  7  (cited  by  Darling). 


860  MEW  GROWTHS 

crease  in  size,  becoming  as  large  as  a  nut  or  exceptionally  as  large  as  a 
small  orange,  and  break  down.  Crowded  lesions,  either  of  the  surface  or 
the  subcutaneous  nodules,  may  undergo  disintegration  and  result  in  the 
formation  of  superficial  fungoid  ulcers.  In  some  cases,  as  in  a  case 
observed  by  me  (a  good  replicate,  but  less  extensive,  of  the  case  shown 
in  Sydenham's  atlas  under  the  name  of  frambesia),  the  lesions  are  for 
the  most  part  small  but  numerous.  In  this  case,  as  in  others,  such  lesions 
shrivel  into  black  spots  or  specks  on  a  level  with  the  surface,  which 
exfoliate  or  drop  off,  leaving  no  trace.  There  is  a  tendency  for  the  erup- 
tion in  some  cases  to  come  out  in  successive  crops. 

Etiology  and  Pathology.— The  disease  is  peculiar  to  certain 
valley  districts  of  the  Western  Andes  in  Peru,  the  rare  cases  seen  else- 


Fig.  209. — Verruga  peruana  (case  referred  to  in  the  text). 

where,  as  the  one  seen  by  me  in  the  Philadelphia  Hospital  referred  to 
above,  having  come  from  that  country.  It  is  inoculable,  and  the  essen- 
tial cause  is  considered  (Yzquierdo)1  to  be  a  bacillus  somewhat  larger 
than  the  tubercle  bacillus.  Barton  and  Darling  and  others  have  found 
certain  bacillus-like  elements  in  the  erythrocytes,  Barton  believing  them 
to  be  protozoa,  and  the  specific  agents  of  the  disease;  they  appear  in 

1  Yzquierdo,  Archiv  fur  path.  Anat.,  etc.,  Berlin,  1885,  vol.  xciv,  p.  411.  Accord- 
ing to  Giltner  (loc.  cit.)  natives  of  the  infected  districts  are  immune,  and  no  authentic 
case  of  infection  by  personal  contact  has  been  known  to  occur  outside  of  infected  dis- 
tricts. Jadassohn  (loc.  cit.),  however,  produced  the  disease  experimentally  in  an  ape — 
the  inoculation  material  being  obtained  from  a  Swiss  guide  who  had  returned  from  a 
visit  to  Peru. 


VERRUCA   PERUANA 


86 1 


the  earlier  febrile  style,  at  first  as  slender  rod-like  forms  with  rounded 
free  ends  and  disappear  about  the  time  the  eruption  comes  out.  De- 
bility from  any  cause  is  a  predisposing  factor.  The  connective-tissue 
growths  originating  in  the  upper  or  lower  part  of  the  derma  are  vascular, 
and  some  are  cavernous. 

A  few  observers  (Manson,  Scheube)  consider  the  malady  as  yaws 
modified  by  environmental  conditions,  but  this  view  is  not  shared  by 
Hirsch,  Plehn,  Jeanselme,  and  others.  Certainly  both  the  objective 
and  constitutional  characters,  especially  the  latter,  speak  for  its  individu- 
ality. 


Fig.  210. — Verruga  peruana  (case  referred  to  in  the  text). 

The  diagnosis  in  the  early  stages  of  the  disease  is  difficult:  it 
may  be  made  by  exclusion,  the  fact  being  known  that  the  patient  has 
resided  in  the  affected  district.  As  soon  as  the  eruption  comes  out 
the  difficulty  is  solved,  as  it  is  peculiar  and  characteristic. 

Prognosis  and  Treatment.— The  disease  is  always  to  be  con- 
sidered grave;  under  favorable  conditions  the  death-rate  is  about  one 
in  six  to  eight;  it  is  much  higher  when  the  disease  is  epidemic  (Crocker). 
The  slow,  sluggish  cases,  with  scarcely  any  fever  after  the  eruption 
appears,  are  the  most  favorable.  My  case  was  under  observation  about 
four  weeks,  and  was  gradually  improving  when  he  left  the  hospital. 
The  •  disease  may  last  for  weeks  or  months.  Death  may  result  before 
the  cutaneous  eruption  appears.  Tonics,  especially  iron  and  quinin, 
and  stimulants,  if  necessary,  are  to  be  prescribed.  It  seems  to  be  agreed 


862  NEW  GROWTHS 

that  the  eruptive  tendency  should  be  encouraged.     Removing  patient 
from  the  affected  region  to  the  seashore  is  stated  to  be  of  great  curative 

value. 

TROPICAL  ULCERS 

This  term  seems  to  be  both  a  comprehensive  and  uncertain  one 
in  the  tropics,  being  largely,  if  not  wholly,  employed  to  designate  the 
occasional  accidental  terminal  ulcerative  condition  of  several  diseases; 
such  ulcers  have  been  referred  to  in  the  course  of  the  text  in  connection 
with  oriental  sore,  frambesia,  tuberculosis,  syphilis,  etc.  It  doubtless 
very  often  means  the  addition  of  a  pyogenic  or  other  factor  to  one  or 
other  of  the  diseases  named,  and  which  to  a  variable  extent  changes 
the  ulcerative  character  of  the  already  existing  disease.  Manson,1 
Crocker,2  and  others  think  there  is  a  suggestive  resemblance  in  tropical 
sloughing  to  hospital  gangrene,  except  that  in  the  former  there  is  a  more 
marked  tendency  to  self-limitation;  and  evidently  believe  that  in  many 
examples  of  so-called  tropical  ulcer  the  sores  of  the  several  diseases 
named  may  have  become  infected  with  the  virus  of  sloughing  phagedena. 
Cabois3  is  also  convinced  that  there  is  a  destructive  Ulcus  phagedasni- 
cum,  due  to  the  Bacillus  phagedaenicus.  It  is  probably,  however,  only 
one  of  many  factors;  the  one  possibly  that  gives  rise  to  the  more  virulent 
cases. 

The  view  that  there  is  no  distinctive  idiopathic  tropical  ulcer  other 
than  explainable  upon  the  basis  already  suggested  is,  however,  the  pre- 
vailing one.  Stitt4  found  a  "number  of  cases  of  chronic  ulceration  in 
the  natives  (Philippines,  Guam),  especially  of  the  lower  extremities, 
but  clinically  they  did  not  differ  from  ulcerations  which  might  be  ex- 
pected from  badly  infected  wounds  or  from  the  infective  granulomata; 
in  none  could  one  eliminate  the  possible  cause  of  tuberculosis  or  infected 
yaws  when  those  due  to  leprosy  were  set  aside."5 

Bulkley,6  from  his  observations  in  the  far  East,  concludes  as  to 

1  Manson,  "Tropical  Diseases." 

2  Crocker,  "Tropical  Diseases  of  the  Skin,"  Jour.  Cutan.  Dis.,  1908,  p.  44. 

3  Cabois,  Jour.  Mai.  Cutan.,  Sept.,  1008,  H.  9  ("Phagedenic  Ulcer  of  the  Tropics"). 
*  Stitt,  "The  Clinical  Groupings  of  Tropical  Ulcers  of  the  Philippines,  with  Some 

Negative  Notes  as  to  Etiology  and  Treatment,"  Jour.  Cutan.  Dis.,  1908,  p.  103. 

5  Stitt  states,  however,  that  after  much  sifting  he  was  able  to  cull  out  two  types 
which  appeared  to  be  more  or  less  distinct  tropical  ulcers.     In  one  there  was  a  history 
of  a  red  spot  or  lump,  usually  on  the  outer  surface  of  the  lower  extremities;  after  en- 
larging several  weeks,  the  circumscribed,  reddened,  glazed  area  of  skin,  giving  the  sen- 
sation of  solid  edema  on  palpation,  begins  to  exude  serum  which  quickly  dries  and  crusts; 
under  this  ulceration  now  proceeds  more  or  less  rapidly,  the  resulting  ulcers  being  shal- 
low, with  irregular,  somewhat  undermined  edges;  later  more  or  less  punched  out,  with 
considerable  induration;  they  were  not  painful,  and  after  variable  progress  for  a  few 
months  to  a  year  began  to  heal  under  the  crusts,  and  terminated  in  a  pale,  somewhat 
puckered  cicatrix,  with  pigmented  margins.     The  other  type  begins,  usually,  in  those 
greatly  dibilitated,  as  a  rather  dry,  angry-looking  spot  of  erythema,  becoming  sur- 
rounded in  a  few  hours  with  a  circle  of  vesicles  beyond  which  is  an  encircling  inflamma- 
tory areola,  and  marked  subjective  pain  with  tenderness;  within  a  few  hours  to  a  few 
days  the  area  within  the  ring  of  vesicles  is  converted  into  a  dark  gray  to  black  pulta- 
ceous  diphtheroid   membrane,   which   when  detached   shows  underlying  projecting 
granulations  covered  with  greenish-yellow  pus;  if  stripped  off,  this  membrane  re-forms 
very  rapidly;  the  resulting  ulcers  may  extend  with  great  rapidity,  and  show,  as  a  rule, 
no  disposition  to  heal. 

6  Bulkley,  "Notes  on  Certain  Diseases  of  the  Skin  Observed  in  the  Far  East," 
Jour.  Cutan.  Dis.,  Jan.,  1910,  p.  33. 


TROPICAL    ULCERS  863 

"tropical  ulcers,"  "nowhere  did  I  find  ulcerative  lesions  which  could 
not  be  more  accurately  defined  and  classified.  Occasionally  on  the 
lower  legs  were  ulcerations  due  to  traumatism  and  subsequent  pus  in- 
fection, but  I  saw  nothing  peculiar  or  distinctive."  Shattuck1  found 
(in  Philippines)  that  about  94  per  cent,  could  be  ascribed  to  syphilis; 
and  states  "owing  to  neglect  the  lesions  are  unusual  in  degree,  if  not  in 
kind,  and  they  become  very  destructive;  a  few  were  thought  to  be,  how- 
ever, due  to  infections  sui  generis" 

Ulcerating  granuloma  of  the  pudenda2  (also  described  under  the 
various  names  of  granuloma  inguinale  tropicum,  venereal  granuloma, 
serpiginous  ulceration  of  the  genitals,  groin  ulceration,  etc.)  was  first 
clearly  described  by  Conyers  and  Daniels,  and  later  by  Galloway, 
Macleod,  Crocker,  Manson,  Sequeira,  and  others;  and  recently  in  our 
own  country  by  Grindon.  It  is  a  slowly  progressive,  destructive,  serpig- 
inous ulcerative  disease  of  the  genito-anal  and  genitocrural  regions,  and 
is  met  with  in  the  dark-skinned  races  (few  exceptions) ;  and  has  been  found 
rather  widely  distributed  in  the  tropics,  and  is  occasionally  encountered 
elsewhere.  Its  earliest  symptoms  consist  usually  of  distinct  or  ill- 
defined  papular  and  nodular  infiltration,  nodule  or  pustule,  which  breaks 
down.  The  disease  advances,  according  to  Manson,  in  two  ways:  by 
continuous  eccentric  peripheral  extension  and  by  auto-infection  of  an 
opposing  surface.  It  may  involve  but  a  part  or  almost  all  of  the  region 
named.  In  addition  to  the  ulcerative  feature  there  may  be  papilloma- 
tous  development.  Scar-tissue  formation  of  low  vitality  follows  in  its 
course.  While  generally  considered  as  a  disease  entity  it  seems  not 
unlikely,  in  some  instances  at  least,  that  it  is  another  example  of  tropical 
ulceration,  the  ulcerative  process  being  grafted  upon  another  affection 

1  Shattuck,  "  Notes  on  Chronic  Ulcers  Occurring  in  the  Philippines,"  Philippine 
Jour,  of  Science,"  1907,  vol.  ii,  No.  6. 

2  Literature  of  ulcerating  granuloma  of  the  pudenda:   Conyers  and  Daniels,  "The 
Lupoid  Form  of  the  So-called  'Groin  Ulceration'  of  this  Colony"  (British  Guiana), 
British  Guiana  Med.  Annual,  1896;  Galloway,  "Ulcerating  Granuloma  of  the  Pudenda," 
Brit.  Jour.  Derm.,  1897,  p.  133  (case  report,  histology,  with  reproduction  of  case  and 
histologic  illustrations  (from  sections  made  by  Galloway)  from  Conyers  and  Daniels' 
paper,  with  review  of  same);  Maitland,  Lancet,  June  17,  1899  (case  report,  with  his- 
tology by  Galloway),  and  British  Med.  Jour.,  1906,  p.  1463  (correspondence);  Renner, 
Jour.  Trap.  Med.,  1903,  p.  139  (notes  on  a  case);  Gifford,  "Infective  Granuloma  in 
Madras,"  The  Report  of  the  Madras  General  Hospital,  Indian  Med.  Gazelle,  1905,  p. 
440;  Wise,  Brit.  Med.  Jour.,  1906,  i,  p.  1274  (etiology);  MacLennan,  "Memorandum 
on  the  Observation  of  Spirochaetae  inYaws  and  Granuloma  Pudendi,"  Brit.  Med.  Jour., 
1906,  ii,  p.  995,  and  Lancet,  1906,  ii,  p.  1217;  Seibert,  Archiv  f.  Schijffs  u.  Tropen- 
Hygiene,  1907,  p.  379  (review,  etiology,  and  histology,  with  bibliography);  Macleod, 
Brit.  Jour.  Derm.,  1907,  p.  73  (case  presentation,  with  histology);  Sequeira,  Brit.  Med. 
Jour.,  March  7,  1908  (case  presentation;  typical  groin  condition,  and  also  unusual 
fungating  ulcer  at  angle  of  mouth);  Cleland  and  Hickenbotham,  Jour.  Trap.  Med., 
May  15,  1909  (cases  seen  in  aboriginal  natives  of  Western  Australia;  has  also  seen  sev- 
eral mild   cases  in  white  man;   histology);   Manson,  "Tropical  Diseases";   Carter, 
Lancet,  1910,  xi,  p.  1128  (describes  the  organisms  found  by  him  in  6  cases  seen  in  British 
India — "In  certain  areas  lie  masses  of  very  large  mononuclear  cells,  their  cytoplasm  dis- 
tended with  from  15  to  20  bean-shaped  bodies,  resembling  the  gregariniform  stage  of 
a  herpetomonas  or  erithidium";  Donovan,  of  Madras  (cited  by  Manson),  had  pre- 
viously called  attention  to  these  bodies;  Daniels,  ibid.,  p.  1648;  Rost,  Miinchen.  Med. 
Wochenschr.,  1911,  Iviii,  p.  1136  (salvarsan  treatment  negative);  Grindon,  Jour.  Cutan. 
Dis.,  April,  1913  (3  cases;  case  and  histologic  illustration;  no  trace  of  spirochaetae  or 
other  parasite  either  with  microscopic  examination  or  cultures;   brief  review,  with 
references). 


864  NEW  GROWTHS 

by  added  infection.  It  has  some  features  of  a  cutaneous  tuberculosis, 
with  an  added  pus-cocci  infection.  Crocker  believed  this  latter  an  im- 
portant factor  in  its  production.  Maitland  considers  that  it  results 
from  an  added  inoculation  to  an  already  present  venereal  sore,  such  as 
an  ulcerating  bubo.  In  some  respects  the  creeping  and  undermining 
ulcerating  tract  starting  from  a  gonorrheal  or  chancroidal  bubo  in  the 
groin  in  a  tuberculous  patient,  occasionally  seen  (formerly  more  than 
now)  in  our  charity  hospital  venereal  wards,  considerably  resembles  it. 
The  malady  is  met  with  in  both  sexes,  usually  in  those  between  the 
ages  of  fourteen  and  fifty.  The  histologic  conditions  in  ulcerating 
pudendal  granuloma,  studied  by  Galloway,  Macleod,  Cleland,  Siebert, 
Grindon,  and  a  few  others,  show  granulomatous  changes,  with  papillary 
elongation  and  some  rete  proliferation.  Various  organisms  have  been 
found,  among  which  protozoa-like  bodies  (Donovan,  Carter)  and  a 
few  kinds  of  spirochaetae  (MacLennan,  Wise),  one  resembling  the  Spiro- 
chaeta  pallida;  Grindon's  search  for  these  organisms  was  negative. 

Prognosis  and  Treatment.— Whatever  the  cause  of  a  tropical 
ulceration  may  be  its  course  is,  except  in  a  proportion  of  the  phagedenic 
ulcers,  slow,  and  it  is  rebellious  to  treatment.  Rost  tried  salvarsan  in 
i  case,  but  without  result.  In  some  instances,  it  is  true,  after  some 
months  or  an  indefinite  time,  spontaneous  healing  ensues,  leaving  often 
disfiguring  cicatrices.  The  most  promising  treatment  seems  to  consist 
of  curettage,  destructive  cautery  measures,  conjoined  with  cleanliness 
and  antiseptics.  In  Madras,  x-ray  treatment  has  proved  quite  successful 
in  pudendal  ulceration. 

CARCINOMA  CUTIS 

The  forms  of  carcinoma  cutis  of  particular  interest  to  the  dermatolo- 
gist are  epithelioma,  or  skin  cancer,  and  Paget's  disease.  Before  taking 
up  their  consideration,  however,  the  several  other  types  known  as  car- 
cinoma lenticulare,  carcinoma  tuberosum,  and  carcinoma  melanoticum, 
belonging  more  especially  to  the  domain  of  surgery,  may  be  briefly 
referred  to.  Lenticular  carcinoma  and  tuberose  carcinoma  are  examples 
of  scirrhus,  sometimes  called  scirrhous,  hard,  or  fibrous  cancer,  and  are 
usually  secondary  to  cancer  of  the  breast  or  other  organs,  only  rarely 
occurring  primarily  in  the  skin. 

Carcinoma  lenticulare,  or  lenticular  carcinoma,  is  seen  most  com- 
monly about  the  breast  in  women,  and  developing  as  a  secondary  mani- 
festation in  mammary  scirrhus,  or  in  the  scar  tissue  resulting  from  an 
operation  for  a  previously  existing  mammary  growth.  It  presents  itself 
as  several  or  more  whitish  or  pinkish  papules  or  small  nodules,  which 
are  usually  firmly  imbedded  in  the  skin,  projecting  but  slightly  above 
the  surface,  or  the  greater  portion  of  the  lesions  may  be  above  the 
skin  level.  They  are  at  first  pin-head-  to  pea-sized,  and  may  persist 
about  the  latter  size  for  some  time,  although  not  infrequently  some  of 
the  growths  may  reach  the  dimensions  of  a  cherry  or  larger.  The  cov- 
ering integument  is  pinkish  to  reddish  in  color,  with  usually  enlarged 
capillaries  coursing  irregularly  over  its  surface.  From  their  growth, 


CARCINOMA    CUTIS  865 

multiplication,  and  extension  they  become  closely  crowded  or  practically 
fuse  together,  and  form  extensive,  hard,  thickened,  nodular  areas.  A 
considerable  part  or  almost  the  entire  upper  part  of  the  chest,  both 
anteriorly  and  posteriorly,  and  shoulders  may  be  gradually  involved. 
In  extreme  cases  the  armor-like  investment  more  or  less  seriously  impairs 
full  respiratory  action,  and  from  a  blocking  off  or  obstruction  of  the  lym- 
phatics and  veins  considerable  swelling  of  the  arms  may  occur,  sufficiently 
marked  as  to  compromise  mobility  of  the  parts  (cancer  en  cuirasse). 
The  progress  is  usually  steady  and  moderately  rapid.  Softening  and 
ulceration  are,  as  a  rule,  sooner  or  later  noted,  a  condition  of  marasmus 
develops,  and  the  patient  gradually  succumbs.  Exceptionally  there 
is  observed  a  disappearance  of  some  of  the  nodules. 

Carcinoma  tuberosum,  tuberose  or  nodular  carcinoma,  is  a  still 
rarer  variety,  and  which  may  present  on  any  part  of  the  body;  it  is 
not  uncommonly  disseminated  or  generalized,  but  probably  oftener  or 
predominantly  on  the  face  or  extremities.  It  may  be  a  primary  or  sec- 
ondary manifestation,  and  is  generally  seen  in  middle  or  advanced  age. 
The  lesions  are,  as  the  name  signifies,  larger  than  those  of  the  lenticular 
variety.  They  begin  as  small  nodules,  somewhat  deeply  seated,  either 
in  the  lower  part  of  the  corium  or  in  the  subcutaneous  tissue,  and  grad- 
ually enlarge  and  project  above  the  surface,  the  overlying  skin  assuming 
a  distended,  shiny,  tense  appearance,  and  of  a  red  color,  usually  with  a 
brownish,  bluish,  or  purplish  tinge.  They  are  of  various  sizes,  some- 
times reaching  the  dimensions  of  an  egg  or  larger,  and  in  some  parts 
frequently  being  so  crowded  as  to  form  large  nodular  masses.  There 
may,  likewise,  be  an  invasion  of  the  internal  organs.  Sooner  or  later 
ulceration  ensues  and  the  patient  drifts  more  or  less  rapidly  into  a  cachec- 
tic or  marasmic  condition  and  succumbs.  The  malady  may  present 
somewhat  slowly  and  run  a  somewhat  tardy  course,  or  it  may  reach  a 
rapid  and  extreme  development  in  several  months. 

Melanotic  or  pigmented  carcinoma,  while  rare,  is  not  so  infrequent 
as  previously  thought,  inasmuch  as  some  cases  heretofore  looked  upon  as 
examples  of  pigmented  sarcoma,  starting  from  pigmented  naevi,  are  now 
believed  to  belong  among  the  carcinomata.  It  would,  however,  be  im- 
possible clinically  to  differentiate  the  cases  of  the  pigmented  sarcomata 
from  those  of  pigmented  carcinoma,1  a  histologic  examination  of  the 
morbid  tissue  being  necessary  for  a  positive  conclusion.  Pigmented 
carcinoma  generally  starts  from  a  congenital  and  acquired  pigmented 
naevus.  There  may  be  presented  but  one  variously  sized  growth, 
although  this  is  exceptional;  more  commonly  there  are  several,  and  they 
may  be  quite  numerous.  Usually  there  is  primarily  a  single  growth,  with 
the  development  of  secondary  nodules  near  by.  They  may  appear  on 
any  part  of  the  surface,  the  extremities  and  genitalia  being  favorite  re- 
gions. The  tumors  vary  in  size  from  a  small  pea  to  considerable  dimen- 
sions, and  may  be  rounded,  flattened,  or  fungoidal  in  character.  In 
some  instances  or  in  some  regions  the  lesions,  small  in  size,  are  crowded 

1  See  Ravogli's  paper,  "Multiple  Nodular  Melanocarcinoma  of  the  Skin  from  a 
Naevus,"  Jour.  Cutan.  Dis.,  June,  IQOI  (with  histologic  cuts,  review,  and  bibliography). 
References  to  the  contributions  of  Gilchrist  and  others  will  be  found  under  sarcoma. 


55 


866  NEW  GROWTHS 

together  and  form  verruca-like  patches  or  infiltrations.  In  color  they 
are  of  various  dark  shades,  from  a  slate  color  to  a  purplish  and  bluish- 
black.  The  larger  growths,  especially  those  having  a  fungoidal  aspect, 
tend  to  break  down  rapidly.  The  malady  is,  as  a  rule,  extremely  rapid 
in  its  course,  often  involving  the  visceral  organs  early,  a  fatal  ending 
sometimes  resulting  in  the  course  of  some  months  or  a  year  or  so. 

The  treatment  of  these  various  forms  consists  in  early  excision. 
If  advanced,  and  operative  measures  are  inadvisable,  the  continued 
administration  of  arsenic,  in  increasing  dosage,  either  by  the  mouth  or 
hypodermically,  should  be  tried;  in  such  instances,  too,  the  possible  fav- 
orable influence  of  x-ray  treatment  should  be  considered. 

FACET'S  DISEASE 

Synonyms. — Paget's  disease  of  the  nipple;  Malignant  papillary  dermatitis  (Thin); 
Eczema  epitheliomatosa;  Eczematoid  epitheliomatosis  of  the  nipple;  Cutaneous  psoro- 
spermosis;  Psorospermosis  cutis;  Mammillaris  maligna;  Fr.,  MaladiedePaget;  Epithe- 
liome  de  Paget;  Ger.,  Paget's  Krankheit. 

Definition. — Paget's  disease  is  a  rare  malignant  disease,  usually 
of  the  nipple  and  areola  in  women,  beginning  as  an  inflammatory-looking, 
eczematoid  affection,  and  eventually  terminating  in  cancerous  involve- 
ment of  the  whole  gland. 

Attention  was  first  called  to  this  malady  by  Paget1  in  1874,  whose 
description  was  based  upon  an  observation  of  15  cases,  in  all  of  which 
— women  between  the  ages  of  forty  and  sixty — cancerous  involvement 
of  the  gland  followed  within  one  or  two  years  after  the  appearance  of 
the  cutaneous  symptoms.  Since  then  many  additional  cases  have  been 
reported,  and  the  malady  has  received  considerable  attention,  both  in 
its  clinical  and  histopathologic  aspects,  by  various  observers,2  among 
whom  Butlin,  Thin,  Duhring,  Wickham,  Bowlby,  Hutchinson,  Jr., 
Jackson,  Wiggin  and  Fordyce,  Hartzell,  Simpson,  and  others. 

Symptoms. — The  disease  is  exceedingly  insidious  in  its  appear- 
ance, and  scarcely  comes  under  notice  until  a  distinctly  eczematoid 
aspect  is  presented.  In  its  very  earliest  stage  it  consists  of  slight,  scaly, 
somewhat  hardened,  thin,  epidermic  collections  or  scurfiness  of  the 
nipple  and  the  immediately  contiguous  portion  of  the  areola,  with, 

1  Paget,  St.  Bartholomew's  Hospital  Reps.,  1874,  vol.  v,  p.  87. 

2  Butlin,  London  Med.-Chirurg.  Soc'y  Trans.,  1876,  vol.  lix,  p.  107,  and  1877,  vol. 
Ix,  p.  153  (with  histologic  illustrations);  Thin,  London  Patholog.  Soc'y  Trans.,  1881, 
vol.  xxxii,p.  218  (with  histologic  cuts) ,  and  Brit.  Med.  Jour.,  i88i,vol.  i,  pp.  760,  798 
(with  histologic  cuts),  "On  Cancerous  Affection  of  the  Skin,"  London,  1886  (with  review 
of  the  subject);  Duhring  and  Wile,  Amer.  Jour.  Med.  Sci.,  1884,  vol.  Ixxxviii,  p.  141 
(pathology  with  references);  Wickham,  "Maladie  de  la  peau  dite  maladie  de  Paget," 
These  de  Paris,  1890  (with  colored  plates,  review,  and  bibliography);  and  Annales, 
1890,  pp.  45  and    139   (with   bibliography);    Bowlby,   London  Med.-Chirurg.  Soc'y 
Trans.,  1891,  p.  341  (notes  of  13  cases);  Hutchinson,  Jr.,  London  Patholog.  Soc'y  Trans., 
1890,  p.  214  (with  histologic  cuts),  Brit.  Jour.  Derm.,  1891,  p.  278;  G.  T.  Jackson,. 
Jour.  Cutan.  Dis.,  1896,  p.  428  (with  review  and  important  references);  Wiggin  and 
Fordyce,  New  York  Med.  Jour.,  1897,  vol.  Ixvi,  p.  445  (with  colored  case  illustration 
and  histologic  cuts);  Hartzell,  Jour.  Cutan.  Dis.,  1906,  p.  289  (2  cases,  *-ray  treatment, 
with  report  of  microscopic  findings  in  one  of  them  after  prolonged  treatment) ;  Simpson, 
Quar.  Bull.  Northwest  Univ.  Med.  School,  June,  1909  (case,  histology,  review,  and  ref- 
erences; decidedly  benefited  by  x-rays). 


CARCINOMA    CUTIS  867 

later,  slight  redness  and  often  more  or  less  itching.  It  may  remain 
limited  to  this  small  circumscribed  area  for  months  or  longer,  during 
which  tune  slight  or  moderate  erosion  of  the  nipple  may  present  and 
crusting  ensue.  After  a  variable  time  the  condition  spreads  out  and 
soon  involves  the  whole  area  of  the  areola,  and  often  extends  beyond. 
When  at  all  developed,  the  diseased  area,  which  is  usually  sharply  mar- 
ginate,  exhibits  a  florid,  intensely  red,  very  finely  granular,  raw  surface, 
attended  with  a  more  or  less  viscid  exudation.  There  is  moderate  in- 
filtration, which  is  well  defined  below,  feeling,  in  fact,  like  a  thin  layer  of 
indurated  tissue  implanted  in  the  skin. 

The  malady  slowly  progresses,  fissuring,  erosion,  and  retraction  of 
the  nipple  gradually  ensuing,  which  sooner  or  later  has  entirely  disap- 
peared. After  some  months  or  several  years  the  process  becomes  more 
intense,  greater  thickening  is  noted,  the  nipple  and  contiguous  part  of 
the  areola  are  ulcerated  or  have  "melted  away,"  and  some  nodular 
hardening  usually  develops  in  the  gland  structure — in  short,  gradual 
scirrhous  involvement  of  the  whole  breast  finally  occurs.  As  a  rule,  the 
superficial  or  eczematoid  area  does  not  extend  more  than  several  inches 
beyond  the  areola,  but  in  some  instances,  as  notably  in  those  reported 
by  Jamieson1  and  Elliot,2  it  is  much  more  extensive;  in  these  2  cases 
the  entire  surface  of  the  breast  was  involved  and  the  axillary  region  partly 
invaded.  In  a  few  instances,  too,  the  malady  has  affected  both  breasts. 
The  course  of  the  malady  is,  moreover,  extremely  variable.  In  some  cases, 
as  in  those  reported  by  Paget,  but  one  or  two  years  elapsed  before  car- 
cinomatous  development  in  the  gland  was  noted;  in  others  the  disease 
remains  for  a  long  time  confined  to  the  surface  as  an  eczematoid  eruption 
— in  Morris's3  case  six  years,  in  Duhring's  case  ten  years,  and  in  Jamie- 
son's  twenty  years.  As  a  rule,  however,  in  two  or  three  years  malignant 
involvement  of  the  breast  has  ensued. 

According  to  the  observations  of  recent  years,  it  would  seem  that 
the  disease  is  not  necessarily  one  limited  to  the  breast.  Crocker4  has 
observed  an  instance  of  its  occurrence  on  the  scrotum,  Tommasoli5 
on  penis,  Pick6  on  the  glans  penis,  Sheild7  on  pubic  region,  extending 
on  to  penis  and  scrotum,  Dubreuilh8  on  the  vulva,  Darier  and  Couil- 
laud9  on  the  scrotum  and  perineal  region,  Winfield10  on  the  lip,  and 
Ravogli11  on  the  nose;  Jungmann  and  Pollitzer12  in  the  axilla,  Colcott 

1  Jamieson,  Diseases  of  the  Skin,  p.  482  (woman  aged  seventy-two). 

2  Elliot,  Jour.  Cutan.  Dis.,  1892,  p.  272. 

3  Henry  Morris,  London  Med.-Chirurg.  Soc'y  Trans.,  1880,  vol.  Ixiii,  p.  37  (colored 
plate  case  illustration  and  histologic  cuts). 

4  Crocker,  London  Patholog.  Soc'y  Trans.,  1889,  vol.  xl,  p.  187  (with  colored  plate 
case  illustration  and  histologic  cuts). 

5  Tommasoli,  Giorn.  ital.,  1893,  vol.  xxviii,  Fasc.  iv. 

*  Pick,  Prager.  med.  Wochenschr.,  1891,  p.  282. 

7  Sheild,  Brit.  Jour.  Derm.,  1897,  p.  35  (man  aged  sixty). 

8  Dubreuilh,  ibid.,  1901,  p.  407. 

•  Darier  and  Couillaud,  Annales,  1893,  p.  33  (man  aged  seventy-two,  fifteen  years' 
duration). 

10  Winfield,  Brooklyn  Med.  Jour.,  March,  1896  (Soc'y  proceedings). 

11  Ravogli,  Trans.  Internal.  Med.  Cong.,  Rome,  1894;  abs.  in  Jour.  Cutan.  Dis.,  1894, 
p.  222  (patient  an  old  lady). 

12  Jungmann  and  Pollitzer,  Dermatolog.  Zeitschr.,  June,  1904. 


868  NEW  GROWTHS 

Fox  and  Macleod1  in  the  umbilical  region,  Fordyce,2  probable  case 
on  the  buttocks,  Davis3  on  the  penis,  and  Hartzell4  on  the  forearm. 
About  18  extramammary  cases  are  a  matter  of  record,  and  of  those 
9  occurred  on  the  external  genitalia  (Hartzell).  I  have  met  with  a 
case  somewhat  similar  to  Ravogli's  case,  in  a  woman  aged  sixty,  the 
whole  nose  being  superficially  involved  and  eroded  and  clinically  sug- 
gestive of  this  malady.  An  instance  of  its  occurrence  on  the  scrotum 
has  also  come  under  my  notice  in  an  old  man  (Dr.  C.  N.  Davis'  patient, 
not  elsewhere  recorded). 

Etiology. — The  disease  is  one  of  advancing  years,  occurring 
most  frequently  between  fifty  and  sixty.  It  is  practically  limited  to 
the  female  sex  and  to  the  nipple  region,  the  cases  occurring  on  other 
parts  in  men  still  being  viewed  with  some  suspicion.  In  one  instance, 
observed  by  Forrest,5  however,  of  apparently  eczematous  disease  of  the 
nipple  in  a  male  aged  seventy-two,  carcinoma  developed.  There  is  a 
somewhat  remarkable  disproportion  in  its  occurrence  on  the  right  side; 
in  not  more  than  25  per  cent,  was  the  left  breast  the  seat  of  the  disease. 
Various  causes  have  been  considered  as  etiologic.  The  malady  was 
formerly  thought  to  be  a  carcinoma  developing  upon  a  long-continued 
eczema,  but  it  is  now  generally  believed  that  the  process  is  malignant 
from  the  start.  Doubtless  fissures  and  persistent  irritation  of  the  nipple 
are  favoring  factors.  Darier  and  Wickham  advanced  the  opinion  that 
psorosperms  are  the  exciting  agents;  psorosperm-like  bodies  have  also 
been  found  by  Bowlby,  Macallum,6  Hutchinson,  Jr.,  and  others.  This 
view  is,  however,  no  longer  maintained;  that  originally  held  by  Thin, 
and  later  by  Unna,  Fordyce,  and  others,  that  these  bodies  merely  repre- 
sent cell  changes,  is  now  generally  accepted.7 

Pathology. — At  the  present  time  there  is  but  little  doubt  as  to 
the  malignant  nature  of  even  the  earliest  phases  of  the  malady. 

The  pathologic  anatomy  has  been  studied  by  various  observers 
(Butlin,  Thin,  Duhring,  Darier,  Wickham,  Fordyce,  Unna,  Hartzell, 
and  others).  There  is  practically  more  or  less  unanimity  in  the  findings. 
"The  morbid  changes  (quoting  Fordyce)  may  be  briefly  stated  as  in- 
flammation of  the  papillary  region  of  the  derma,  leading  to  an  edema  and 
vacuolation  of  the  constituent  cells  of  the  epidermis,  followed  by  their 
complete  destruction  in  places  and  their  abnormal  proliferation  in  others. 
The  change  in  the  epithelium  of  the  lactiferous  canals  and  glandular 

1  Colcott  Fox  and  MacLeod,  Brit.  Jour.  Derm.,  1904,  p.  43  (with  case  illustration, 
histologic  cuts,  review  of  these  special  cases  and  a  general  review  of  the  disease,  and 
references;  man  aged  sixty-five,  of  eleven  years'  duration). 

2  Fordyce,  Jour.  Cutan.  Dis.,  1005,  p.  193  (with  histologic  cuts),  a  probable  case  of 
the  gluteal  region  (woman,  aged  sixty,  of  six  years'  duration). 

1  C.  N.  Davis,  Jour.  Cutan.  Dis.,  1910,  p.  412  (case  demonstration). 

*  Hartzell,  "Extramammary  Paget's  Disease,"  Jour.  Cutan.  Dis.,  1910,  p.  379 
(report  of  case  on  forearm,  refers  to  4  unpublished  cases;  review,  and  bibliography; 
case  and  histologic  illustrations). 

5  Forrest,  Glasgow  Med.  Jour.,  vol.  xvi,  p,  459  (patient  aged  seventy-two). 

'jMacallum,  Canadian  Med.  Practitioner,  1890,  p.  473. 

7  Fabry  and  Trautmann,  Archiv,  1904,  vol.  Ixix,  p.  37,  found  an  yeast  fungus,  and 
suggest  a  possible  relationship  between  Paget's  disease  and  blastomycetic  dermatitis. 
Inasmuch  as  this  has  not  been  observed  by  other  careful  investigators,  it  is  probable 
that  in  this  instance  its  presence  was  secondary  or  accidental. 


CARCINOMA    CUTIS  869 

epithelium,  which  is  also  of  a  proliferative  and  degenerative  nature,  is 
secondary  to  the  changes  in  the  surface  epithelium,  and  may  be  regarded 
as  of  the  same  nature,  and  probably  produced  by  the  action  of  the  same 
irritant.  The  over-distention  of  the  lactiferous  canals  by  the  proliferat- 
ing epithelium,  resulting  in  a  malignant  infection  of  the  surrounding 
connective  tissue,  is  the  usual  termination  of  the  affection."  As  all 
observers  have  found,  as  Fordyce  further  states,  "the  earliest  and  most 
carefully  studied  changes  in  Paget's  disease  are  those  met  with  in  the 
surface  epithelium.  It  is  here  that  the  cell  changes  and  inclusions  are 
met  with  which  were  first  described  by  Darier,  and  afterward  by  Wick- 
ham  and  others,  as  coccidia.  ...  A  more  careful  study  of  these 


"*     «.  w 

Fig.  211. — Paget's  disease,  in  middle  stage,  showing  the  peculiar  epithelial  cell  degener- 
ation and  the  psorosperm-like  bodies  (courtesy  of  Dr.  A.  R.  Robinson). 


cell  degenerations  has  pretty  conclusively  demonstrated  the  non-parasitic 
character  of  many  of  them.  The  infectious  nature  of  Paget's  disease 
has,  however,  by  no  means  been  absolutely  disproved,  and  an  element 
of  doubt  yet  remains  as  to  the  character  of  certain  of  the  cell  changes 
which  are  found  in  the  affection."  The  role  which  Darier,  Wickham, 
and  others  gave  these  peculiar  cell-degenerations,  under  the  erroneous 
impression  that  they  were  coccidia  or  psorosperms,  has,  as  already  stated, 
been  practically  abandoned. 

Diagnosis. — The  disease,  in  its  earliest  stage,  is  to  be  distin- 
guished from  eczema,  a  matter  in  some  instances  of  some  difficulty, 
until  the  case  has  been  under  observation  for  a  short  period.  In  its 


870  NEW  GROWTHS 

later  stages,  and  especially  when  the  gland  involvement  is  already  evi- 
dent, a  mistake  could  occur  only  as  a  result  of  a  hasty  and  careless  exami- 
nation. The  diagnostic  features  are:  The  age  of  the  patient;  the  sharp 
limitation;  the  well-defined,  indurated  film  of  infiltration;  the  peculiar, 
red,  raw,  granulating  appearance;  and,  later,  the  retraction  of  the  nipple; 
and,  finally,  the  involvement  of  the  deeper  parts.  A  persistent  circum- 
scribed ec/ematous-looking  eruption  of  the  nipple  and  areola  should 
always  be  viewed  with  suspicion  in  those  advancing  in  years,  which  be- 
comes almost  a  certainty  if  it  is  rebellious  to  the  usual  treatment  of 
eczema.  In  the  earlier  stage  in  doubtful  cases  examination  may  be 
made  for  the  psorosperm-like  bodies,  which  are  characteristic,  and  not 
to  be  found  in  eczema. 

Prognosis  and  Treatment. — If  the  disease  is  recognized  early 
and  properly  treated  a  cure  may  be  often  anticipated;  but  later  the 
prognosis  is  essentially  the  same  as  that  of  scirrhus  of  the  breast,  and 
depending  upon  the  progress  of  the  disease  and  the  amount  of  breast 
involvement. 

Treatment,  when  the  diagnosis  is  clearly  established,  should  be 
radical,  consisting  of  the  plans  mentioned  for  epithelioma,  radical  opera- 
tion being  the  first  choice.  While  mild  and  palliative  applications  can 
do  no  direct  harm,  half-way  measures  are  not  permissible,  as  the  latter 
simply  serve  to  spur  the  disease  to  more  rapid  advancement.  In  doubt- 
ful cases  the  various  plans  of  treating  eczema  are  at  first  to  be  employed, 
and  if  this  disease,  the  condition  will  usually  readily  yield.  In  clear 
cases  of  the  disease,  in  which  radical  measures  are  refused,  palliative  and 
soothing  applications  are  to  be  made.  In  Elliot's  patient  the  use  of  an 
ointment  of  fuchsin,  2  to  5  grains  (0.135-0.35)  to  the  ounce  (32.)  of 
lanolin  and  rose-water,  of  a  strength  just  short  of  producing  irritation, 
acted  satisfactorily,  giving  considerable  relief  and  promoting  cicatrization. 

J^-ray  treatment  sometimes  benefits,  and  in  the  very  earliest  stage 
of  the  disease,  before  the  ducts  and  glands  are  involved,  might  prove 
curative;  i  of  HartzelPs  cases,  i  of  my  cases,  and  Simpson's  case  improved 
under  this;  Jungmann  and  Pollitzer  report  a  cure  of  their  axilla  case  and 
Fordyce  in  his  gluteal  case;  and  Milligan  a  cure  of  umbilicus  case  with 
radium.1 

EPITHELIOMA 

Synonyms. — Skin  cancer;  Epithelial  cancer;  Carcinoma  epitheliale;  Cancroid; 
Noli  me  tangere;  Fr.,  Epitheliome;  Cancroide;  Ger.,  Hautkrebs;  Epithelialkrebs. 

Definition. — The  term  epithelioma,  in  its  strict  dermatologic 
significance,  may  be  defined  as  an  epithelial  new  growth  with  destructive 
tendency,  having  its  origin  in  the  epithelium  of  the  epidermis  or  of  the 
glands  of  the  skin. 

Symptoms. — Epithelioma  presents,  when  at  all  developed,  va- 
rious clinical  phases  or  characters,  usually  with,  in  different  cases,  a 
predominance  of  one  of  the  several  features  over  the  others,  so  that  it 
would  be  possible  to  make  a  number  of  varieties.  For  practical  and 
descriptive  purposes,  however,  the  three  divisions  commonly  made  are 

1  Milligan,  Brit.  Jour.  Derm.,  1911,  p.  411  (case  demonstration — patient,  woman 
aged  thirty-one). 


CARCINOMA    CUTIS  8/1 

sufficiently  comprehensive.  These  several  forms  of  epithelioma  are  desig- 
nated the  superficial,  or  discoid,  the  deep-seated,  and  the  papillomatous. 
Superficial  Variety.— The  superficial,  or  discoid,  form,  sometimes 
also  named  the  flat  variety,  is,  of  the  several  varieties,  that  most  fre- 
quently encountered.  It  may  beghi  in  one  of  several  ways:  as  a  small, 
firm,  reddish,  yellowish,  or  pearly  papule  or  tubercle,  or  as  an  aggrega- 
tion of  two  or  three  such  lesions;  as  a  warty  excrescence,  primarily  of  a 
benign  character,  such  as  a  simple  wart  or  small,  elevated,  fleshy  mole; 
and  as  a  small  pea-  to  bean-sized,  smooth,  or  roughened  keratosis  or 
greasy,  scaly,  seborrheic  patch  (see  Keratosis  senilis  and  Atrophia  senilis). 
In  the  event  of  it  beginning  as  one  of  the  several  small,  solid  lesions  named, 
the  first  evidence  of  the  degenerative  change  is  usually  a  slight  fissure  or 
surface  abrasion,  which  persists  and  slowly  enlarges,  and  often  becomes 
thinly  crusted.  After  some  months  the  slight  pearly,  warty,  or  mole 
formation  has  in  great  measure  slowly  yielded  to  the  degenerative  action, 
and  in  great  part  or  wholly  disappeared,  giving  place  to  a  surface  ulcera- 


Fig.  212. — Epithelioma,  superficial  type,  in  an  old  man  aged  sixty-five,  showing  the 

roll-like  border. 

tion  a  trifle  larger  than  the  lesion  which  it  has  gradually  displaced.  In 
some  cases,  however,  a  long  time  elapses — some  months  or  one  or  two 
years — before  the  first  lesion  has  wholly  gone,  and  it  is  not  uncommon 
for  it  to  be  gradually  destroyed  in  the  upper  part,  and  the  basal  portion 
remain  for  a  shorter  or  longer  period,  with  an  ulcerated  surface  covered 
with  a  thin  or  slightly  thickish  incrustation,  which  is  knocked  off  or  falls 
off  from  time  to  time,  but  which  soon  reforms.  After  the  lesion  has, 
however,  sunken  to  and  usually  a  trifle  below  the  skin  level  and  a  shallow 
ulcer  is  in  its  place,  it  is  commonly  observed  to  have  a  slightly  elevated 
and  often  a  pearly,  roll-like  border,  which  is  gradually  pushed  further 
as  the  ulcer  becomes  larger.  In  rare  instances,  as  in  those  observed  by 
Danlos,  Brocq,  Fordyce,  Hartzell,  and  myself,1  the  superficial  epithe- 

1  Danlos,  Annales,  1899,  p.  656  (case  demonstration — patient,  woman  aged  forty- 
three,  with  lesion  on  the  neck);  Brocq,  ibid,  (discussion — 2  cases,  both  women,  aged 
fifty-five  and  sixty,  with  lesion  about  the  nose);  Stelwagon,  Trans.  Amer.  Derm.  Assoc. 
for  1899,  p.  166  (case  demonstration — patient,  male,  aged  forty,  with  flat  epithelioma 
of  the  temporal  region,  with  almost  an  inch-wide  superficial,  morphea-like  border); 
Fordyce,  Jour.  Amer.  Med.  Assoc.,  Oct.  24,  1908,  p.  1398;  Hartzell,  "Morphea-like 
Epithelioma,"  Jour.  Amer.  Med.  Assoc.,  July  24,  1909,  p.  262  (3  cases  with  brief 
review  and  references). 


8/2 


NEW  GROWTHS 


lioma  spreads  by  an  invading  flattened,  morphea-like,  slightly  raised 
band  of  j  to  \  inch  or  so  in  width  (morphea-like  epithelioma);  the 
morphea-like  formation,  but  slightly  raised,  seems  to  be  the  first  stage, 
this  later  showing  trifling  crusting  with  underlying  degenerative  changes 
in  the  central  portion;  the  ulcerative  action  slowly  spreads,  and  the 
morphea-like  border  at  the  same  time  may  also  extend. 

The  ulcer,  which  has  a  slight  serous  or  serosanguinolent,  viscid, 
or  varnish-like  discharge,  keeps  more  or  less  continuously  crusted, 
and  the  crust,  when  it  is  not  frequently  rubbed  or  knocked  off,  may 
become  quite  thick.  The  discharge  is  sometimes  mixed  with  pus,  but 
it  is  only,  as  a  rule,  in  the  more  advanced  stages,  when  the  ulcer  becomes 
large  and  tends  to  extend  more  deeply,  that  the  purulent  character  of 
the  discharge  is  at  all  noticeable,  and  never  so  pronounced  or  distinctly 
purulent  as  in  syphilitic  ulcers.  The  superficial  variety  of  epithelioma 


Fig.  213. — Epithelioma  of  superficial  type,  crusted,  in  a  woman  aged  fifty-eight. 

rarely,  certainly  not,  as  a  rule,  until  after  some  years'  duration,  extends 
to  much  depth.  In  course  of  time  it  does,  it  is  true,  gradually  eat  in, 
so  that  when  on  the  side  of  the  nose  there  is  risk  of  final  penetration. 
In  occasional  instances  of  these  sluggish  superficial  types,  and  especially 
that  form  with  the  pearly  border,  as  the  disease  spreads  there  is  displayed 
in  the  older  parts  a  tendency  to  cicatricial  healing. 

In  other  cases  the  disease  pursues  a  course  which  has  given  it  the 
name  of  rodent  ulcer  (Jacob's  ulcer;  Cancroid  ulcer;  Ulcus  exedens: 
Ulcus  rodens;  Noli  me  tangere;  Ulcere  cancreux;  Der  flache  Hautkrebs)1, 
formerly  these  cases  were  also  designated  lupus  exedens.  The  special 
characteristic  of  this  type  is  its  lateral,  steadily  progressive  spread,  with 
but  little,  and  sometimes  no,  elevated  or  infiltrated  border;  in  other 
words,  the  ulcerating  feature  is  conspicuous,  whereas  the  new  growth 
element  is  almost  nil.  Not  infrequently,  especially  in  the  earlier  stages, 


CARCINOMA    CC777S  873 

there  is  a  slight,  pearly,  roll-like  border.  Some  observers  are  inclined 
to  consider  this  a  distinct  malady  from  epithelioma,  although  admitting 
it  to  be  an  allied  disease,  but  the  origin,  behavior,  and  pathologic  charac- 
ters are  in  all  essential  particulars  similar  to  those  of  other  superficial 
cases.  It  is  true,  as  Paget  states,  that  it  frequently  begins  as  a  brownish 
nodule,  different  from  the  pearly  tubercle  or  warty  growths  which  mark 
the  other  superficial  type,  but  rodent  ulcer,  or  a  lesion  clinically  indis- 
tinguishable, may  also  begin,  as  I  have  often  observed,  in  the  same  man- 
ner as  in  the  cases  of  the  superficial  form  already  referred  to.  The  rodent 
ulcer  variety  is  commonly  a  disease  of  the  upper  half  of  the  face,  being 
especially  frequent  about  the  eyelids  and  sides  of  the  nose. 

The  course  of  superficial  epithelioma,  as  has  already  been  intimated, 
is  usually  pre-eminently  slow,  and  the  disease  of  a  relatively  benign  char- 


Fig.  214. — Epithelioma,  rodent  ulcer  type,  in  a  man  aged  sixty,  of  fifteen  years'  dura- 
tion; recurrence  several  times  after  curetting  and  cauterization. 

acter,  many  years  often  elapsing  before  serious  progress  has  been  made. 
The  rodent  ulcer  form  is  often  eventually  extremely  destructive,  extend- 
ing deeply  as  well  as  laterally.  The  lymph-glands  are  rarely  involved 
in  these  superficial  cases,  but  there  is  a  possibility  in  all  instances  of  final 
glandular  involvement1  and  a  change  of  type  into  a  deep-seated  or  papil- 
lary variety  of  the  disease. 

Deep-seated  Variety.— The  deep-seated  or  nodular  variety  of  epi- 
thelioma may  start  from  the  superficial  type,  or  it  begins  as  a  tubercle 
or  nodule  in  the  skin  or  subcutaneous  tissue.  It  gradually  increases 
in  dimensions,  projecting  both  downward  and  above  the  level  of  the  skin, 
with  the  overlying  integument  pinkish  or  reddish,  and  frequently  with 

1  See  interesting  paper  by  D.  W.  Montgomery,  "Report  of  a  Case  of  Epithelioma 
of  the  Skin  with  Unusual  Course  of  Infection  of  Lymph-nodes,"  Annals  of  Surgery, 
1898,  vol.  xxvii,  p.  193. 


8/4 


NEW  GROWTHS 


dilated  capillaries  coursing  over  it.  There  may  be  some  lateral  extension 
into  the  surrounding  tissue.  In  the  course  of  several  months  or  longer 
the  nodule,  which  has  frequently  reached  the  size  of  a  cherry  or  larger, 
breaks  down  centrally,  an  ulcer  is  formed,  with  usually  prominent  and 
infiltrated  reddish  and  inflammatory-looking  borders.  The  surface 

of  the  ulcer  is  reddish  and  granu- 
lar and  secretes  a  viscid,  and  often 
ichorous  discharge,  and  crusts 
over  from  time  to  time.  When 
arising  from  the  superficial  variety 
of  epithelioma,  this  latter  is 
usually  noted  to  become  more 
angry-looking,  especially  about 
the  edges,  the  latter  becoming 
more  prominent,  showing  increas- 
ing infiltration,  and  the  base  of 
the  growth  likewise  tending  to  be- 
come thicker  and  hard,  and  there 

may,  in  some  instances,  be  considerable  elevation.  The  progress  of  the 
deep-seated  type  is  usually  steadily  progressive,  and,  as  a  rule,  at  a  rela- 
tively rapid  pace.  The  infiltration,  which  is  the  pronounced  feature  of 
this  form,  spreads  gradually,  sometimes  rapidly;  the  ulcer  enlarges  both 
peripherally  and  in  depth,  and  presents  hard,  everted,  often  more  or  less 


Fig.  215. — Small  beginning  epithelioma. 


Fig.  "2 1 6. — Epithelioma,  deep-seated,  "crateriform"  variety. 

undermined  edges,  sometimes  showing  here  and  there  small  waxy  nodules; 
the  base  is  noted  to  be  irregular,  not  infrequently  slightly  or  moderately 
papillomatous  or  vegetating,  and  with  often  considerable  viscid,  varnish- 
like,  sanguinolent,  partially  or  markedly  purulent  discharge.  The  base 
exhibits,  as  a  rule,  a  disposition  to  slight  bleeding  upon  the  slightest 


CARCINOMA    CUTIS 


provocation,  such  as  a  trifling  knock  or  insignificant  roughness  in  its 
washing  or  dressing.  In  some  cases  the  ulcerative  tendency  is  displayed 
chiefly  in  the  central  portion,  the  surrounding  infiltration  being  somewhat 
hard  and  elevated,  and  the  invasion  and  progress  rapid,  constituting  the 
"crateriform  ulcer"  of  Hutchinson.1  This  rare  variety,  which  usually 
is  seated  on  the  upper  part  of  the  face,  may  also  start  as  a  superficial 
rodent  ulcer  type.  Muscle,  cartilage,  and  bone  often  finally  become 
invaded.  The  neighboring  lymphatic  glands  are  sooner  or  later  im- 
plicated; pains  of  a  burning  or  neuralgic  type  are  experienced,  and  with 
or  without  recognizable,  metastatic  tumors  in  the  internal  organs,  death 
eventually  ensues. 

Papillary  Variety. — The  papillary  or  papillomatous  variety  of  epithe- 
lioma  usually  arises  from  the  superficial  or  deep-seated  type;  or  it  may 


Fig.  217. — Epithelioma  of  deep-eating  rodent  type,  in  a  woman  aged  sixty  (courtesy  of 
Dr.  A.  Van  Harlingen). 

begin  primarily  as  a  papillary  or  warty  growth.  Beginning  in  the  latter 
manner,  it  may  for  some  months  or  longer  maintain  a  pseudoverrucous 
appearance,  projecting  higher,  however,  than  ordinary  warts,  involving 
more  surface, — \  to  i  inch  or  so  in  diameter, — with  a  slightly  or 
moderately,  mildly  inflammatory,  infiltrated  base,  which  may  extend  a 
line  or  two  beyond  the  edge  of  the  papillary  formations.  When  the  area 
of  disease  is  small,  the  vegetations  are  usually  noted  to  be  somewhat 
higher  centrally,  although  in  larger  areas  also  the  papillary  projections 
are  generally  much  less  prominent  toward  the  extreme  peripheral  portion. 
When  a  papillary  epithelioma  is  fully  developed,  it  matters  not  in  what 
manner  it  may  have  originated,  it  presents  an  ulcerated,  fissured,  and 
papillomatous  surface,  usually  having  a  viscid  or  thick  secretion,  with  a 

1  Hutchinson,  "The  Crateriform  Ulcer  of  the  Face,  a  Form  of  Acute  Epithelial 
Cancer,"  Trans.  London  Patholog.  Soc'y,  1889,  vol.  xl,  p.  275  (with  colored  plates). 


8/6  NEW  GROWTHS 

variable  proportion  of  purulent  admixture.  The  surface  may  bear  re- 
semblance to  a  digitate  wart,  to  a  cauliflower  excrescence,  or  it  may  be 
distinctly  condylomatous  in  appearance.  Exceptionally  there  is  a 
tendency  toward  slight  pedunculation.  Sometimes  the  secretion  is 
scanty,  the  ulcerative  action  more  in  the  nature  of  deep  fissures  extending 
down  between  the  papillary  projections,  and  the  surface  of  the  growth 
may  present  a  somewhat  hard  or  horny,  thin  or  moderately  thick  incrus- 
tation. In  some  cases  the  surface  is  irregularly  ulcerated  and  papillo- 
matous,  the  granulations  usually  presenting  an  exuberant  and  fleshy 
character,  which  bleed  quite  readily.  It  is  slowly,  sometimes  rapidly, 
progressive,  and  sooner  or  later  develops  a  malignant  tendency,  showing 
deep-seated  infiltration,  involvement  of  the  neighboring  lymph-glands, 
and  death,  as  in  the  malignant,  deep-seated  variety,  gradually  results. 

Epithelioma  of  the  lip,  usually  on  the  lower  lip  toward  one  side, 
comes  more  commonly  under  the  care  of  the  surgeon,  although  in  its 
earliest  stage  it  is  not  infrequent  in  dermatologic  practice.  It  begins  in 
one  of  the  several  ways  described  in  connection  with  its  appearance  on  the 
cutaneous  surface.  Its  most  common  commencement  is  as  a  slight  scurfi- 
ness,  abrasion,  crack,  or  small  papule  or  warty-looking  lesion,  and  in  many 
cases  advice  is  not  sought  until  a  superficial  ulcer,  with  variable  infiltra- 
tion, is  noticed,  which  presents  in  several  months  or  longer.  The  future 
course  is  about  the  same  as  with  the  more  rapid  skin  cancers,  there  being 
usually  considerable  infiltration  and  swelling,  with  comparatively  early 
involvement  of  the  lymphatic  glands.  The  surface  is  commonly  granular- 
looking,  in  places  often  crusted.  Cancer  of  the  tongue,  which  may  also, 
in  its  beginning  stage,  first  come  under  the  inspection  of  the  dermatolo- 
gist, begins  as  a  small  abrasion  or  fissure,  often  started  by  irritation  pro- 
duced by  a  tooth,  or  developing  upon  a  leukoplakia.  A  superficial  ulcer 
soon  results,  later  infiltration  beneath  and  surrounding,  and  more  or 
less  rapid  course  and  destruction.  Epithelioma  of  the  genital  organs  is 
also  met  with,  the  glans  penis,  prepuce,  and  clitoris  being  not  unusual  sites. 
On  these  parts  the  papillomatous  variety  is  of  common  occurrence, 
starting  from  an  abrasion  or  a  warty  growth.1 

The  favorite  sites  of  election  in  skin  cancers  are,  first  of  all,  the  various 
parts  of  the  face,  especially  the  nose,  eyelids,  and  lips.  The  forehead 
and,  more  frequently,  toward  or  at  the  temporal  region,  the  ear,  the  back 
of  the  hand,  and  the  genitalia  are  also  localities  frequently  invaded. 
Any  other  part  may,  however,  be,  but,  as  a  rule,  only  rarely,  the  seat  of 
such  growth.  On  the  dorsal  surface  of  the  hand  the  lesion  begins  usually 
either  as  a  warty  excrescence,  developing  into  the  papillomatous  type, 
or  as  a  keratosis  or  degenerative  seborrheic  patch,  which  scales  or  crusts 
off  from  time  to  time,  as  already  described,  and  gradually  breaks  down 
and  into  the  ordinary  epitheliomatous  ulcer.  As  a  rule,  the  growth  is 
single,  although  in  exceptional  cases  two  or  three  lesions  may  be  present; 
and  in  some  instances  of  numerous,  scattered,  senile,  degenerative,  sebor- 
rheic patches  about  the  face,  several  or  more  may  gradually  undergo 
epithelial  change, — epitheliomatose  sebacee  of  the  French, — and  mul- 

1  For  detailed  description  and  management  of  lip,  tongue,  and  genital  cases  the 
reader  is  referred  to  works  on  surgery. 


8/7 


tiple  epithelioma  result.  Mention  should  also  be  made  here  of  the  con- 
dition occasionally  met  with,  which  will  be  found  described  elsewhere 
under  the  title  "multiple  benign  cystic  epithelioma"  (q.  v.).  In  this, 
numerous  lesions,  discrete  or  bunched,  usually  about  the  face  or  upper 
part  of  the  trunk,  are  present,  of  a  character  closely  similar,  if  not  identi- 
cal with,  the  pearly  growths  and  border,  both  clinically  and  pathologic- 
ally, seen  in  some  cases  of  ordinary  epithelioma;  in  view  of  the  few  in- 
stances in  which  in  this  mild  malady  degenerative  changes  have  occurred 
it  is  highly  probable  that  the  future  of  these  cases  may  show  that  the 
term  "benign"  is  scarcely  acceptable. 

In  the  milder  phases  of  epithelioma  no  subjective  symptoms  are 
complained  of,   but  in  the  deep-seated  and  papillomatous  varieties 


Fig.  218. — Epithelioma  of  deep-seated  type  in  a  man  aged  fifty-seven. 

burning  sensations  or  pain  of  a  lancinating  character  frequently  develop 
late  in  the  disease.  Unless  in  close  proximity  to  lymphatic  glands, 
these,  in  average  cases,  rarely  show  involvement  in  the  earliest  months, 
and  sometimes  never  during  the  whole  course  of  the  malady;  but  if 
closely  situated,  more  especially  with  the  deep-seated  and  papillomatous 
varieties,  the  lymphatics  are  sooner  or  later  implicated.  In  the  average 
run  of  cases  of  the  type  naturally  gravitating  to  the  dermatologic  special- 
ist, however,  glandular  implication,  judged  by  my  own  observation, 
which  covers  a  large  aggregate  number,  is  relatively  rare;  nor  have  I 
seen,  with  the  exception  of  a  few  instances,  a  recurrence  presenting  itself 
in  the  glands.  It  is  only  fair  to  state,  however,  that  most  of  my  cases, 


8/8 


NEW  GROWTHS 


fortunately,  have  happened  to  be  of  the  mild,  superficial  variety,  with 
only  in  a  moderate  proportion  of  instances  a  disposition  to  a  rapidly 
malignant  tendency. 

Etiology. — The  cause  of  cancer  is  still  an  undetermined  question. 
There  are  several  factors,  however,  which  may  be  considered  as  adjuvant 
or  contributing  that  are  well  known.  The  majority,  by  far,  of  epithelio- 
mata  of  the  skin  or  adjoining  mucous  surfaces  are  observed  in  males. 
The  malady  is  essentially  one  of  advancing  years,  somewhat  rare  before 
the  age  of  forty,  and  more  commonly  seen  after  fifty  or  sixty.  Excep- 
tional instances,  it  is  true,  are  now  and  then  noted,  as  in  the  recent  cases 
recorded  by  Hartzell,1  Allen,2  Sequeira,3  and  others,  in  which  the  growth 
presents  in  earlier  years.  Local  irritation  is  likewise  a  recognized  ex- 


Fig.  219. — Epithelioma  developing  from  a  keratosis,  in  a  case  of  psoriasis;  the 
keratoses  (some  of  which  can  be  seen  in  the  illustration)  appearing  after  long-continued 
administration  of  arsenic. 

citing  agent.  This  is  shown  in  the  cases  in  which,  from  the  accidental 
knock  or  other  injury,  often  trifling,  an  ordinary  wart,  fleshy  mole,  or 
pigmented  naevus  of  long  duration  begins  to  show  epithelial  development. 
The  disease  has  also  often  been  noted  to  start  at  the  site  of  a  scratch, 
cut,  or  other  accidental  traumatism;  and  the  factor  of  pressure  or  irrita- 
tion produced  by  the  pipe-stem  or  cigar  in  the  production  of  epithelioma 

1  Hartzell,  "Epithelioma  (Rodent  Ulcer)  in  a  Boy  of  Fourteen,"  New  York  Med. 
Jour.,  Mar.  5,  1898  (refers  to  several  recorded  cases,  with  literature  references). 

2  Allen,  Jour.  Cutan.  Dis.,  1899,  p.  571  (case  demonstration,  in  man  aged  twenty- 
four,  on  the  lip);  ibid.,  1900,  p.  122  (case  demonstration — patient  male,  aged  twenty- 
eight — on  lip). 

3  Sequeira,  Brit.  Jour.  Derm.,  1912,  p.  391,  reports  a  case  of  "Rodent  Ulcer  of  the 
Back  in  a  Boy  of  Twelve,"  and  refers  to  his  previous  cases — one  on  the  ala  nasi,  begin- 
ning when  the  patient  was  twelve,  and  another  on  the  lower  lid  of  a  girl  aged  fifteen. 


CARCINOMA    CUTIS 


879 


of  the  lip  in  many  instances  is  well  known.  A  neglected  or  irritated 
senile  seborrheic  spot  or  keratosis  often  is,  as  already  referred  to,  the 
starting-point  of  the  disease.  Hyde,1  Dubreuilh,2  and  others  have  called 
attention  to  the  possible  factor  of  continued  exposure  to  the  sun's  rays; 
and  it  is  well  known  that  workers  in  petroleum  and  tar  products  develop 
keratoses  and  papillomata  with  malignant  tendency.  Epithelioma  has 
also  developed  at  the  site  of  patch  or  ulceration  of  lupus  vulgaris  and 
syphilis,  and  exceptionally  upon  a  lupus  erythematosus.  Hutchinson, 
White,  Hartzell,  and  others  have  recorded  cases  developing,  in  psoriasis 
patients,  from  the  keratosis  following  the  prolonged  administration  of 
arsenic,3  this  drug,  therefore,  having  apparently  a  direct — certainly 


Fig.  220. — From  a  squamous-celled  epithelioma,  showing  the  so-called  "pearls,"  "cell- 
nests,"  or  "globes"  (courtesy  of  Dr.  J.  A.  Fordyce). 

indirect — influence  (arsenical  cancer,  arsenical  epithelioma).  From 
time  to  time  various  claims  as  to  the  discovery  of  parasitic  organisms 
have  been  made,  but  a  judicial  review  of  the  evidence  shows  that  this 
field  of  investigation  has  not,  up  to  the  present,  borne  convincing  results. 
So  far  we  have  not  got  beyond  the  recognition  of  a  local  irritation — espe- 

1  Hyde,  Amer.  Jour.  Med.  Sci.,  January,  1906. 

2  Dubreuilh,    Annales,    1907,    p.    387    (with    valuable   statistical    tabulations  of 
epithelioma  cases  from  Ferrer's  "These  (Bordeaux,  1906-07),  Etiologie  clinique  de 
1'epithelioma  cutane"  (432  cases). 

3  Hartzell,  "Epithelioma  as  a  Sequel  of  Psoriasis  and  the  Probability  of  its  Arsen- 
ical Origin,"   Amer.   Jour.   Med.  Sci.,  Sept.,   1899  (report  of  a  case  and  review  of 
recorded  cases,  with  references);  Dubreuilh,  "Keratose  arsenicale  et  Cancer  arsenical," 
Annales,  Feb.,  1910,  (adds  few  cases,  and  reviews  the  subjects  of  arsenical  keratosis  and 
arsenical  cancer  with  tabulations  of  reported  cases,  with  references) ;  Wile,  "Arsenical 
Cancer,  with  a  Report  of  a  Case,"  Jour.  Cutan.  Dis.,  1912,  p.  192  (on  fingers;  good  re- 
view, with  references;  19  cases  collected). 


88O  NEW  GROWTHS 

dally  of  a  keratotic  lesion  and  frequently  of  other  benign  skin  lesions — 
being  a  factor  of  importance;  and  that  this  irritant  may  be  of  various 
kinds  and  sources1 

Pathology. — Histopathologic  studies  of  the  epitheliomatous  proc- 
ess which  especially  interests  the  dermatologist,  show  that  it  consists, 
briefly  described,  in  the  proliferation  of  epithelial  cells — pavement 
epithelium — from  the  epidermis  or  from  the  epithelium  of  the  hair- 
follicles  or  glandular  structures,2  or  from  the  mucous  membrane;  the  cell- 
growth  takes  place  downward,  in  the  form  of  finger-like  prolongations  or 
columns,  or  it  may  spread  out  laterally  and  deeply  so  as  to  form  rounded 
masses,  the  centers  of  which  usually  undergo  horny  transformation, 
resulting  in  the  formation  of  onion-like  bodies,  the  so-called  "pearls," 
"cell-nests,"  or  "globes."  The  rapid  cell-growth  requires  increased 

1  In  a  paper  in  which  the  possible  etiologic  factors  are  gone  over,  and  carefully 
considered,  Hartzell  ("Etiology  and  Pathology  of  Malignant  Diseases  of  the  Skin 
Affecting  Epithelial  Tissue,"  Jour.  Cutan.  Dis.,  1900,  p.  435),  concludes  as  follows: 
"We  may  regard  it  as  fairly  well  demonstrated  that  carcinoma  results  from  a  pro- 
found and  more  or  less  permanent  alteration  of  the  mechanism  of  cell-division.     This 
alteration  may,  in  my  opinion,  result  from  long- continued  irritation  of  a  mechanical  or 
chemical  kind,  including  under  this  latter  the  effects  of  toxins  resulting  from  micro- 
organisms.    Accordingly  it  seems  likely   that  the  immediate  causes  of  cancer  are 
multiple." 

Ten  years  later,  in  a  similar  study  and  review,  Fordyce  ("The  Pathology  of 
Malignant  Epithelial  Growths  of  the  Skin,"  Jour.  Amer.  Med.  Assoc.,  Nov.  5,  1910, 
p.  1624)  reaches  practically  the  same  conclusion:  "A  study  of  skin  cancers  suggests 
to  the  observer,  if  it  does  not  demonstrate  absplutely,  that  no  one  agent  is  con- 
cerned in  the  malignant  proliferation  of  epithelial  tumors  and  that  cutaneous  car- 
cinomata  have  a  multiple  etiology.  The  development  of  epitheliomata  following 
exposure  to  sunlight,  rt-rays,  or  other  radiant  energy  is  a  strong  argument  against 
the  parasitic  nature  of  the  disease.  Likewise,  the  occurrence  of  epitheliomata  in 
xeroderma  pigmentosum  and  allied  conditions  of  the  skin  which  come  on  in  old 
age  or  middle  life  is  an  additional  argument  against  this  theory.  These  conditions 
are  preceded  by  changes  identical  with  those  met  with  in  xeroderma  pigmentosum, 
such  as  a  dry  atrophic  skin,  telangiectases,  warty  growths  and,  finally,  malignant 
transformation.  Furthermore,  the  action  of  chemical  substances  on  epithelium,  for 
which  they  have  a  special  predilection,  such  as  arsenic,  tar,  scarlet  R.,  tobacco,  etc., 
demonstrate  that  a  variety  of  agents  have  the  power  to  stimulate  epithelial  mitoses 
which  may  pass  into  malignancy.  Cancers  which  develop  on  scar  tissue  or  antecedent 
conditions  of  the  skin  like  lupus,  syphilis,  etc.,  suggest  that  we  are  dealing  with  mis- 
placed cells  in  some  cases  and  in  others  with  degenerative  processes  which  lead  to  the 
abolition  of  the  functional  activity  of  the  cells,  which  is  followed,  as  a  consequence, 
by  vegetative  activity,  according  to  the  theory  of  Oertel,  Adami,  and  others.  In 
primary  multiple  epitheliomata  we  have  several  foci  in  which  an  infectious  agent  or 
some  internal  sensitizing  agent  may  have  acted  on  the  cells  and  rendered  them  sus- 
ceptible to  a  local  factor." 

See  also  paper  by  Schamberg,  "Cancer  in  Tar  Workers,"  Jour.  Cutan.  Dis.,  1910, 
p.  644  (4  personal  cases;  review  of  the  literature  bearing  upon  cancer  in  workers  in  tar, 
paraffin,  soot  (chimney-sweep's  cancer),  with  bibliography) ;  by  Loeb,  "Etiology  of  Can- 
cer of  the  Skin,"  Jour.  Amer.  Med.  Assoc.,  1910,  Iv,  p.  1607  (reviews  the  various  theories 
and  concludes  that  irritation  is  of  the  greatest  etiologic  significance);  Bowen,  "Precan- 
cerous  Dermatoses,"  Jour.  Cutan.  Dis.,  1912,  p.  241  (report  of  2  cases;  reviews  the 
subject  of  the  various  precancerous  dermatoses  with  literature  references);  Sachs, 
Wien.  klin.  Woehenschr.,  Nov.  9,  1912  (remarkable  production  of  warts  and  warty 
eczema  on  the  hands  of  those  working  in  anilin  dyes;  experimental  investigations  with 
animals  (rabbits)  confirmed  the  property  of  these  dyes  to  induce  granulation  and  epi- 
thelioma-like  excrescences,  which  may  undergo  degeneration) . 

2  As  to  its  origin  in  the  sweat-glands  see  Fordyce's  paper,  "Adenocarcinoma  of  the 
Skin,  Originating  in  the  Coil-gland,"  Jour.  Cutan.  Dis.,  1895,  p.  41  (report  of  a  case 
with  histologic  cuts  and  review  and  references),  and  for  an  admirable  general  pres- 
entation with  case  illustrations  and  histologic  cuts;  Fordyce,  "Clinical  and  Patho- 
logical Observations  on  Some  Early  Forms  of  Epithelioma  of  the  Skin,"  New  York 
Med.  Jour.,  June  9  and  23,  1900. 


CARCINOMA    CUT  IS 


881 


nutriment,  and  hence  the  blood-vessels  become  enlarged;  moreover,  the 
pressure  of  the  cell-masses  and  their  invasion  of  other  tissues  give  rise 
to  irritation  and  inflammation  and  consequent  increased  blood-supply, 
with  corresponding  serous  and  round-cell  infiltration. 

Epitheliomata  of  the  skin  histologically  present  two  types,  the  lobu- 
lated  and  the  tubular.  The  former,  which  is  the  more  frequent,  shows, 
as  the  name  signifies,  a  massing  of  the  epithelial  new  growth  in  the  form 
of  lobules,  and  each  lobule  is  noted  to  be  composed  of  concentric  strata 
of  cells,  which  correspond  in  their  changes  to  the  several  strata  of  the 
epidermis — from  those  of  the  rete  to  those  of  the  corneous  layer.  The 


Fig.   221. — Epithelioma — section  from  the  margin  of  a  deeply  eating  rodent  ulcer 
variety  of  the  eye  region;  eye  already  destroyed  (courtesy  of  Dr.  A.  R.  Robinson). 

innermost  cells  of  the  lobule  show  imperfect  cornification,  while  the  outer- 
most cells  correspond  to  those  of  the  basic  cylindric  cells  of  the  rete, 
those  of  between  layers  showing  the  various  changes  from  the  latter  to 
the  former.  Owing  to  the  pressure  upon  the  central  mass  of  cells,  the 
onion-like  bodies,  or  cell-nests,  already  referred  to,  are  produced.  These 
are  usually  found,  at  least  most  abundantly  and  of  typical  formation, 
in  the  deeper  parts.  In  some  instances  this  central  portion  undergoes 
colloid  degeneration.  Offshoots  from  the  down-growing  lobules  are 
frequently  noticed,  and  these  present  the  same  characters  and  undergo 
the  same  changes  as  in  the  parent  lobules.  When  the  epithelial  masses 

56 


882  NEW  GROWTHS 

are  of  rapid  growth,  the  cells,  from  mutual  pressure,  may,  in  places,  be 
spindle  shaped.  In  the  tubular  or  cylindric  type  the  epithelial  growth 
is  in  the  form  of  cylindric  processes,  which  freely  anastomose  with  one 
another.  They  run  usually  more  or  less  perpendicularly  to  the  sur- 
face, but  in  some  instances  may  be  parallel  to  the  epidermis  and  occa- 
sionally presenting  a  pseudoglandular  appearance.  The  cells  are  com- 
posed of  smaller  cells  than  those  of  the  other  variety,  and  correspond 
more  closely  to  those  of  the  deeper  layer  of  the  rete.  They  show  prac- 
tically no  tendency  to  horny  transformation  and  the  formation  of  the 
cell-nests,  which  occur  in  the  lobulated  types  of  growth. 

The  conditions  in  the  rodent  ulcer  type  are  essentially  those  of 
tubular  epithelioma,  many  observers  believing  that  the  epithelial  pro- 
liferation takes  its  origin  in  the  epithelium  of  the  rete  (Collins  Warren, 
Robinson,  Unna),1  of  the  hair-follicle  (Tilbury  Fox,  Colcott  Fox,  Sang- 
ster,  Hume),2  sweat-glands  (Thin,  Walker),3  sebaceous  glands  (Thiersch, 
Butlin).  Fordyce4  views  it  as  a  small-celled  epithelioma  originating 
from  the  deep  layer  of  the  epidermis  or  the  hair-follicles.  Paul,  Boyce, 
Darier,  and  others  regard  it  simply  as  a  slow-growing  epithelioma  which 
may  start  from  the  epithelium  of  any  of  the  skin  structures,  and  this  view, 
judged  by  the  various  findings  referred  to,  is  probably  the  correct  one. 

Bodies  thought  to  be  organisms,  supposed  to  be  coccidia,  have  been 
found  in  cancer-cells,  chiefly  by  Albarran  and  Malassez;  they  occur  in 
very  small  number,  and  principally  in  the  very  center  of  the  cell-nests, 
but  the  investigations  and  studies  of  Borrel5  and  Hutchinson,6  Jr.,  have 
led  them  to  the  conclusion  that  they  are  not  of  parasitic  nature.  Welch, 
Noeggerath,  Torok,  and  others  (cited  by  Fordyce),  have  also  failed  to 
substantiate  the  claims.  Gaylord's  interesting  observations  as  to  the 
presence  of  organisms  are  too  incomplete  to  warrant  a  definite  conclu- 
sion. Most  of  the  findings  so  far  made  by  investigators  are  thought  to 
represent  various  forms  of  cell  degeneration. 

Diagnosis. — The  main  diagnostic  points  in  epithelioma  to  re- 
member are:  the  age  of  the  patient;  the  usually  single  character  of  the 
growth;  its  beginning  in  a  wart,  mole,  nodule,  or  scurfy  spot;  the  char- 
acter of  the  border — pearly,  with  roll-like  elevation  or  a  hard,  elevated 
infiltration;  the  scant,  and,  in  the  later  stages,  viscid  discharge,  frequently 
streaked  with  blood;  its  usually  slow  progress;  the  frequent  situation 
about  the  nose,  eyelids,  or  other  parts  of  the  face;  its  finally  involving, 
in  many  instances,  the  neighboring  lymphatic  glands,  more  especially 
when  the  lesion  is  seated  near  these  structures.  Microscopic  examina- 
tion of  a  section  of  the  tissue  is  generally  conclusive  in  doubtful  cases. 

1  Collins  Warren,  The  Anatomy  and  Development  of  Rodent  Ulcer,  Boston,  1872; 
Unna,  Histo pathology. 

2  Tilbury  Fox  and  Colcott  Fox,  London  Patholog.  Soc'y  Trans.,  1879,  vol.  xxx,  p. 
360  (with  histologic  cuts);  Sangster,  Brit.  Jour.  Derm.,  1882,  p.  777. 

3  Thin,  loc.  tit.;  Walker,  Brit.  Jour.  Derm.,  1893,  p.  286. 

4  Fordyce,  loc.  cit.,  and  Morrow's  System,  vol.  iii  (Dermatology),  p.  655,  to  whose 
article  I  am  indebted. 

5  Borrel,  "Sur  la  signification  des  figures  decrites  comme  coccidies  dans  les  epithe- 
liomes,"  Arch,  de  med.  exper.,  1800,  p.  786  (with  colored  plate  presenting  5  histologic 
cuts). 

•Hutchinson,  Jr.,  "On  Psorosperms  and  Skin  Diseases,"  Brit.  Jour.  Derm.,  1891, 
p.  277. 


CARCINOMA    CUTIS  883 

The  lesions  from  which  it  is  to  be  differentiated  are  syphilitic  ulcera- 
tion,  warts,  and  lupus  vulgaris.  The  differentiation  from  the  last  is 
given  under  that  disease.  The  tubercular  ulcerating  syphiloderm, 
like  epithelioma,  is  frequently  seated  upon  the  face,  but  it  differs  in  sev- 
eral particulars  from  the  latter.  It  is  usually  multiple,  consisting  of 
several  superficial  ulcerations  and  not,  as  a  rule,  rounded  in  shape,  but 
segmental  or  irregularly  circinate.  Tubercles  which  have  not  as  yet 
undergone  destructive  change,  or  without  such  tendency,  are  also  com- 
monly seen  in  association  with  the  syphilitic  ulcerations,  and  with  the 
same  disposition  to  the  segmental  or  serpiginous  configuration.  More- 
over, syphilitic  ulcers  have,  as  a  rule,  quite  a  free  discharge,  and  generally 
of  distinctly  purulent  character. 

Benign,  warty-looking  formations  and  fleshy  moles  are  to  be  differen- 
tiated from  those  of  beginning  malignant  growths  by  attention  to  their 
history  and  course;  in  fact,  long-continued  observation  may  be  necessary 
before  a  positive  opinion  is  warrantable.  The  appearance  of  any  tend- 
ency to  crusting,  to  break  down,  or  ulcerate,  is  significant  of  epithelio- 
matous  degeneration.  Such  a  benign-looking  lesion,  showing,  therefore, 
one  or  two  fissures  at  the  summit  or  edge  of  the  base,  or  exhibiting  slight 
abrasions,  which  are  persistent,  is  to  be  viewed  as  a  beginning  epithe- 
lioma. 

On  the  lip  a  persistent,  localized  thickening  or  abrasion  of  several 
months'  or  more  duration,  especially  when  on  the  lower  lip,  and  occurring 
in  an  individual  over  forty,  means  almost  always  an  epithelioma.  The 
possibility  of  this  region  being  the  seat  of  the  initial  lesion  of  syphilis  is 
not,  however,  to  be  forgotten,  and  in  the  earliest  stage  a  differentiation 
is  sometimes  impossible,  but  the  more  rapid  development  of  the  latter, 
with  usually  but  little  tendency  to  active  or  large  ulceration,  and  with 
soon  the  appearance  of  secondary  symptoms  of  the  disease,  will  serve 
for  final  differentiation.  About  the  genitalia  epitheliomata  practically 
present  the  same  features  as  elsewhere,  frequently  beginning  as  a  warty- 
looking  lesion,  and  slowly  and  gradually  developing  into  a  spreading 
infiltrated  and  destructive  epitheliomatous  ulcer.  It  is  here  to  be  dis- 
tinguished from  a  chancre  and  from  the  tuberculogummatous  infiltration 
and  ulceration  of  later  syphilis. 

Prognosis. — In  an  opinion  as  to  prognosis  in  epithelioma  several 
factors  are  to  be  considered — the  variety,  extent,  duration,  and  rapidity 
of  the  process.  In  all  instances  the  earlier  treatment  is  instituted,  the 
less  chance  is  there  of  recurrence.  In  many  cases  of  the  more  superficial 
forms,  the  disease,  even  if  neglected,  is  slow  in  its  progress,  often  lasting 
for  ten,  fifteen,  or  more  years  before  seriously  threatening  the  patient's 
life.  Thin1  records  an  extreme  instance  of  a  cancerous  ulcer  of  the  rodent 
type  in  a  woman  aged  sixty-eight,  involving  shoulder  and  upper  part 
of  the  back,  which  had  begun  forty-three  years  previously  as  a  pimple 
or  wart.  In  the  earliest  stages  of  the  cases  ordinarily  met  with  in  derma- 
tologic  practice,  when  the  disease  is  limited,  on  the  face,  and  of  a  super- 
ficial type,  treatment  is  almost  invariably  successful  and  permanently 

1  Thin,  London  Patholog.  Soc'y  Trans.,  1879,  vol.  xxix,  p.  237  (was  histologically 
of  cylindric  type  and  had  apparently  started  in  the  sweat-glands). 


884  NEW  GRO WTHS 

so.  I  have  had  a  large  number  of  such  cases  under  my  care,  and  if  not 
far  advanced  or  if  not  of  the  rapid,  deep-seated,  or  papillomatous  type, 
with  no  glandular  involvement,  the  result  has  been  uniformly  good. 
Even  when  such  cases  are  moderately  advanced,  the  outlook  is  usually 
favorable.  The  same  may  be  said  of  the  deep-seated  and  papillomatous 
varieties  if  not  of  too  long  duration,  but  in  these  glandular  involvement 
is,  after  a  time,  not  uncommon,  and  quite  the  rule  later.  Cases  in  which 
conspicuous  destruction  has  already  ensued,  and  in  which  there  is  con- 
siderable surrounding  infiltration  and  of  long  duration,  the  prognosis  as 
to  successful  permanent  removal  is  not  so  favorable,  and  particularly 
so  if  the  glands  are  already  infected.  The  rodent  ulcer  type,  when 
allowed  to  have  full  sway  and  neglected,  and  covering  a  large  area,  is 
of  serious  nature,  removal,  unless  early  and  complete,  often  being  fol- 


Fig.  222. — Epithelioma  of  papillomatous  type  in  a  woman  aged  sixty-three. 

lowed  by  recurrence  and  finally  death.  Epithelioma  of  the  back  of  the 
hand  is  usually  responsive  to  proper  measures,  but  the  prognosis  is  not 
so  favorable  as  with  the  ordinary  face  cases,  and  axillary  gland  involve- 
ment sometimes  presents  early.  Epithelioma  of  the  genitalia  is  always 
of  serious  import,  although  prompt  action  in  the  beginning  disease  is 
commonly  successful. 

Treatment. — The  object  to  be  kept  in  view  in  the  treatment  of 
the  disease  is  the  thorough  destruction  or  removal  of  the  epitheliomatous 
tissue.  For  this  purpose  operative  measures  are  preferred  by  the  sur- 
geon,1 while  the  specialist  in  dermatologic  practice  usually  favors  the 
caustic  plans.  To  a  great  extent,  I  believe  this  difference  of  opinion  to 

1  Bloodgood,  "The  Surgical  Treatment  of  Malignant  Growths,"  Jour.  Amer.  Med. 
Assoc.,  1910,  Iv,  p.  1615  (based  on  malignant  pigmented  moles  65,  Sarcoma  of  the  derma 
45,  and  epithelial  tumors  of  the  skin  and  mucous  membranes  812,  and  benign  moles  75). 


CARCINOMA    CUTIS  885 

be  due  to  the  fact  that  those  cases  coming  under  our  care  are  relatively 
superficial  and  slight,  circumscribed,  and  slow,  whereas  those  coming 
to  the  knowledge  of  the  surgeon  are  for  the  most  part  of  a  more  serious, 
malignant,  and  extensive  nature.  The  former  do  well  and  probably 
better  with  caustic  methods,  the  latter  with  surgical  measures.  With 
well-defined,  sharply  circumscribed  epitheliomata,  especially  if  of  the 
deep-seated  and  papillomatous  varieties,  surgical  removal  is  to  be.  given 
the  preference,  particularly  if  the  lesion  is  seated  upon  parts  of  loose 
and  soft  texture,  where  excision  can  be  followed  by  approximation  of  the 
edges  and  thus  leave  but  a  linear  scar.  When  the  neighboring  glands 
are  implicated,  these,  too,  should  be  extirpated.  Such  cases,  however, 
naturally  belong  to  the  domain  of  surgery.  A  combination  of  the  surgical 
plan  of  thoroughly  curetting  the  area  and  then  following  with  caustic, 
such  as  the  application  of  a  50  per  cent,  solution  of  zinc  chlorid  or  60 
per  cent,  acid  nitrate  of  mercury  solution,1  or  momentary  cauterization 
with  caustic  potash  or  with  several  days'  use  of  a  strong  pyrogallol  salve, 
to  be  referred  to  later,  constitutes  a  successful  method,  applicable  in 
many  instances.  This  latter  plan  is  to  be  commended  for  epitheliomata 
of  moderate  size  and  infiltration.  For  those  instances,  however,  in  which 
the  slightest  mention  of  operative  procedure  is  met  with  opposition 
or  withdrawal,  the  caustic  plans  of  treatment  can  be  resorted  to;  and  for 
the  superficial  skin  cancers,  those,  as  a  rule,  without  glandular  involve- 
ment, and  which  often  come  to  the  specialist  in  dermatology,  I  am  con- 
vinced, from  considerable  experience,  that  the  method  is  not  only  a 
practicable  one,  but  usually  permanently  successful.2  The  effect  of  the 
caustic  seems  to  extend  beyond  the  escharotic  action  produced. 

The  favorite  caustics  are  pyrogallol,  zinc  chlorid,  caustic  potash, 
and  arsenious  acid.  After  their  use  the  subsequent  treatment  consists, 
when  possible,  of  the  continuous  application  of  poultices  until  the  slough 
comes  away,  and  then  a  mild  healing  ointment  of  i  to  2  per  cent,  pyrogal- 
lol salve,  one  of  equal  parts  of  mercurial  plaster  and  petrolatum,  or  of 
zinc  oxid.  When  poultices  are  not  practicable,  the  healing  ointment 
can  be  immediately  applied  after  the  cauterization;  in  such  instances, 
however,  the  slough  comes  away  much  more  slowly.  The  part  is  washed 
once  or  twice  daily,  and  oftener  if  there  is  much  discharge.  Pyrogallol 
is  applied  in  the  form  of  a  salve  of  25  to  40  per  cent,  strength,  in  the  man- 
ner described  under  Lupus  vulgaris,  and  continued  for  from  one  to  two 
or  three  weeks,  according  to  the  character  of  the  growth  and  the  rapidity 
of  action.  A  good  formula  consists  of  the  following: 

1$.     Pyrogallol,  3iiss-iij  (io.-i2.); 

Ac.  salicylic!,  gr.  xxv-1  (1.65-3.33); 

Cerat.  simp.,  3HJ  (4--8.); 

Petrolati,  q.  s.  ad  5j  (32.)- 

1  Sherwell,  Jour.  Cutan.  Dis.,  1910,  p.  487  (with  a  number  of  excellent  case  photo- 
graphs), has  had  remarkable  success  with  the  method  of  treatment-curetting  and 
supplementary  cauterization  with  the  acid  nitrate  of  mercury  solution. 

2  See  papers  on  the  caustic  treatment  by  Robinson,  Internal.  Jour.  Surg.,  1892,  p. 
179,  and  1893,  p.  164,  and  New  York  Med.  Rec.,  Mar.  31,  1900;  Gottheil,  "The  Treat- 
ment of  Skin  Cancers,"  New  York,  1899;  Stelwagon,  Jour.  Amer.  Med.  Assoc.,  Dec.  15, 
1900;  and  Heidingsfeld,  ibid.,  July  13,  1901;  Van  Harlingen,  Jour.  Cutan.  Dis.,  1906, 
p.  345,  strongly  commends  the  caustic  potash  treatment. 


886 


NEW  GROWTHS 


The  amount  of  cerate  depends  upon  the  season,  whether  warm  or  cold. 
The  formula  also  mentioned  under  Lupus  is  equally  available,  and  is 
sometimes  to  be  preferred  on  account  of  greater  adhesiveness.  Pyrogal- 
lol  is  a  relatively  painless  application,  and  has  its  chief  field  in  superficial 
epitheliomata  in  old  people  who  cannot  bear  well  the  stronger  caustics; 
and  also  is  of  great  value  as  a  supplementary  caustic  to  curetting,  as 
already  remarked.  It  is,  however,  a  weak  caustic  and  has  a  limited 
field.  Like  arsenic,  it  generally  spares  the  healthy  tissue. 

Zinc  chlorid  is  a  caustic  formerly  much  in  vogue  for  its  destructive 
action.  It  is  painful  and  destroys  morbid  and  healthy  tissue  alike. 
Its  action  is  peculiar  in  that  it  seems  to  mummify  the  tissue,  and  there- 
fore is  especially  applicable  to  epitheliomata  situated  over  blood-vessels. 


Fig.  223. — Epithelioma  of  papillomatous  lype;  showing  also  old-age  changes — freckle- 
like  pigmentation  and  scurfy  patches. 

It  is  most  commonly  applied  as  Bougard's  paste,  but  for  satisfactory 
compounding  it  requires  ordinarily  somewhat  more  water  than  given, 
although  it  is  advisable  to  exceed  the  quantity  in  the  formula  as  little 
as  possible,  so  that  the  paste  may  be  like  stiff  dough,  and  then  to  add  at 
the  time  of  application  a  sufficient  quantity  of  a  saturated  solution  of 
cocain  hydrochlorate  to  bring  it  up  to  working  consistence.  The  for- 
mula is  as  follows:  fy  Farinae  trit.  (wheat  flour),  pulv.  amyli,  aa  5ss 
(16.);  pulv.  ac.  arseniosi,  gr.  iv  (0.26);  pulv.  hydrarg.  sulph.  rub.,  pulv. 
ammonii  chlorid.,  aa  gr.  xx  (1.33);  pulv.  hydrarg.  chlorid.  corr.,  gr.  ij 
(0.135);  zinci  chlorid.  cryst.,  3iv  (16.);  aqua?  fervid.,  5j  (32.).  The  first 
six  ingredients  are  thoroughly  mixed,  the  zinc  chlorid  dissolved  in  the 
water,  and  the  two  mixtures  rubbed  up  together  secundum  artem. 


CARCINOMA    CUTIS  887 

This  is  spread  on  any  suitable  material  and  applied  to  the  growth,  ex- 
tending slightly  beyond  the  border.  The  depth  destroyed  is  usually 
one  or  two  times  the  thickness  of  the  layer  of  paste.  It  takes  about 
twenty-four  to  forty-eight  hours  for  sufficient  destruction;  it  is  some- 
times necessary  to  remove  the  mummified  mass  by  paring  it  away 
and  reapplying  a  fresh  plaster.  There  is  considerable  inflamma- 
tory swelling.  In  superficial  lesions  rarely  more  than  one  application 
is  necessary.  The  separation  of  the  slough  requires  from  five  to  twenty 
days. 

Caustic  potash  is  a  powerful  caustic  and  must  always  be  used  with 
care.  It  is  rapid  in  its  action,  one  thorough  application  usually  sufficing 
to  destroy  the  entire  growth.  It  has  its  special  field  in  small  and  be- 
ginning cutaneous  skin  cancers,  and  in  those  in  which  time  is  important 
and  in  which  the  patient  can  remain  under  observation  only  a  short 
period.  The  stick  should  be  employed,  or  the  strongest  possible  solution ; 
the  former  is  preferable.  If  the  surface  of  the  growth  is  crusted,  this 
should  be  removed,  and  the  parts  outside  of  the  diseased  area  protected 
with  a  layer  of  vaselin,  after  which  the  caustic  is  applied.  If  the  lesion 
is  small  and  superficial,  the  desired  effect  is  usually  sufficiently  attained 
in  a  minute  or  two,  and  then  further  action  is  to  be  prevented  by  the 
application  of  dilute  acetic  acid  or  vinegar.  This  caustic  is  painful,  but 
only  at  the  time  of  application. 

Arsenic  is  undoubtedly  the  best  caustic  to  employ  in  many  of  these 
cases.  It  certainly  has,  relatively  speaking  at  least,  an  elective  action, 
ordinarily  sparing  healthy  tissue,  so  that  it  is  especially  applicable  in 
places  where  unnecessary  destruction  and  disfigurement  are  to  be  avoided, 
as  particularly  about  the  nose  and  in  the  neighborhood  of  the  eyelids.  It 
should  not  be  applied  to  a  large  surface,  not  larger  than  a  square  inch. 
Marsden,  Robinson,  Gottheil,  and  others,  including  myself,  who  have 
employed  it  frequently,  have  never  seen  dangerous  absorption  from  its 
cautious  use.  It  may  be  employed  in  several  strengths,  according  to  the 
case  and  the  effect  required.  Marsden  advised  a  paste  (Marsden's 
paste)  made  of  two  parts  of  arsenious  acid  and  one  of  mucilage  of  acacia. 
Robinson  recommends  two  strengths,  one  of  equal  parts  of  arsenious 
acid  and  powdered  acacia,  and  one  of  two  parts  of  the  arsenic  and  one 
of  the  acacia,  using  sufficient  water  at  the  time  of  application  to  make  into 
a  paste  of  the  consistence  of  stiff  butter.  I  have  employed  it,  in  most 
cases,  in  about  equal  proportions,  in  small  and  somewhat  deep-seated 
lesions,  using  two  or  three  parts  of  arsenious  acid  to  one  of  acacia,  making 
up  into  a  paste  with  a  saturated  solution  of  cocain  hydrochlorate.  It 
requires  from  twelve  to  thirty-six  hours  for  sufficient  action,  producing 
a  good  deal  of  inflammatory  swelling  and  edema;  occasionally  a  second 
application  is  necessary.  It  is  painful,  but  many  patients  prefer  it  to 
surgical  operation.  It  is  the  principal  ingredient  in  most  of  the  quack 
cancer  plasters.  The  slough  separates  slowly. 

Recently  carbon-dioxid  snow  (q.  v.)  has  been  extolled  for  its  favorable 
cauterizing  action  in  the  small  superficial  and  beginning  rodent  ulcer 
types. 

Electrolysis  has  also  had  occasional  advocates  for  certain  mild  or 


888  NEW  GROWTHS 

slight  cases — with  the  needle  in  small  lesions  or  recurring  small  tubercles 
in  the  scar  after  other  treatment;  and  with  the  small  metallic  plate,  as 
in  lupus  vulgaris,  in  small  flat  growths.  If  used  with  a  current  of  5  to 
20  milliamperes,  it  is  capable  of  active  destruction. 

The  treatment  of  epithelioma  by  the  Finsen  concentrated  chemic 
light  method  (see  Lupus  vulgaris)  has  been  favorably  reported  upon 
by  some  writers,  among  whom  the  latest,  Bie,1  who  had,  in  16  cases, 
a  good  proportion  of  satisfactory  results.  Finsen  regards  it  as  most 
favorable  in  those  cases  which  are  superficial  and  well  demarcated. 
According  to  these  observers,  about  30  exposures,  of  about  one  hour 
each,  are  required,  the  growth  gradually  shrinking  and  healing. 

The  plan  of  treatment  most  in  vogue  at  the  present  moment  is  that 
by  the  re-ray.  The  experience  of  Williams,  Pusey,  Pfahler,  and  many 
others,  including  myself,  attests  its  favorable  and  sometimes  curative 
action.  It  is  usually  slow,  and  on  this  and  other  accounts  is  not,  as  a 
rule,  to  be  advised  as  the  sole  measure  of  treatment;  in  superficial  forms, 
especially  when  involving  the  neighborhood  of  the  eye,  it  often  acts  well 
and  comparatively  quickly.  Its  special  field  of  usefulness  is,  in  my 
opinion,  as  a  supplementary  measure  to  those  methods  already  practised 
and  described  above.  To  secure  a  result  it  must  often  be  pushed  to  the 
point  of  producing  a  mild  erythema  or  even  moderate  dermatitis.  Ex- 
posures are  made  every  one  to  three  days,  at  a  distance  of  3  to  15  inches, 
and  of  six  to  twenty  minutes'  duration,  depending  upon  the  effect;  and 
in  superficial  cases  or  those  of  but  slight  or  moderate  depth  with  a  soft 
to  medium  tube.  It  is  not  a  good  plan,  however,  to  use  a  tube  of  the 
same  degree  of  vacuum  throughout;  otherwise  some  possible  deeper- 
lying  morbid  tissue  may  escape  its  favorable  action.  I  have  found  it  a 
good  plan  to  begin  the  seance  with  a  vacuum  equal  to  about  a  ^-inch 
spark,  and  then  to  do  away  with  the  regulator;  the  vacuum  slightly  rises, 
and  the  whole  depth  of  tissue  gets  its  share  of  the  full  effect  of  the  rays.2 
The  surrounding  parts  are  to  be  protected  by  thin  lead  foil.  The  first 
effects  consist  of  a  drying-up  of  the  secretion  and  a  gradual  shrinking 
of  the  ulcerated  area.  Some  cases  are  much  more  responsive  than  others, 
and  a  few  fail  to  show  any  marked  change.  In  some  cases  favorable 
influence  and  cure  in  cancerous  growths  follows  the  application  of 
radium,3  and  in  a  few  instances  under  my  own  care  it  has  been  of  helpful 
service. 

From  time  to  time  various  remedies  have  been  suggested  for  con- 
stitutional administration  as  having  a  favorable  action  in  certain  in- 
stances; arsenic  has  had  the  most  frequent  mention,  but,  excepting  a 
few  observers,  it  has  but  little  support.  Sherwell4  is  convinced  of  its 
value,  and  makes  its  administration  a  routine  practice,  along  with  proper 

1  Bie,  Dermatolog.  Zeitschr.,  Aug.,  1900,  p.  630 — abs.  in  Brit.  Jour.  Derm.,  1900, 
P-  376. 

2  The  details  on  a;-ray  treatment  are  more  fully  given  under  General  Remarks  on 
Treatment,  in  the  first  part  of  the  volume. 

3  Abbe,  "Radium  in  Surgery,"  Jour.  Amer.  Med.  Assoc.,  1906,  vol.  xlvii,  p.  183; 
Wickham  and  Degrais,  "Radiumtherapie,"  Paris,  1909. 

4  Sherwell,  "The  Use  of  Arsenic,  etc.,  in  Cancerous  and  Other  Neoplasms,"  Med. 
Record,  April  28,  1900. 


XERODERMA   PIGMENTOSUM  889 

local  measures;  Lassar1  has  also  reported  favorable  effects,  and  Pusey2 
thinks  it  may  have  an  inhibitory  action. 

XERODERMA  PIGMENTOSUM3 

Synonyms.— Angioma  pigmentosum  atrophicum  (Taylor);  Dermatosis  Kaposi 
(Vidal);  Atrophoderma  pigmentosum  (Crocker);  Melanosis  lenticularis  progressiva 
(Pick) ;  Liodermia  essentialis  cum  melanosi  et  telangiectasia  (Neisser) ;  Lentigo  maligna 
(Piffard);  Epitheliomatose  pigmentaire  (Besnier). 

Definition — A  malignant  disease,  usually  developing  in  early 
life,  characterized  primarily  by  freckle-like  spots,  especially  upon  ex- 
posed surfaces,  followed  by  telangiectases,  atrophic  changes,  angiomatous 
and  verrucous  lesions,  with  increased  pigmentary  deposit,  and  finally, 
generally  after  some  years,  by  epitheliomatous  growths  and  fatal  ending. 

This  malady  was  not  known  until  Kaposi  described  it  in  1870,  but 
since  then  new  cases  have  been  observed,  so  that,  at  the  present  time, 
over  80  are  on  record.  In  this  country  cases  have  been  reported  by  Tay- 
lor, Burning,  White,  Brayton,  Hutchins,  A.  H.  Bowen,  and  others. 

Symptoms. — This  rare  disease  begins  almost  invariably  in  the 
first  year  or  two  of  life,  and  probably  most  frequently  at  the  age  of 

1  Lassar,  Berlin,  klin.  Wochenschr.,  1893,  p.  83. 

2  Pusey,  "Treatment  of  Malignant  Growths  of  the  Skin  from  a  Dermatological 
Standpoint,"  Jour.  Amer.  Med.  Assoc.,  1910,  Iv,  p.  1611. 

3  Literature:   Kaposi,  Wien.  med.  Jahrbucher,  1882,  p.  619  (with  4  colored  plates 
showing  4  patients,  and  3  histologic  cuts);  and  Wien.  med.  Wochenschr.,  1885,  p.  1334 
(case  demonstration,  with  brief  report  and  a  tabulation  of  38  cases) ;  Taylor,  Med.  Record, 
Mar.  10,  1888  (detailed  history  of  7  cases,  extending  over  fourteen  years,  and  tabulated 
history  and  abstract  (including  his  7)  of  40  cases  to  date);  Archambault,  "Dermatose 
de  Kaposi,"  These  de  Bordeaux,  1890  (review  of  cases);  Lukasiewicz,  Archiv,  1895, 
vol.  xxxiii,  p.  37  (with  8  excellent  histologic  cuts).     These  several  papers  cover  73  cases 
recorded  to  date.     Phillips,  St.  Bartholomew's  Hasp.  Reps.,  1895,  p.  221;  West  (same 
case  as  the  preceding),  Brit.  Jour.  Derm.,  1896,  p.  45,  and  1898,  p.  57;  Crocker,  ibid., 
1896,  p.  442  (case  demonstration  of  one  of  his  previously  reported  cases);  Pringle, 
ibtd.,  1897,  p.  157  (case  demonstration — patient  aged  three);  Falcao,  Trans.  Third  In- 
ternal. Derm.  Cong.,  London,  1896 — abs.  ref.  in  Jour.  Cutan.  Dis.,  1897,  p.  173  (re- 
ported case  of  woman,  aged  eighty-eight,  and  refers  to  3  others  observed  by  him,  aged 
respectively  seventy-two,  eighty-nine,  and  ninety — -these  are  rather  suggestive  of  cases 
of  atrophia  senilis);  Jamieson,  Brit.  Jour.  Derm.,  1898,  p.  325  (case  demonstration, 
girl  aged  six— a  younger  sister  also  showing  suspicious  freckling) ;  Bareldt,  Br it.  Med. 
Jour.,  1898,  ii,  p.  1342  (brief  report;  patient  aged  two  and  a  half);  Bronson,  Jour. 
Cutan.  Dis.,  1899,  p.  572  (case  demonstration — girl  of  eight,  first  evidence  when  six 
months  old);  Okamura,  Archiv,  1900,  vol.  li,  p.  87  (report  especially  as  to  blood  ex- 
aminations of  3  cases);  Hutchins,  Jour.  Cutan.  Dis.,  1893,  p.  402;  Brayton,  ibid.,  1892, 
p.  129  (with  colored  plate),  and  Jour.  Amer.  Med.  Assoc.,  April  29,  1899  (3  cases  in 
same  family);  A.  H.  Bowen,  ibid,  (i  case).     The  case  by  Duhring,  Amer.  Jour.  Med. 
Sci.,  Oct.,  1878,  and  2  (brother  and  sister)  by  J.  C.  White,  Jour.  Cutan.  Dis.,  1885, 
p.  353,  are  included  in  Taylor's  summary  and  review;  Francoz,  Contribution  a  I'etude 
du  Xeroderma  pigmentosum,  These,  Lyon,  1905  (complete  bibliography);  Nicolas  and 
Favre,  Annales,  1906,  p.  536  (clinical  and  histologic;  2  cases,  i  a  woman  aged  seventy- 
one);  W.  B.  Adams,  Jour.  Cutan.  Dis.,  1907,  p.  473  (case  report,  with  plate  case  illus- 
tration; patient,  young  woman,  aged  nineteen);  Hahn  and  Weik,  Archiv,  vol.  Ixxxvii,  H. 
2  and  3  (2  cases;  and  experimental  investigation  of  the  operation  of  different  kinds  of 
light);  Schonnefeld,  Archiv,  Oct.,  1910,  civ  (benign  case  with  short  review  of  reported 
benign  cases;  and  literature  references  to  185  cases  of  the  disease);  Rouviere,  An- 
nales, Jan.,  1910,  p.  34  (in  a  family  of  four  brothers  and  four  sisters,  three  of  the  sis- 
ters had  the  disease,  and  one  death  followed  soon  after  glandular  enlargements  ap- 
peared; an  apparent  cure  in  one  case  by  x-ray  treatment);  C.  J.  White,  Boston  Med. 
and  Surg.  Jour.,  May  4,  1911  (case  report,  patient  Irish  girl,  aged  n — first  evidence 
when  several  months  old;  histolog.  exam.);  Toyama,  Japanische  Zeitschr.  f.  Derma- 
tologie  und  Urologie,  May,  1912,  abs.  Jour.  Cutan.  Dis.,  1912,  p.  499  (finds  a  report 
of  33  cases  in  Japanese  literature;  four  of  his  own). 


890  NEW  GROWTHS 

five  or  six  months.  The  first  symptom  noted  consists  of  lentiginous 
spots,  scarcely,  if  at  all,  distinguishable  from  ordinary  freckles.  These 
are  more  particularly  observed  in  summer  or  after  sun-exposure,  and 
especially  upon  exposed  portions,  the  disease  at  this  time  being  more  or 
less  confined  to  the  face,  scalp,  neck,  upper  shoulders,  hand  and  forearms. 
The  scalp  is  not  often  affected,  although  sometimes  scaly;  in  Duhring's 
case,  however,  this  region  was  notably  involved.  These  lesions  may  dis- 
appear in  winter,  and  reappear  the  following  summer;  this  may  occur 
once  or  several  times;  finally  they  remain,  and  become  more  intensely 
pigmented.  Not  infrequently  an  erythematous  condition  of  the  skin  due 
to  sun-  or  wind-exposure  precedes  the  appearance  of  the  freckles.  Shortly 
following  the  first  outbreak,  or  some  months  afterward,  telangiectases 
are  also  noted,  and  atrophic  white  spots  begin  to  present,  scattered 
irregularly  among  the  other  lesions,  and  here  and  there  with  a  tendency 
toward  coalescence,  resulting  in  larger,  rounded,  or  irregular  cicatricial- 
looking  areas,  upon  which  the  skin  is  often  smooth,  shiny,  and  wrinkled, 
and  sometimes  covered  with  thin  scales;  or  the  surface  has  a  stretched, 
glistening  appearance,  with,  in  some  areas,  a  pinkish  tinge,  and  with 
the  veins  showing  through.  The  sensibility  of  the  atrophic  areas  is 
sometimes  lessened,  and  the  sweat-glands  are  less  active.  The  freckle- 
like  spots,  which  may  be  rounded  or  irregular  in  outline,  gradually  in- 
crease in  numbers  and  in  places  seem  almost  confluent;  in  others  the 
skin  is  noted  to  be  considerably  darkened  in  hue,  with  a  freckle-like 
accentuation  here  and  there.  The  discoloration  is  most  marked  on  ex- 
posed parts,  and  primarily,  as  a  rule,  only  there,  but  in  some  instances, 
especially  later  on,  covered  surfaces  may  display  a  similar,  blotchy  pig- 
mentation. The  telangiectases  are  usually  upon  uncovered  surfaces, 
and  consist  of  minute,  red,  pin-point  to  pea-sized  spots,  vascular  twigs, 
and,  particularly  later,  small  angiomatous  growths.  The  vascular 
lesions  are  more  noticeable  in  the  leukodermic  areas. 

The  malady  may  thus  continue  for  months  or  several  years.  As 
a  rule,  sooner  or  later  more  positive  changes  ensue.  Some  of  the  pig- 
mented spots  become  elevated,  thickened,  and  papillomatous,  and 
when  small,  apparently  similar  to  warts.  At  this  stage,  therefore,  pig- 
mented, freckle-like  lesions,  clearly  pigmented  areas,  atrophic,  thinned, 
glistening,  or  slightly  scaly,  white,  cicatricial  spots  and  plaques,  and 
pit-like  depressions,  dark  warts,  and  small,  dark,  wTarty-looking  patches, 
with  scattered  telangiectases  and  some  small  angiomatous  growths, 
are  to  be  seen — for  the  most  part  on  the  face,  ears,  n«ck,  upper  chest, 
hands,  and  forearms,  although  often  to  some  extent  upon  other  regions. 
Ectropion  and  ulcerative  keratitis  are  usual  concomitants,  and  there 
may  also  be  cicatricial  contraction  about  the  nose  and  mouth.  The 
skin  of  the  affected  regions  is  more  or  less  atrophic,  somewhat  thinned, 
stretched-looking,  and  hence  the  term  xeroderma,  or  parchment  skin. 
While  the  various  lesions  often  arise  without  any  dependence  one  upon 
the  other,  in  some,  according  to  Kaposi,  the  pigment  spot  gradually 
becomes  telangiectatic,  and  later  undergoes  sclerosis,  atrophy,  and 
whitening.  Taylor  thought  the  pigmentation  followed  upon  the  telan- 
giectasis,  but  Duhring,  White,  and  others  recognized  that,  at  least  as  to 


XERODERMA    PIGMENTOSUM  89! 

most  early  lesions,  there  was  no  interdependence.  In  some  instances  the 
melanoderma  has  been  more  or  less  uniform  and  widespread.  The 
disease  frequently  remains  relatively  or  completely  quiescent  for  several 
months  or  longer,— in  one  of  Crocker's  cases  for  a  period  of  six  years,— 
although,  as  a  rule,  there  is  a  steady  progress,  with  a  tendency  of  the 
sclerosed  skin  to  undergo  superficial  ulceration.  In  most  cases,  after 
several  years  or  much  longer,— ten  to  thirty  years  in  some  instances,— 
the  verrucous  and  angiomatous  growths  or  the  pigmented  spots  become 
the  seat  of  malignant  changes  of  an  epitheliomatous  or  sarcomatous 
character, — so  that  ulcerating  growths,  one,  several,  or  more,  are  added 
to  the  already  described  symptom-complex.  The  patients,  as  the  dis- 
ease persists,  usually  become  despondent  and  depressed,  brooding  over 
the  disfigurement  and  hopeless  character  of  the  malady. 

The  case  thus  progresses,  and  in  rare  instances  there  is  malignant 
involvement  of  the  internal  organs.  As  a  rule,  however,  the  process  is 
confined  to  the  integument,  sometimes  involving  the  mucocutaneous 
junctions,  and  in  rare  instances  insignificant  pigment  or  telangiectatic 
lesions  on  the  palpebral  conjunctiva,  lips,  and  buccal  cavity  are  seen. 
The  general  health  of  the  patients,  which  is  often  apparently  undisturbed 
in  the  first  years  of  the  malady,  now  begins  to  suffer  from  the  pain  and 
the  drain  of  the  malignant,  ulcerative  formations,  and  a  condition  of 
marasmus  or  exhaustion  is  gradually  engendered,  and  death  finally 
results,  although  this  does  not  usually  take  place  until  many  years  after 
the  first  appearance  of  the  lesions.  In  rare  cases,  after  some  years,  the 
disease  remains  stationary.  These  malignant  growths  may  be  scanty 
in  number,  or  may  constitute  the  chief  feature  at  this  time;  as  soon  as 
they  present,  the  malady  immediately  becomes  a  grave  one,  as  the  end 
generally  ensues  sooner  or  later.  In  some  instances  the  tumor  growths 
appear,  as  in  Falcao's  case,  within  a  year  or  so  after  the  first  appearance 
of  the  disease;  in  some  the  pigment  spots  may  be  scanty,  as  in  Stern's 
case,  and  the  tumor  element  conspicuous;  in  others  the  freckling  may 
remain  the  chief  feature  of  the  disease  for  many  years  before  its  serious 
character  develops.  In  Brayton's  case,  at  the  time  of  his  report,  the 
patient  had  already  had  the  disease  sixteen  years  without  serious  lesions 
save  the  ectropion,  and  was  still  enjoying  good  general  health.  As  a 
rule,  there  are  no  subjective  symptoms,  although  the  ulcerative  tumors 
are  sometimes  quite  painful. 

Etiology. — The  disease  has  its  beginning,  as  a  rule,  in  early  life, 
although  in  exceptional  instances  (Schwimmer,  Riehl,  Kaposi,  Hutchins, 
and  a  few  others)  it  has  first  presented  after  the  fifteenth  year.  It 
apparently  occurs  in  both  sexes  indifferently,  and  in  those  variously  cir- 
cumstanced. It  is  frequently  met  with  in  two  or  more  members  of  a 
family,  and  in  some  instances  there  seemed  a  hereditary  or  congenital 
predisposition.  Five  of  Taylor's  7  cases  occurred  in  two  Jewish  families, 
and  2  of  his  cases  were  cousins  of  3  others.  White's  2  cases  were  brothers, 
and  a  brother  of  Brayton's  2  cases  had  died  from  the  malady.  Rouviere 
had  3  sisters  with  the  disease  in  a  family  of  4  boys  and  4  girls.  Ruder 
had  7  brothers  with  the  disease  in  a  family  of  13  children,  and  so  might 
be  added  the  records  of  others,  although,  except  Rlider's  observation,  no 


892 


GROWTHS 


other  instance  of  more  than  3  cases  in  the  same  family  has  been  recorded. 
Some  authors  are  inclined  to  consider  the  sunlight  as  a  factor  in  starting 
the  pigmentary  process;  in  support  of  this  the  observation  has  been  made 
(Lukasiewicz,  Eulenberg,  and  others)  that  such  children  frequently 
develop  an  erythema  solare  or  similar  condition  after  sun-  or  wind- 
exposure.  This  is  scarcely  to  be  considered  more  than  an  accidental 
element,  and  even  with  such  an  assumption  there  must  be  a  peculiar 
inherent  susceptibility.  The  behavior  of  the  disease  and  its  frequent 
occurrence  in  2  or  3  members  of  a  family  have  suggested  a  parasitic  and 
contagious  cause,  but  the  investigations  of  Funk  and  others  in  this  direc- 
tion have  disclosed  nothing  tangible.  Kaposi's  belief  that  the  malady 
has  its  basis  upon  a  congenital  formative  and  nutritive  anomaly  of  the 
vascular  and  pigmented  portions  of  the  papillary  layer  is  somewhat 
disparaged  by  the  observation  of  its  occasional  beginning  in  later  life. 
In  fact,  beyond  the  significance  of  its  family  prevalence,  nothing  definite 
is  known  as  to  its  true  etiology. 

Pathology.  —  The  disease  is  an  atrophic  degenerative  process, 
with,  doubtless,  an  underlying  neurosis  and  congenital  tendency.  That 
does  not,  however,  take  us  very  far,  and  the  accruing  number  of  cases 
now  on  record  —  over  80  —  do  not  seem  to  have  added  much  to  our  knowl- 
edge of  the  subject.  The  oligocythemia  shown  by  Okamura's  blood 
investigations  of  3  cases  is,  as  he  suggests,  probably  due  to  functional 
skin  impairment,  resulting  from  the  integumentary  changes,  and,  there- 
fore, of  no  special  significance.  The  pathologic  histology  has  been  studied 
by  numerous  observers  (Kaposi,  Crocker,  Taylor,  Vidal,  Quinquaud, 
Unna,  Pollitzer,1  and  others),  and  discloses  the  usual  changes  which  the 
different  lesions  suggest.  In  fact,  there  is  no  distinctive  characteristic, 
the  usual  conditions2  found  in  lentigo,  atrophy,  verruca,  naevus  pigmen- 
tosus,  papillomatous  and  malignant  growths,  being  correspondingly 
exhibited  in  the  various  lesions  of  the  disease.  French  observers  are 
inclined  to  consider  the  malady  of  the  nature  of  a  pigmentary  epithe- 
lioma.  Pollitzer  states  that  in  one  section  of  a  tumor  growth  examined 
by  him  characters  of  epithelioma,  sarcoma,  myxoma,  granuloma,  etc., 
with,  however,  the  features  of  the  first  (epithelioma)  predominating, 
could  be  seen.  As  already  observed,  by  some  the  vascular  changes  are 
considered  primary,  by  others  as  secondary. 

Diagnosis.  —  A  well-developed  case  —  with  the  pigmentary  spots, 
telangiectases,  atrophy,  new  growths,  etc.  —  can  scarcely  be  mistaken 
for  any  other  affection.  The  earliest  stage,  with  merely  the  freckle- 
like  lesions,  probably  is  indistinguishable  from  ordinary  freckles,  although 
the  distribution  over  face,  neck,  shoulders,  hands,  and  forearms  might 
suggest  further  observation.  As  a  rule,  these  cases  rarely  come  under 
notice  before  the  telangiectatic  and  atrophic  tendencies  have  presented, 

1  Pollitzer,  Jour.  Cutan.  Dis.,  April,  1892,  gives  a  good  resume  of  the  histologic 
findings  of  the  various  investigators. 

2  Kaposi  has  given  the  different  histologic  phases  in  9  cuts  in  his  article  in  Twen- 
tieth Century  Practice,  vol.  v   ("Diseases  of  the  Skin"). 

Councilman  and  Magrath,  Jour.  Med.  Research,  Oct.,  1900,  studied  2  fatal  cases; 
they  found  that  the  tumors  did  not  penetrate  below  the  corium,  and  that  there  were  no 
metastases,  either  lymph-nodes  or  internally. 


SAXCOMA    CUTIS  893 

and  the  malady  is  then  generally  readily  recognized.  Scleroderma,  with 
its  accompanying  pigmentation,  sclerosis,  and  atrophy,  might,  if  care- 
lessly considered,  be  confounded  with  the  disease,  but  the  inception  and 
the  extent  and  characters  of  xeroderma  are  wholly  different  from  the 
former.  It  could  scarcely  be  confused  with  lupus  or  with  macular  leprosy 

Prognosis  and  Treatment.— The  prognosis  has  been  touched 
upon  sufficiently;  the  outlook  is  unfavorable,  the  delayed  tumor  forma- 
tions indicating  long  duration,  while  their  early  appearance  usually 
foreshadows  an  early  end. 

No  plan  of  treatment  has  yet  been  noted  to  have  a  favorable  influence 
upon  the  course  of  the  disease.  Arsenic,  mercurials,  potassium  iodid, 
cod-liver  oil,  etc.,  apparently  have  proved  without  result.  The  subcuta- 
neous injections  of  arsenic  in  increasing  dosage  might  be  worthy  of  a 
thorough  and  long-continued  trial.  The  therapeutic  management  of 
the  disease  is  essentially  palliative;  protection  against  sun-  and  wind- 
exposure  is  advisable.  Ulcerative  lesions  often  heal  under  mildly  stimu- 
lating antiseptic  salves,  or  used  conjointly  with  curetting;  excision  of 
troublesome  tumor  growths  is  usually  followed  by  healing.  The  eye 
conditions  require  attention,  a  boric  acid  lotion  applied  freely  and  often 
being  the  most  satisfactory.  By  persistent  care  the  patient  is  certainly 
made  more  comfortable,  epitheliomatous  development  possibly  delayed 
and  life  probably  prolonged  some  years.  Rouviere  (loc.  cit.}  reports 
an  apparent  cure  in  i  case  from  z-ray  treatment. 

SARCOMA  CUTIS 

Synonyms. — Sarcoma  of  the  skin;  Sarcomatosis  cutis;  Fr.,  Sarcome  cutane;  Sar- 
comatose  cutanee. 

The  cases  may  be  conveniently,  but  somewhat  arbitrarily,  divided 
into  three  classes:  (i)  Non-pigmented  sarcoma,  local  or  generalized;  (2) 
melanotic  sarcoma;  (3)  multiple  pigmented  (hemorrhagic)  sarcoma, 
the  last  being  that  form  originally  described  by  Kaposi.  This  division 
corresponds  essentially  to  that  adopted  by  De  Amicis,  whose  observation 
of  sarcomatous  cases  has  been  unusually  extensive.1 

Primary  Single  or  Localized  Non-pigmented  Sarcoma. — This  is  a 
relatively  less  malignant  type  of  sarcoma  than  other  forms,  and  may 
remain  as  a  single  or  localized,  slowly  growing  tumor  for  some  months 
or  years  before  destructive  changes  set  in  or  more  or  less  generalized 
and  metastatic  growths  appear.  It  varies  considerably  in  size  in  dif- 

1  De  Amicis,  Trans.  Twelfth  Internal.  Med.  Cong.,  at  Moscow,  1897;  abs.  in  Brit. 
Jour.  Derm.,  1897,  p.  440. 

Some  other  valuable  general  literature:  Perrin,  "De  la  sarcomatose  cutan6e," 
These  de  Paris,  1886,  with  review  of  the  subject  and  bibliography  to  date;  Funk,  "Klin- 
ische  Studien  iiber  Sarkome  der  Haut,"  Monatshefte,  1889,  pp.  19  and  60  (with  numer- 
ous references) ;  De  Amicis,  ibid.,  1897,  vol.  xxv,  p.  309  (with  some  references) ;  Fordyce 
gives  a  good  account  in  Morrow's  System,  vol.  iii  ("Dermatology") ;  J.  C.  Johnston  ("Sar- 
coma and  the  Sarcoid  Growths  of  the  Skin"),  Jour.  Cutan.  Dis.,  1901,  p.  305,  reviews 
the  whole  subject,  illustrated  by  many  admirable  photomicrographs;  Lieberthal,  Jour. 
Amer.  Med.  Assoc.,  Dec.  6, 1002,  p.  1454  (with  references) ;  Fernet,  "Congenital  Sarco- 
mata," Trans.  Path.  Soc'y,  London,  1902,  vol.  liii,  p.  360;  Mallory,  "Pathology  of 
Malignant  Diseases  of  Non-Epithelial  Formation,"  Jour.  Amer.  Med.  Assoc.,  No.  2, 
1910,  p.  1621. 


894  NEW  GROWTHS 

ferent  cases:  it  may  be  small,  scarcely  larger  than  a  good-sized  pea, 
or  more  commonly  the  dimension  of  an  egg  or  an  orange.  According 
to  Perrin,  the  original  tumor  rarely,  if  ever,  exceeds  the  latter  size. 
In  color  it  may  remain  almost  that  of  the  normal  skin,  but  is  usually 
pale  red  or  bluish,  with  often  the  surface  showing  dilated  capillaries. 
In  some  instances  the  blood-vessels  of  the  tumor,  which  are  generally 
abundant,  may  be  large  and  well  developed — sufficiently  so  to  give  to  the 
touch  a  perceptible  pulsation.  In  shape  it  may  be  nodular,  encapsulated, 
mushroom-like,  or  somewhat  diffused  in  outline,  and  occasionally  pedun- 
culated.  In  its  earliest  stage  it  may  be  cutaneous  or  subcutaneous  in 
situation.  It  originates  commonly  from  some  local  injury  or  other  forma- 
tion, such  as  warts,  vascular  or  pigmented  naevi,  sebaceous  cyst,  etc.; 
or  in  some  instances  apparently  from  the  healthy  skin.  It  is  met  with 
at  all  ages  and  in  both  sexes. 

Generalized  Non-pigmented  Sarcoma. — In  this  form  several  or  more 
tumors  may  appear  simultaneously  at  near  or  remote  points,  or  it  may 
result  from  a  primary  single  sarcoma,  as  already  described,  or  in  associa- 
tion with  leukemia  and  pseudoleukemia.  Arning,  Joseph,  Touton, 
Wagner,  Funk,  and  others  (quoted  by  Fordyce)  have  reported,  in  con- 
nection with  the  latter  affection,  the  general  development  of  pea-  to 
walnut-sized,  waxy,  dark-red  or  bluish,  cutaneous  and  subcutaneous 
tumors,  forming  adhesions  to  the  skin,  with  more  or  less  intense  itching, 
and  in  some  instances  tending  to  break  down  and  ulcerate.  It  is  not 
improbable  that  some  of  the  cases  associated  with  leukemia  reported  by 
Biesiadecki,  Kaposi  (lymphodermia  perniciosa),  Hochsinger  and  Schiff, 
Besnier,  Vidal,  and  others  have  been  more  closely  allied  to  granuloma 
fungoides  than  to  leukaemia  cutis  or  to  true  sarcomatosis.  Both  Vidal 
and  Paltauf 1  have  called  attention  to  this  point.  Some  cases,  too,  of 
generalized  cutaneous  distribution  doubtless  are  secondary  to  an  over- 
looked sarcoma  in  a  visceral  organ,  in  lymph-glands,  testicle  (Kobner), 
parotid  gland  (Holden  and  Butlin).  There  are  instances,  however,  in 
which  this  type  of  generalized  sarcoma  seems  primary  in  the  skin.  In 
general  non-pigmented  sarcomata  the  skin  overlying  the  tumors  may  be 
close  to  the  normal  hue,  with  a  reddish  or  bluish  cast,  or  it  may  be, 
especially  later  in  the  disease,  of  a  dark-blue  color.  The  growths,  which 
are  somewhat  variable  as  to  size,  as  in  primary  single  sarcoma,  are 
seated  primarily  either  in  the  cutaneous  or  subcutaneous  tissue,  and  may 
be  present  in  scanty  numbers  or  extremely  numerous,  as  in  Cheever's 
case,2  a  woman  aged  sixty-five,  in  whom  all  parts  except  the  head  were 
the  seat  of  nodular,  ulcerating  lesions,  some  of  which  underwent  involu- 
tion. In  other  instances  the  growths  are  more  or  less  crowded  and  lim- 
ited to  one  region,  a  rather  remarkable  example  of  which  came  under 
the  notice  of  Cohn,3  in  which,  in  a  woman  aged  fifty- two,  the  entire  scalp 
and  temporal  regions  were  the  seat  of  numerous  and  bunched,  cherry- 
to  egg-sized  and  larger  growths. 

1  Paltauf,  "The  Lymphatic  Affections  of  the  Skin,"  Trans.  Second  Internal.  Derm. 
Cong.,  Vienna,  1889. 

2  Cheever,  Boston  Med.  and  Snrg.  Jour.,  Jan.  14,  1885  (also  seen  by  Dr.  J.  C. 
White). 

3  Cohn,  Jour.  Cutan.  Dis.,  1892,  p.  393  (with  illustrations). 


SARCOMA    CUTIS  89$ 

This  class  of  sarcomata,  in  some  of  its  cases,  approaches  somewhat 
closely  to  the  third  division — the  multiple  pigmented  sarcoma  of  Kaposi; 
and  in  others,  especially  the  cases  in  which  a  tendency  to  ulceration  is 
exhibited,  the  similarity  to  granuloma  fungoides  is  also  striking,  this 
latter  being  considered  by  some  observers  as  in  reality  a  variety  of  sar- 
coma, a  view  that  clinically,  as  to  the  tumor  stage,  has  much  apparent 
support,  but  which  is  not  borne  out  by  the  history,  course  of  the  malady, 
and  the  histologic  findings.  Their  occasional  striking  resemblance  to 
granuloma  fungoides  is  recognized  in  the  name  proposed  by  Perrin  for 
this  variety  of  this  class, — generalized  primitive  pseudomycosic  sarcoma- 
tosis  of  the  skin, — and  also  that  by  Funk,  of  multiple  idiopathic  gumma- 
toid  sarcomata  of  the  skin,  a  suggestive  example  of  which  is  reported  by 
Bowen,1  and  another  by  Minne,2  and  indicative  of  possible  transition 
cases.  The  course  of  generalized  sarcomata  is  a  variable  one,  and, 
according  to  Perrin,  death  usually  ensues  within  two  years  after  the  cuta- 
neous growths  have  appeared.  The  multiplication  of  the  growths  is 
supposed  to  be  due  to  dissemination  of  the  morbific  cells  through  the 
agency  of  the  blood  circulation. 

Melanotic  Sarcoma. — This  variety,  the  second  class  of  De  Amicis, 
is  the  most  malignant,  usually  running  a  rapid  course.  It  is  often  con- 
fused with  sarcomata  of  other  varieties  showing  discoloration,  but 
between  such  and  true  melanotic  sarcoma,  as  Hartzell3  states,  a  distinc- 
tion must  be  made;  the  coloring-matter  of  the  latter  is  presumably  a 
product  of  the  cells  of  the  neoplasm,  which  frequently  has  its  origin  in 
tissues  normally  pigmented,  as  the  choroid  and  pigmented  naevi,  whereas 
in  the  former  the  origin  of  the  pigment  is,  for  the  most  part,  hematic. 
If  the  conclusions  of  Unna,4  Gilchrist,5  Waelsch,6  Whitfield,7  Darier,8 
and  a  few  others9  are  to  be  accepted,— that  the  cells  in  pigmented  moles 
which  give  rise  to  melanotic  growths  are  in  reality  of  epithelial  origin, — 
then  the  tumor  of  this  variety  thus  originating  must  of  necessity,  as 
these  observers  contend,  be  taken  from  the  sarcomatous  class  and  trans- 
ferred to  the  carcinomatous.  In  a  recent  valuable  paper,  Johnston10 

1  Bowen,  "Mycosis  Fungoides  and  Sarcomatosis,"  Jour.  Cutan.  Dis.,  1897,  p.  65. 

2  Minne,  Annales,  1899,  p.  751. 

3  Hartzell,  "Sarcoma  Cutis,"  Jour.  Cutan.  Dis.,  1893,  p.  21. 

4  Unna,  Histopathology. 

5  Gilchrist  ("A  Case  of  Melanotic  Sarcoma,  Primary  in  the  Skin,  m  a  Negro,  with 
Pathology"),  Trans.  Amer.  Derm.  Assoc.  for  1898. 

6  Waelsch,  Archiv,  1900,  vol.  xlix,  p.  249  (with  6  colored  histologic  cuts). 

7  Whitfield,  Brit.  Jour.  Derm.,  1900,  p.  267. 

8  Darier,  La  Pratique  Dermatologie,  1903,  vol.  iii. 

9  Schalek  ("Histogenesis  of  Melanosarcoma  Cutis"),  Jour.  Cutan.  Dis.,  1900,  p.  147, 
has  contributed  a  valuable,  original,  and  review  paper  on  this  subject,  based  upon  exami- 
nation of  several  cases.     See  also  paper  by  Heitzmann  ("Microscopic  Studies  on  Mela- 
notic Tumors  of  the  Skin"),  Jour.  Cutan.  Dis.,  1888,  p.  201  (with  illustrations),  which 
also  has  some  bearing  upon  this  point. 

10  Tames  C   Johnston,  "Melanoma,"  Jour.  Cutan.  Dis.,  Jan.  and  1-eb.,  1905.      A 
monograph  that  reviews  the  whole  subject,  with  case  citations,  original  investigations, 
numerous  histologic  cuts,  and  complete  bibliography.     His  conclusions  are:  i.  Aside 
from  the  natural  division  into  choroid  and  skin  tumors,  melanotic  neoplasms,  whicn, 
from  their  diversity  of  origin,  are  best  called  melanomata,  show  several  varieties.     2 
The  commonest,  and  therefore  most  important,  is  that  derived  from  soft  naevi  which 
are  endotheliomata  of  lymph-vessel  origin.     Naevomelanoma,  whose  histogenesis  i 
is  not  possible  to  determine,  must  be  referred  to  the  same  origin.     3.  A  second  vanety 


896 


NEW  GROWTHS 


takes  issue  with  the  conclusions  of  these  investigators,  and  joins  the  Ger- 
man general  pathologists  in  support  of  the  view  that  has  generally  been 
held  until  recently,  that  the  malignant  growth,  called  by  Unna  melanocar- 
cinoma,  takes  its  origin  from  the  lymphatic  endothelium.  Fordyce1 
takes  conservative  ground,  believing  that  there  is  still  some  doubt  as  to 
the  origin  and  nature  of  these  growths,  and  prefers  for  the  time  the  non- 
committal name  melanoma.  In  addition  to  the  points  of  origin  named, 
melanotic  sarcoma  may  originate  in  any  pigmented  spot  in  the  skin, 
although  in  some  instances  its  source  is  not  readily  demonstrable.  It 


Fig.    224.  —  Melanotic   sarcoma,"  starting   in  a 

Hospital  case). 


mole — (Stelwagon-Gaskill,  Jefferson 


not  infrequently  has  its  origin  on  the  hands  or  feet,  at  the  dorsal  or  lateral 
aspects,  sometimes  the  first  evidence  presenting  being  an  easily  abraded 

exists  with  the  same  histologic  pictures,  which  does  not  spring  from  naevi,  and  whose 
origin  is  directly  traceable  to  endothelium,  probably  also  lymphatic.  This  group  in- 
cludes melanotic  whitlow  and  the  malignant  lentigo  of  the  French.  4.  The  third  di- 
vision is  truly  epithelial  in  origin,  although  its  existence  has  been  denied.  These  tumors 
are  of  various  types  and  show  only  a  very  slight  tendency  to  malignancy,  a  fact  suffi- 
cient in  itself  to  determine  a  cardinal  difference  from  the  melano-endotheliomata,  whose 
capacity  in  this  connection  can  hardly  be  exaggerated.  5.  A  histologic  diagnosis  is 
the  only  proper  method  of  differentiation  between  the  two. 

1  Fordyce,  "Melanomas  and  Some  Types  of  Sarcoma  of  the  Skin,"  Jour.  Amer.  Med. 
Assoc.,  Jan.  8,  1910,  p.  291  (with  histologic  cuts,  review  of  the  subject,  and  references); 
Gibbon  and  Despard,  "Melanotic  Neoplasms,"  Internal.  Clinics,  vol.  iii,  i8th  series 
(report  of  cases,  review,  and  bibliography),  also  consider  the  matter  unsettled;  Gaskill, 
"Melanotic  Sarcomas  Resulting  from  Irritation  of  Pigmented  Nsevi,"70/<r.  Amer.  Med. 
Assoc.,  Feb.  i,  1913  (reports  an  interesting  case,  with  case  and  histologic  illustrations, 
brief  review  and  references — case  illustrated  in  the  text). 


SAKCOMA    CUTIS  897 

black  superficial  blister.  Funk  states  that  the  initial  evidence  is  some- 
times noted  to  be  dilated  capillaries  or  a  purpuric  spot,  or  its  first  step 
may  be  the  "melanotic  whitlow"  of  Hutchinson,  beginning,  as  this  ob- 
server and  also  Duplay  and  Halle  have  described,  as  a  pigmentation 
around  the  border  of  a  nail.  The  first  changes  in  melanotic  sarcoma 
may  be  slow  and  insignificant,  consisting  simply  of  a  dark-colored  abra- 
sion with  a  smooth,  irregular,  or  slightly  fungating  surface.  Or  there 
may  be  an  insignificant  tumor  growth,  pea  to  small  nut  in  size.  In  other 
instances  the  early  appearances,  as  in  Stower's1  case,  involving  the  left 
ear  in  a  girl  of  eleven,  consist  of  a  slate-colored,  a  somewhat  uneven  and 
verrucous  area,  or  the  patch  may  be  smooth  and  slightly  thickened. 
Its  course  is  rapid,  general  involvement  soon  ensuing,  as  illustrated  by 
a  case  under  my  care  in  a  woman  aged  fifty;  the  development  was  ex- 
treme, numerous  tumors  not  only  in  the  skin,  but  also  in  the  mouth, 
throat,  and  eye,  with  a  general  discoloration  of  the  skin  and  mucous 
membranes,  death  ensuing  from  exhaustion  within  a  year  after  the  dis- 
ease first  presented. 

Multiple  Pigmented  (Hemorrhagic)  Sarcoma. — The  cases  of  this,  the 
third,  class  division  made  by  De  Amicis,  are  those  known  as  multiple 
pigmented  sarcoma  of  Kaposi,2  who  first  described  the  disease  upon 
a  basis  of  an  observation  of  5  cases,  to  which  were  later  added  others, 
making  a  total  in  all  of  25  patients.  The  number  has  been  added  to  by 
various  other  observers,  among  the  earliest  of  whom  Vidal,  Wiggles- 
worth,  De  Amicis  (n),  Semenow  (10),  Donner,  Hardaway,  Duhring, 
Hallopeau,  Funk,  Schwimmer,  and  Mackenzie.  In  more  recent  years 
reports  of  new  cases  have  been  made  by  Fordyce,3  Sherwell,4  Brayton,5 
Magliano,6  Wende,7  Bernard,8  Sequeira,9  and  others,  so  that  the  aggre- 
gate is  becoming  fairly  large. 

The  malady,  with  rare  exceptions,  first  presents  upon  the  extremi- 
ties, and  usually  simultaneously.  The  beginning  lesions  may  be  small 
nodular,  discrete,  aggregated,  or  crowded  together,  and  scarcely  exceeding 

1  S  towers,  Brit.  Jour.  Derm.,  1893,  p.  305. 

2  Kaposi,  Pathologic  und  Therapie  der  Haulkrankheiten,  fifth  ed.,  p.  922. 

3  Fordyce,  Jour.  Cutan.  Dis.,  1891,  p.  i,  with  colored  plate;  this  and  Schwimmer's 
case  report  (Internal.  Atlas,  1889,  ii,  plate  iv)  give  references  to  previous  cases. 

4  Sherwell,  Amer.  Jour.  Med.  Sci.,  Oct.,  1892. 

5  Brayton,  Indiana  Med.  Jour.,  Nov.,  1893. 

6  Magliano,  Morgagni,  May,  1894,  xxxvi — abs.  in  Brit.  Med.  Jour.,  1895,  p.  196. 

7  G.  W.  Wende,  Jour.  Cutan.  Dis.,  1898,  p.  205  (with  illustrations  and  histologic 
cuts). 

8  Bernard,  Archiv,  1899,  vol.  xlix,  p.  207  (2  cases  with  review  of  the  literature). 
'Sequeira  and  Bulloch,  Brit.  Jour.  Derm.,  1901,  p.  201  (case  with  colored  plate 

and  brief  review  of  subject,  with  numerous  references) .  Some  later  reports :  Bernhardt, 
Archiv  1902,  vol.  Ixii,  p.  237  (with  references);  Koehler  and  Johnston,  Jour.  Cutan. 
Dis.,  1902,  p.  5  (with  case  illustration  and  histologic  cuts);  Sellei,  Archil),  1903,  vol. 
Ixvi  p.  i  (with  plate  and  bibliography) ;  Krzysztalowicz,  Monatshefte,  1904,  vol.  xxxvm, 
p.  215  (includes  2  cases— histologic) ;  Parkes  Weber  and  Daser,  Brit.  Jour.  Derm.,  1905, 
p.  135;  and  histology  of  this  case  and  histologic  review,  with  references,  by  Macleod, 
ibid.,  1905,  p.  173;  Selhorst  and  Polano,  Archiv,  1906,  vol.  Ixxxii,  p.  33  (i  case;  male, 
patient  aged  seventy;  began  when  aged  fifty;  colored  histologic  illustration,  and 
partial  bibliography);  W.  Pick,  ibid.,  1907,  vol.  Ixxxvii,  p.  267  (2  cases;  with  colored 
plate  case  illustration,  histologic  cuts,  and  partial  bibliography);  Dalla  Favera,  Archiv. 
1911  Bd.  cix,  p.  387,  abs.  in  Brit.  Jour.  Derm.,  1912,  p.  82  (based  on  6  cases,  3  dying; 
autopsy;  review  of  the  subject;  in  2  of  the  cases  metastatic  growths  were  found  in  the 
internal  viscera). 
57 


NEW  GROWTHS 


a  pea  in  size.  In  some  instances  or  in  some  areas,  instead  of  distinct 
tumor  formation  there  is  a  thickening  or  diffused  infiltration.  In  color 
they  may  vary  from  a  reddish-blue  to  a  purplish  color;  on  the  lower 
extremities  a  dark-brown  shade  or  even  a  blackish  hue  may  be  observed. 
The  growths  and  areas  of  infiltration  are  generally  of  firm  consistence, 
and  may  be  spontaneously  painful,  or  more  usually  simply  tender  upon 
pressure.  Occasionally  growths  are  observed  somewhat  suggestive  of 
angiomata,  and  which  can  be  made  smaller  when  firmly  pressed  upon. 
In  some  tumors  there  may  be  a  central  depression,  probably  from  partial 
involution  changes  or  relatively  more  active  peripheral  growth.  Com- 
plete involution  is  noted  at  times  in  some  growths,  disappearing  and 
usually  leaving  a  somewhat  depressed,  stained  area  or  scar.  Some,  after 


Fig.  225.— Small  round-celled  sarcoma  (X  250)  (courtesy  of  Dr.  J.  C.  Johnston). 


having  lasted  some  months,  may  exhibit  ulcerative  tendency,  but,  as 
a  rule,  this  is  exceptional,  and  only  observed  late  in  the  disease.  Dilated 
capillaries  around  the  nodules  and  interspersed  are  frequently  seen. 
The  progress  of  the  malady  is  a  steady  one,  new  growths  and  infiltration 
being  added  from  month  to  month;  the  legs,  especially  below  the  knees, 
show  much  thickening  and  deformity,  presenting  a  mild  degree  of  ele- 
phantiasis-like enlargement.  When  well  advanced,  the  general  health 
is  gravely  affected,  the  mucous  membranes  are  invaded,  and,  according 
to  the  findings  of  autopsies,  the  visceral  organs  are  also  sooner  or  later 
involved.  The  average  duration  of  the  malady  is,  according  to  Kaposi, 
whose  experience  is  the  largest,  about  four  years;  Favera  makes  the  dura- 
tion eight  to  ten  years,  varying  in  the  different  cases  from  two  to  twenty 
or  more. 


SARCOMA    CUTIS 


899 


Utiology. — Possible  etiologic  factors  have  been  casually  men- 
tioned in  describing  the  several  varieties.  The  causes  are  yet  to  be 
discovered.  Beyond  the  effect  of  local  irritation  being  an  important 
starting  factor  in  some  instances, — more  especially  the  single  non- 
pigmented  and  melanotic  varieties, — nothing  is  practically  known. 
Scarcely  any  age  is  exempt  from  the  malady,  although  most  cases  are 
probably  seen  under  twenty  and  over  forty.1 

In  multiple  pigmented  sarcoma  no  light  has  been  thrown  upon  its 
origin.  It  is  almost  wholly  observed  in  males,  and  after  the  age  of  forty. 
I  have  met  with  2  instances  of  the  disease,  one  a  male,  the  other  a  female, 
and  both  past  middle  life,  the  disease  running  a  fatal  course  in  four  or 
five  years.  All  of  Kaposi's  cases  were  males,  and  Sequeira  (loc.  cit.), 
out  of  73  cases  in  the  literature,  found  a  record  of  only  5  females,  and 


Fig.  226. — Spindle-celled  sarcoma  (X  250)  (courtesy  of  Dr.  B.  H.  Buxton). 

was  not  sure  that  all  of  these  were  examples  of  the  disease.  His  investi- 
gation disclosed  also  that  most  of  the  men  were  of  powerful  build.  Ac- 
cording to  Sequeira,  in  3  instances  the  disease  began  after  a  chill;  gout  was 
present  in  4  cases,  and  rheumatism  and  valvular  cardiac  disease  were 
also  observed  in  some  instances. 

Pathology. — The  growths  of  the  non-pigmented  variety  are 
made  up  chiefly  of  round  cells  or  mixed  round  and  spindle  cells.  A 

1  F.  A.  Packard,  University  Med.  Mag.,  April,  i8qi,  has  reported  a  case  of  multiple 
sarcoma  (lymphosarcoma)  culis  in  a  male  infant  of  six  months,  beginning  when  aged 
seven  or  eight  weeks  by  the  appearance  of  two  or  three  pea-sized  nodules  of  purplish 
color  on  the  back,  the  disease  running  a  fatal  course  in  six  months. 


poo 

case  of  a  moderate  number  of  tumors,  observed  by  Crocker,1  in  which 
the  early  lesions  were  all  excised,  these  were  typical  of  alveolar  sarcoma, 
whereas  the  tumors  which  subsequently  recurred  were  round-cell  sar- 
comata. Hartzell  also  noted,  in  a  case  under  his  care  of  numerous  sar- 
comatous  growths  on  the  leg,  that  the  histologic  features  of  these  tumors 
bore  but  a  faint  resemblance  to  those  of  the  growths  which  subsequently 
appeared  in  the  stump.  In  the  cases  associated  with  leukemia  (leukae- 
mia cuds)  and  pseudoleukemia  (quoting  Fordyce),  "the  structure  of  the 
tumors  is  composed  of  small  round  cells  of  the  size  and  appearance  of 
white  blood-corpuscles ;  in  the  early  stage  of  development  forming  nodular 
collections  at  the  junction  of  the  cutis  and  subcutaneous  cellular 
tissue."  Sarcomata  of  the  spindle-cell  and  mixed  type  have  also  been 
observed  in  leukemic  subjects.  Occasionally  growths  show  a  predomi- 
nant fibrous  character  (fibrosarcoma)  or  excessive  lymphatic  element 
(lymphosarcoma)  or  the  growths  are  made  up  of  connective-tissue  ele- 
ments, originating  from  the  adventitia  of  the  vessels,  with  conspicuous 
development  of  new  blood-vessels  (angiosarcoma)  .2  In  melanotic  sar- 
coma spindle  cells  and  small  and  large  round  cells  have  been  variously 
observed,  although  generally  the  tumors  are  composed  of  spindle-shaped 
cells.  These  growths  have  also  been  noted  to  be  of  the  alveolar 
type.  The  pigment,  as  already  stated,  is  a  product  chiefly  of  the 
neoplasm  cells,  the  growths  usually  originating  from  normally  pig- 
mented  tissue. 

Multiple  pigmented  sarcoma,  Kaposi  (loc.  tit.}  states,  is  a  round-cell 
growth,  except  that  in  a  few  places  the  characters  of  spindle-cell  sarcoma 
are  seen.  The  pigmentation  is  due  to  the  capillary  hemorrhages  noted. 
Other  observers  have  found  a  predominance  of  fusiform  cells — in  For- 
dyce's  examination  arranged  in  bundles  extending  longitudinally,  trans- 
versely, and  obliquely,  their  transverse  sections  looking  not  unlike  round 
cells.  Wende  (loc.  tit.}  also  found  spindle-cell  nests  as  a  predominant 
feature,  Macleod,  from  his  examination  of  Weber  and  Daser's  case, 
clinically  characteristic  of  "the  affection,  states  "that  histologically  it  was 
not  a  sarcoma,  but  a  growth  of  organizing  connective-tissue  cells  asso- 
ciated with  marked  vascular  dilatation,  edema,  and  the  deposition  of 
blood-pigment."  While  its  classification  is  not  yet  definitely  decided, 
it  seems  closer  to  the  granulomata  than  to  the  sarcomata. 

Diagnosis. — In  the  recognition  of  the  various  sarcomata  the 
history  and  course  must  be  taken  into  consideration,  and  very  frequently 
a  final  opinion  is  possible  only  on  histologic  examination.  A  pigmented 
nsevus  undergoing  enlargement  or  showing  irritation  is  suggestive  as  to 
melanotic  sarcoma,  and  when  the  case  is  advanced,  the  history  of  such, 
together  with  the  melanotic  characters  of  the  growths,  will  usually  be 
conclusive.  The  maladies  ordinarily  to  be  excluded  are  syphilis,  granu- 
loma  fungoides,  and  leprosy. 

1  Crocker,  Diseases  of  the  Skin. 

2  Cases  of  somewhat  varying  character  have  been  recently  reported  by  Winfield 
(Jour.  Cutan.  Dis.,  1900,  p.  113,  with  illustrations);  Fordyce  (Amer.  Jour.  Med.  Sci., 
1900,  vol.  cxx,  p.  159,  with  histologic  cuts);  Johnston,  Jour.  Cutan.  Dis.,  1901,  p.  126 
(with  histologic  cut);  Wolters,  Archiv,  Sept.,  1900,  p.  269  (with  histologic  plates); 
Spiegler,  ibid.,  1899,  vol.  1.,  p.  163  (with  colored  and  other  cuts). 


SARCOMA    CUTIS 


9OI 


Prognosis  and  Treatment — A  fatal  issue  is  to  be  expected 
sooner  or  later  in  all  cases  in  which  generalization  has  taken  place, 
varying  from  a  few  months  to  several  years  or  longer,  depending  upon 
the  variety  and  extent.  The  melanotic  type  is  the  most  rapidly  fatal. 

The  multiple  pigmented  form,  usually  the  slowest  in  its  course — Bray- 
ton's  case  over  twenty-five  years,  and  Taylor's1  patient,  with  a  number 
of  sarcomatous  growths,  was  still  in  good  health  twenty-four  years  after 
its  first  appearance,  and  Jackson's2  case,  twenty-one  years.  Rare  ex- 
ceptions of  final  spontaneous  recovery  have  been  noted,  the  most  re- 
markable of  which  was  Hardaway's3  generalized  case,  which,  after 
lasting  for  over  ten  years,  entirely  disappeared.  In  2  cases  observed  by 
Bazin  and  Funk  (loc.  tit.},  of  a  somewhat  peculiar  variety  of  the  disease, 
complete  involution  took  place. 

Operative  measures  are  usually  the  sole  method  in  those  cases  in 
which  the  tumors  are  single  or  scanty  in  number.  The  x-ray  treat- 
ment has  been  credited  with  a  favorable  influence  in  exceptional  instances. 
It  has  sometimes  been  noted  that  excision  of  a  melanotic  sarcoma  seemed 
to  spur  the  process  onward. 

Under  treatment  by  arsenic,  preferably  employed  subcutaneously, 
several  instances  of  cure  and  marked  palliation  have  been  observed,4 
usually  in  the  multiple  pigmented  variety.  Lustgarten5  saw  marked 
improvement  in  a  case  of  this  type  from  x-ray  treatment;  and  Wall- 
hauser6  had  an  apparent  cure  in  one  instance,  and  temporary  arrest 
in  another,  with  wet  compresses  of  mercuric  chlorid  solution  (i:  500). 

The  fact  that  some  instances  of  recovery  have  followed  accidental 
erysipelas  led  to  the  somewhat  dangerous  use,  by  Coley7  and  others, 

1  Taylor,  Arch.  Derm.,  1875,  p.  307. 

2  G.  T.  Jackson,  Jour.  Cutan.  Dis.,  1897,  p.  473. 

3  Hardaway,  ibid.,  1883,  p.  97,  with  colored  plate;  ibid.,  1884,  p.  289;  ibid.,  1890, 

p.  21. 

4  Kb'bner  (Berlin,  klin.  Woche-isch.,  1883,  p.  21),  case  of  a  girl  of  eight  and  one-half 
years,  was  wholly  relieved  by  hypodermic  injections  of  2\  to  4  minims  of  freshly 
prepared  Fowler's  solution  with  2  parts  water,  and  was  free  from  a  return  five  years  sub- 
sequently.    Later  (Berlin,  klin.  Wochensch.,  p.  193),  owing  to  the  difficulty  of  securing 
freshly  made  solution,  Kobner  expressed  a  preference  for  a  solution  of  sodium  arsenate. 
Sherwell  (Jour.  Cutan.  Dis.  (discussion),  1897,  p.  141)  states  that  a  patient  with  mul- 
tiple pigmented   sarcoma,  the  lesions  mostly  upon  the  lower  extremities,  got  entirely 
well  under  full  and  increasing  doses  of  Fowler's  solution,  and  was  well  a  year  later 
when  last  seen.     This  same  observer  (Amer.  Jour.  Med.  Sci.,  Oct.,  1892)  also  reported 
a  multiple  case  in  which  the  involution  of  the  lesions  was  markedly  influenced,  new 
ones  appearing  as  soon  as  the  patient  discontinued  the  remedy.     Hyde  (Hyde  and 
Montgomery,  Diseases  of  the  Skin,  fifth  edit.)  also  refers  to  a  case  exhibited  at  the  In- 
ternational Dermatological  Congress,  London,  1896,  in  which  the  eruption  on  the  hands 
disappeared  under  this  plan  of  treatment;  De  Amicis  (Monatshefte,  1897,  vol.  xxv,  p. 
309)  has  reported  i  case  cured  and  i  greatly  relieved;  Lassar  and  Shattuck  (both 
cited  by  Wende,  loc.  tit.)  have  also  had  good  results,  and  Wende's  case  was  showing 
some  favorable  influence;   Lustgarten  (Discussion,  Jour.  Cutan.  Dis.,  1897,  p.  83), 
in  a  case  of  sternal  osteosarcoma  with  axillary  gland  involvement  in  which  a  prominent 
surgeon  refused  operation,  saw  a  complete  disappearance  in  three  months  under  in- 
jection of  sodium  arsenite,  administered  in  a  2  per  cent,  carbolic  acid  solution. 

5  Lustgarten,  Jour.  Cutan.  Dis.,  April,  1905,  p.  171  (case  demonstration). 
'  Wallhauser,  Jour.  Amer.  Med.  Assoc.,  1909,  vol.  liii,  p.  1608. 

7  Coley,  "Treatment  of  Malignant  Tumors  by  Repeated  Inoculations  of  Erysipelas, 
etc.,"  Amer.  Jour.  Med.  Sci.,  1893,  vol.  cv,  p.  487,  with  analytic  table  and  full  bibli- 
ography and  "Recent  Cases  of  Inoperable  Sarcoma  Successfully  Treated  with  Mixed 
Toxins  of  Erysipelas  and  Bacillus  Prodigiosus,"  Surgery,  Gynecology,  and  Obstetrics, 
Chicago,  Aug.,  1911  (a  favorable  record). 


902 


NEW  GROWTHS 


of  the  induction  of  this  lattter  by  injections  of  cultures  of  the  strepto- 
coccus of  this  disease,  and  also  by  the  combined  toxins  of  this  coccus 
and  the  bacillus  prodigiosus. 

MULTIPLE  BENIGN  SARCOID1 

Synonyms. — Sarcoid  Tumor;  Sarcoid;  Miliary  lupoid;  Benign  miliary  lupoid. 

The  name  multiple  benign  sarcoid  is  one  usually  employed  to  desig- 
nate a  group  of  neoplasmata  characterized  by  a  limited  growth  and 
comparative  benignancy,  and  a  favorable  response  in  a  proportion  of  the 
cases  to  arsenical  treatment.  It  was  Boeck's  notable  paper  in  1897  that 
first  attracted  attention  to  this  relatively  mild  form  of  tumor,  and  later 
Darier  who  added  much  further  knowledge;  followed  by  Pawloff,  Spieg- 
ler,  Fendt,  Gottheil,  Hallopeau,  Pollitzer,  G.  H.  Fox  and  Wile,  Paul 
Unna,  Jr.,  and  others.  Darier's  study  of  his  own  cases  and  the  literature 
led  to  his  division  of  the  reported  cases  into  four  distinct  types  or  groups: 
(i)  the  multiple  benign  sarcoid  of  Boeck;  (2)  the  subcutaneous  sarcoid 
of  Darier-Roussy;  (3)  the  nodular  erythema-induratum-like  sarcoid 
of  the  extremities,  and  (4)  the  Spiegler-Fendt  sarcoid,  with  some  appar- 
ent kinship  to  the  neoplastic  lymphoderma.  In  addition  to  these  four 
types,  Darier  calls  attention  to  the  fact  that  a  mixed  type  is  occasionally 
observed. 

The  Boeck  type  of  sarcoid  may  present  as  a  single  lesion  or  in 
moderate  or  even  large  numbers,  and  upon  face,  back,  shoulders,  and 
extensor  surfaces  of  the  arms.  The  lesions  may  be  papular,  nodu- 
lar, or  infiltrated  plaques,  and  make  their  appearance  slowly  or  rap- 
idly, some  being  superficial,  others  deep  in  the  cutis.  The  growths 
vary  in  size  from  a  millet-seed  to  a  large  bean,  and  are  at  first  faintly 
pinkish  or  rose  colored,  later  reddish,  livid,  and  finally  brownish;  they 
are  smooth,  firm  and  elastic,  intimately  associated  with  the  skin,  and 
move  with  it;  telangiectases  are  sometimes  to  be  seen  peripherally, 
and  under  glass  pressure  minute  grayish-yellow  foci  are  often  to  be 
detected  in  the  nodule,  hence  the  later  term,  "miliary  lupoid,"  given  by 
Boeck  to  the  malady.  A  plaque,  if  present,  usually  consists  of  a  limited 
or  somewhat  diffused,  more  or  less  even  infiltration,  or  of  closely  crowded 
nodules  with  associated  infiltration.  Boeck  recognized  three  types  of 

1  Important  Literature:  Boeck,  Jour.  Cutan.  Dis.,  1899,  p.  543;  Kaposi,  Festschrift 
zu  lion  Moritz,  1900,  p.  153;  and  Archiv,  1905, 'hcxm,  p.  71;  Darier  et  Roussy,  Annales, 
1904,  v,  pp.  144  and  347;  Darier,  Monatshefte,  1910,  L,  p.  419  (with  review  and  full 
bibliography);  Colcott  Fox,  Brit.  Jour.  Derm.,  1893,  pp.  225,  293,  and  338;  Spiegler, 
Archiv,  1894,  xxvii,  p.  163;  Joseph,  Archiv,  1898,  xlvi,  p.  177;  Philippson,  Giorn.  ital., 
1898,  xxxiii,  p.  61;  Thibi6rge  et  Revaut,  Annales,  1899,  p.  513;  Fendt,  Archiv,  1900, 
Hii,  p.  213;  Carle,  Lyon  Med.,  1901,  xcvi,  p.  358;  Gottheil,  Jour.  Cutan.  Dis.,  1902,  p, 
400;  Pawloff,  Monatshefte,  1904,  xxxviii,  p.  469;  Winkler,  Archiv,  1905,  Ixxvii,  p.  3; 
Pelagatti,  Giorn.  Hal.,  1907,  xlviii,  p.  425;  Thibierge  and  Bord,  Annales,  1907,  p.  113; 
Opificius,  Archiv,  1907,  Ixxxv,  p.  239;  Pollitzer,  Jour.  Cutan.  Dis.,  1908,  p.  15;  Kreibich 
und  Kraus,  Archiv,  1908,  xcii,  p.  173;  Kren  und  Weidenfeld,  Archiv,  1909,  xcix,  p.  79; 
Urban,  Archiv,  1910,  ci,  p.  175;  G.  H.  Fox  and  Wile,  Jour.  Cutan.  Dis.,  1911,  p.  375 
(case  report  with  case  and  histologic  illustrations;  with  brief  review  and  bibliography  of 
main  papers;  I  am  indebted  to  this  paper);  Pohlmann,  Archiv,  1910,  cii,  p.  108  (case 
report  with  review);  Polland,  "Sarcomatosis  Cutis"  (Spiegler),  Archiv,  1912,  cxi,  No.  i, 
P-  3 — abs.  in  Jour.  Cutan.  Dis.,  1912,  p.  362;  and  Unna,  Jr.,  Monatshefte,  1912,  Iv, 
p.  1203,  (case  illustrations  and  review). 


MULTIPLE  BENIGN  SARCOID 


903 


his  group:  (i)  the  large  nodular,  with  pea-  to  pigeon's-egg-sized  lesions; 
(2)  the  small  nodular-papular,  millet-seed-  to  pea-sized  tumors,  some- 
times close  together,  and  (3)  the  diffuse  infiltrating  form,  probably  a 
combination  of  the  other  two.  Occasionally  the  surface  may  show  slight 
scaliness.  A  peculiarity  of  many  of  the  tumors  is  that  they  are  much 
smaller  looking  to  the  sight  than  to  palpation.  After  some  duration, 
months  or  years,  a  nodule  frequently  tends  to  involution,  usually  first 
shrinking  centrally,  and  gradually  disappearing,  leaving  a  brownish  stain 
or  slight  atrophic  scar.  There  seems  to  be  no  tendency  to  caseation  or 
ulceration.  There  are  usually  no  subjective  symptoms.  Enlargement 
of  the  lymphatic  glands  is  observed  in  some  cases.  The  malady  pre- 
sents in  some  instances  a  rough  resemblance  to  lupus  vulgaris  and 
sarcoma. 

The  second  or  Darier-Roussy  type  consists  of  painless,  hazel-nut- 
to  walnut-sized  round  or  oval  subcutaneous  nodules,  occurring  on  the 
trunk  and  especially  the  upper  part;  it  is  rare,  but  few  cases  having  been 
recorded.  The  third,  or  erythema-induratum-like  group  comprise  the 
cases  reported  by  Pelegatti,  Thibie'rge  and  Bord,  Colcott  Fox,  Darier, 
and  others;  the  lesions  bear  close  resemblance  to  the  erythema  induratum 
of  Bazin,  occur  chiefly  in  women,  and  on  the  legs  and  arms;  are  nut-  to 
pigeon's-egg-sized,  reddish,  purplish  or  livid  tumors,  chronic  in  their 
course,  and  occasionally  terminating  in  ulceration.  The  fourth,  or 
Spiegler-Fendt,  type,  resembles  clinically  the  other  groups,  more  espe- 
cially the  first  two.  While  the  cases  comprised  under  these  four  groupings 
by  Darier  are  not  common — rather  rare,  in  fact — those  of  the  third  group 
are  met  with  most  frequently  and  following  this,  in  the  order  named, 
those  of  the  first,  fourth,  and  second.  The  malady  is  seen  predominantly 
in  women.  The  first,  second,  and  third  groups  seem  to  show  some  re- 
lationship to  tuberculosis,  the  fourth  group  showing  a  suggestion  of 
lymphogranulomata.  Darier  and  Roussy  advanced  the  theory  that 
sarcoid  is  a  tuberculide,  and  possibly  due  to  a  low-grade  infection  with 
the  tubercle  bacilli,  basing  it  mainly  on  the  histopathology;  tuberculosis 
has  been  found,  however,  in  a  proportion  of  the  patients,  and  in  almost 
one-third  of  the  cases  there  has  been  a  reaction  to  tuberculin. 

Histologic  examination,  upon  which  diagnosis  must  be  mainly  based, 
discloses  (Boeck)  "through  the  whole  depth  of  the  corium  from  the  papil- 
lary layer  to  the  limits  of  subcutaneous  tissue,  sharply  circumscribed 
foci  of  a  new  growth  separated  from  each  other;  higher  power  shows  that 
the  cells  of  the  new  growth  are  of  the  type  of  epithelioid  connective-tissue 
cells,  and  that  the  tumor,  as  a  rule,  has  its  origin  in  the  perivascular 
lymph  spaces.  The  proliferated  cells  soon  enclose  the  greatly  dilated  ves- 
sels with  a  compact  cylindric  mass;  as  proliferation  increases  and  the 
foci  take  different  shapes,  though  still  sharply  circumscribed,  the  resem- 
blance to  epithelioid  cells  becomes  more  marked.  The  nuclei  are  large 
and  vesicular,  less  deeply  stained  and  show  distinct  nucleoli;  the  nuclei 
are  sometimes  multiple.  The  cell  protoplasm  is  increased  in  amount 
and  sends  out  prolongations  in  different  directions.  In  a  few  instances 
giant-cells  of  the  sarcomatous  type  are  found.  Mitosis  is  scarcely  any- 
where to  be  detected."  At  the  periphery  are  seen  lymphocytes  in  varying 


904 


NEW  GROWTHS 


numbers,  few  plasm  cells,  and  scattered  here  and  there  giant-cells  having 
many  nuclei,  and  rarely  giant-cells  of  the  true  Langhans  type  (Fox  and 
Wile) .  There  is  no  evidence  of  caseation  necrosis.  The  histology  of  the 
lesions  of  the  second  group  is  in  the  main  very  similar,  but  presents  an 
even  closer  resemblance  to  tuberculosis;  numerous  giant-cells  are  seen. 
The  Spiegler-Fendt  tumor  show  "aggregations  of  round  cells  more  or 
less  circumscribed,  at  times  enclosed  in  a  capsule  of  connective  tissue. 
Giant-cells  and  epithelioid  cells  occur  in  small  numbers." 

Prognosis  and  Treatment. — All  these  various  cases  are  slow  in 
progress,  and  with  the  exception  of  the  erythema-induration  type,  which 
sometimes  breaks  down,  give  rise  to  no  pain  or  actual  discomfort,  except 
the  disfigurement  and  stiffness  and  unwieldiness  of  the  affected  parts 
when  much  infiltrated.  The  malady  is  benign,  but  few  instances  of 
fatal  termination  occurring.  The  duration  is  indefinite,  but  in  some  cases 
gradual  disappearance  ensues,  and  in  others  there  is  favorable  response 
to  arsenical  medication.  Darier  reports  also  favorable  influence  from 
the  x-ray,  calomel,  and  tuberculin. 

GRANULOMA  FUNGOIDES1 

Synonyms. — Mycosis  fungoides;  Granuloma  sarcomatodes;  Inflammatory  fungoid 
neoplasm;  Fibroma  fungoides;  Lymphodermia  perniciosa;  Sarcoma tosis  generalis; 
Fr.,  Lymphadenie  cutanee;  Mycosis  fongolde;  Ger.,  Multiple  Granulationsgeschwiilste; 
Mycosis  fungoides. 

Definition. — A  chronic  malignant  disease  characterized  usually 
by  percursory  symptoms  of  months'  or  years'  duration,  of  an  eczematous, 

1  Literature,  usually  with  review  and  bibliography,  and  together,  with  the  other 
literature  referred  to  in  the  course  of  the  text,  covering  the  entire  subject:  Duhring, 
Arch.  Derm.,  1879,  p.  i,  and  1880,  p.  i  (with  2  case  illustrations  and  3  histologic  cuts; 
autopsy);  De  Amicis,  "Dermo-linfoadenoma  fungoide,"  Naples,  1882,  and  Trans, 
Internal.  Med.  Cong.,  Washington,  1887,  p.  275;  Vidal  and  Brocq,  La  France  medicate, 
1885,  pp.  946,  957,  969,  983,  993,  1005,  and  1018;  Tilden,  Boston  Med.  and  Surg.  Jour., 
1885  (with  colored  plates  and  histologic  cuts),  2,  p.  386;  Payne,  Trans.  London  Patholog. 
Soc'y,  1886,  p.  22,  and  "Rare  Diseases  of  the  Skin,"  1889;  Ledermann,  Archiv,  1889, 
vol.  xxi,  p.  683,  with  2  cuts,  review,  and  bibliography;  Pelissier,  "Mycosis  fongolde  ou 
Lymphadenie  cutanee,"  These  de  Montpellier,  1889 — abs.  Brit.  Jour.  Derm.,  1890,  p. 
56;  Besnier,  Jour.  mal.  cutan.,  1892,  p.  314;  -Annales,  1892,  p.  241;  Funk  (loc.  cit.); 
Stelwagon  and  Hatch,  Jour.  Cutan.  Dis.,  1892,  pp.  i  and  51  (with  colored  plates); 
Besnier  and  Hallopeau,  Annales,  1892,  p.  987;  Morrow,  Jour.  Cutan.  Dis.,  1896,  p. 
465  (with  colored  plate  and  other  illustrations);  Hyde  and  Montgomery,  ibid.,  1899, 
p.  253  (the  last  three  papers  deal  more  especially  with  the  "premycosic"  stage);  Gal- 
loway and  Macleod,  Brit.  Jour.  Derm.,  1900,  pp.  153  and  187  (with  4  histologic  cuts); 
Joseph,  Archiv,  Erganzungsband,  1900  (Kaposi's  Festschrift),  with  illustration  and  his- 
tologic cuts;  Stowers,  Brit.  Jour.  Derm.,  1903,  p.  47,  reports  a  case,  and  gives  a  table  of 
31  cases  (and  resume  of  20  of  them)  reported,  published  during  the  past  ten  years; 
Riecke,  Archiv,  1903,  vol.  Ixvii,  p.  193  (2  cases;  i,  d'emblee  type,  died  one-and-one  half 
years  after  onset;  at  autopsy  metastatic  growths  were  found  in  the  kidneys,  suprarenal 
glands,  retroperitoneal  glands,  and  dura  mater);  Sereni,  Dermatolog.  Zeitschr.,  1904, 
p.  41  (girl  of  sixteen,  a  mycosis  d'emblee,  death  two  and  one-half  years  from  onset); 
Greig,  Brit.  Jour.  Derm.,  1904,  p.  251  (histologic  report  by  Macleod);  Hancock,  Jour. 
Amer.  Med.  Assoc.,  1904,  vol.  xlii,  p.  705  (case  report,  with  autopsy  and  histologic 
findings);  Bozzi,  Polidin  (Rome),  1904,  vol.  xi,  p.  97;  Hodara,  Monatshefte,  1904,  vol. 
xxxviii,  p.  490  (3  cases  treated  by  ichthyol  internally,  with  improvement),  in  2 
cases  investigated  found  at  beginning  of  the  malady  a  characteristic  leukocytosis; 
Pelegatti  (mycosis  fungoides  and  leukemia),  ibid.,  vol.  xxxix,  pp.  369  and  433;  Towle, 
Boston  Med.  and  Surg.  Jour.,  1904,  vol.  cli,  p.  629;  Schiele,  Petersb.  med.  Wochenschr., 
1904,  vol.  xxix,  p.  535;  Ullmann,  Monatshefte,  1904,  vol.  xxxix,  p.  631  (chiefly  histologic); 
Orton  and  Locke,  Jour.  Amer.  Med.  Assoc.,  Jan.  12,  1907  (2  fatal  cases;  pathologic 


GRANULOMA   FUNGOIDES 


905 


urticarial,  or  erysipelatous  aspect,  with  the  subsequent  appearance  of 
pinkish  or  reddish,  tubercular,  nodular,  lobulated,  or  furrowed  tumors 
or  flat  infiltrations,  which  frequently  ulcerate  and  form  fungoidal  or 
mushroom-like  growths. 

Alibert  was  the  first  to  call  attention  to  this  rare  affection,  although 
he  originally  thought  it  allied  to  yaws  and  described  it  (1814)  as  "pian 
fongoiide,"  but  afterward  (1832)  gave  it  the  name  of  mycosis  fongoide, 
on  account  of  its  mushroom-like  tumors.  Among  other  later  writers 
who  have  added  contributions  to  the  subject  may  be  mentioned  Besnier, 
Vidal,  and  Brocq,  in  France;  Duhring,  Morrow,  Hyde,  Tilden,  Blanc,  and 
myself,  in  this  country:  Payne,  Galloway,  and  Macleod,  in  England; 
Auspitz,  Geber,  Kobner,  Kaposi,  and  Schiff,  in  Germany  and  Austria; 
and  De  Amicis,  in  Italy. 

Symptoms. — As  ordinarily  observed,  the  course  of  the  disease 
may  be  divided  roughly  into  several  stages:  The  first  stage  is  that  of 
erythematous  and  slight  eczematoid  manifestations,  comprising,  as  a 
rule,  fugacious  erythematous  lesions,  such  as  simple  erythema,  mild 
erythematous  eczema,  and  urticarial  efflorescences;  the  second  stage 
(stage  of  infiltration)  is  somewhat  similar  to  the  first,  except  that  the 
eruptive  phenomena  show  a  degree  of  infiltration  and  are  not  so  evanes- 
cent in  character.  The  third  stage  is  distinguished  by  its  tumor  growths, 
varying  in  size  from  a  pea  to  an  orange,  with  a  disposition  to  become 
superficially  ulcerated  and  fungoidal;  but  even  these  lesions  may  appear 
and  disappear  more  or  less  capriciously.  The  next  stage  is  that  in  which 
the  ulcerations  tend  to  become  deeper-seated,  with  a  marked  fungoidal 
tendency,  and  we  then  have  the  disease  presenting  itself  as  a  conglomera- 
tion of  eczematoid  eruption,  tumors,  fungoid  masses,  mushroom-like 
or  crateriform  ulcers.  Exceptionally,  the  first  two  stages,  which  may 
be  considered  the  premycosic,  may  be  extremely  short  or  entirely  want- 
ing. In  most  instances,  however,  the  first,  or  earliest  premycosic  stage, 
is  an  ill-defined  one,  with  symptoms,  often  those  of  eczematous  appear- 
ance, patchy  or  diffused,  and  usually  with  remissions  or  even  temporary 
periods  of  freedom.  Intermingled  with  the  erythematous  or  erythem- 
atosquamous  eruption  there  may  be  at  times  some  urticarial  or  hive- 
like  efflorescences,  and  rarely  there  may  be  noted,  independently  or  con- 
jointly with  the  other  manifestations,  some  papular  or  even  vesicular 

findings,  and  brief  review  with  references);  Giovannini,  Archiv,  1906,  vol.  Ixxviii,  p. 
3  (i  case  associated  with  universal  alopecia;  2  plates);  vonZumbusch  (of  Riehl's  clinic), 
Archiv,  1906,  vol.  Ixxviii,  pp.  21  and  263  (5  cases;  clinical,  histologic,  blood,  and  treat- 
ment); Roman,  Jour.  Cutan.  Dis.,  1910,  p.  506  (2  cases;  autopsy  in  i  case,  numerous 
lesions  in  lungs,  and  apparently  involvement  of  stomach,  and  marked  enlargement  of 
lymph-glands;  in  second  case  x-ray  treatment  seemed  to  bring  about  toxaemia);  Pardee 
and  Zeit,  Jour.  Cutan.  Dis.,  1911,  p.  7  (case  woman  aged  57;  pathologic  findings  of  the 
tumors  of  the  skin,  and  internal  organs  suggest  a  true  lymphatic  leukaemia,  but  the 
clinical  picture  was  that  of  granuloma  fungoides,  at  least  indistinguishable  from  the 
latter.  This  valuable  contribution  is  largely  illustrated  (case  and  histologic  illustra- 
tions, including  histologic  cuts  of  liver  and  lung);  Strobel  and  Hazen,  "Mycosis  Fun- 
goides in  the  Negro,"  Jour.  Cutan.  Dis.,  1911,  p.  147,  2  cases;  illustrations;  a  study 
and  review;  analytic  tables  of  data  and  bibliography  of  the  disease  and  various  allied 
diseases;  C.  J.  White,  Boston  Medical  and  Surgical  Jour.,  May  4,  1911  (case  report,  fe- 
male aged  46,  death,  after  seven  or  eight  years;  pyonephrosis  (left);  autopsy,  new 
growth-like  mass  in  peritoneal  cavity,  histologically  similar  to  that  of  the  corium  of 
the  skin). 


906 


GROWTHS 


lesions  of  an  eczematous  character,  and  exceptionally  an  eruption  of  a 
psoriatic  aspect.1  Very  rarely  the  earliest  lesions  may  be  papular. 
Probably  the  most  frequent  early  or  primary  manifestation  is  an  ery- 
thematosquamous  plaque,  usually  circinate  or  well  denned,  one  or  several 
inches  in  diameter,  which  may  be  present  scantily  or  in  numbers.  In  i 
of  my  cases  there  was  primarily  a  single  plaque  of  this  character  at  the 
axillary  fold,  which  lasted  over  a  year,  and  then  under  treatment  dis- 
appeared, to  be  followed  a  few  months  later  by  the  appearance  of  several 
scattered  patches.  This  insidious  beginning  is  not  uncommon,  and  the 
possibility  of  the  earliest  area  being  the  point  of  infection  —  if  the  malady 
can  be  so  considered  —  is  a  matter  of  considerable  interest  and  import. 
The  eruption  may,  and  usually  does,  become  quite  extensive,  and  to  all 
appearances  consists  of  ill-defined,  circumscribed  and  diffused,  reddened 
areas,  with  often  slight  scaliness,  and,  as  a  rule,  but  little,  if  any,  per- 
ceptible infiltration.  The  red  color  of  the  eruption  is  often  slightly 
mellowed  by  a  yellowish  tinge. 

After  thus  continuing  for  months  or  several  years  or  more,  the  second 
stage  —  the  stage  of  infiltration  —  is  gradually  presented.  This  infiltra- 
tion is  more  especially  noted  with  the  circumscribed  areas.  Soon  small 
pea-  to  cherry-sized,  rounded  or  flattened  nodules  begin  to  appear, 
scantily  or  in  profusion.  These,  as  well  as  the  diffused  erythematous 
patches,  may  disappear  suddenly,  to  be  supplanted  by  similar  lesions  on 
the  same  or  other  regions.  The  color  of  the  eruption  at  this  time  is,  as 
a  rule,  a  duller  red  than  in  the  earliest  period,  and  the  red  may  at  times, 
or  in  places,  have  a  violaceous  or  brownish  hue. 

Sooner  or  later  the  next  or  tumor  period  is  imperceptibly  ushered 
in.  The  infiltrated  patches  or  nodules  become  more  infiltrated  and  larger, 
and  lead  to  the  formation  of  distinct  tumors;  or  these  latter  arise  from 
apparently  normal  surface;  at  first  they  may  be  few  in  number,  the 
earlier  cutaneous  phenomena  still  playing  the  chief  role.  They  are  of 
different  sizes,  from  a  cherry  to  an  egg,  and  exceptionally  approaching 
the  size  of  an  orange.  As  a  rule,  however,  the  earliest  tumors  are  small, 
not  usually  exceeding  the  size  of  a  hen's  egg.  They  are  solid  in  charac- 
ter, with  rounded  or  oval  configuration,  and  generally  come  slowly. 
They  frequently  disappear,  but  others  continue  to  come,  ordinarily  much 
more  thickly  and  larger  and  larger,  although  they  may  be  present  in 
scant  number  throughout.  In  isolated  growths,  the  largest,  as  a  rule, 
there  are  sometimes  noticed  softening  and  ulceration  at  the  apex.  The 
disease  progresses,  the  tumors  are  noted  to  be  larger,  and  show  a  greater 
disposition  to  break  down,  and  the  last  stage  of  the  disease  is  entered  — 
the  fungoidal  stage  and  what  might  also  be  called  the  cachectic  stage. 
In  the  previous  period  the  general  health  seems  unaffected,  except  as  to 
the  depression  produced  by  the  knowledge  of  the  existence  of  the  malady 
and  the  loss  of  sleep  which  may  result  from  the  itching.  In  fact,  this 

1  In  the  case  reported  by  Biddle  (The  Physician  and  Surgeon,  Jan.,  1900)  the  earlier 
eruption  resembled  psoriasis,  the  body  being  profusely  covered  with  a  brownish-red, 
slightly  elevated,  scaly  eruption,  of  a  variegated  pattern,  but  with  a  tendency  to  irreg- 
lar  oval  and  gyrate  figures.  In  one  of  Strobel  and  Hazen's  cases  (he.  cit.)  the  primary 
lesions  were  papules,  usually  seated  at  the  follicular  openings,  and  often  with  either  a 
normal  or  broken  hair  piercing  the  center. 


PLATE  XXIX. 


Granuloma  fungoldes.  Case  shown  in  the  upper  illustration  was  of  thirteen  years' 
duration,  the  tumor  stage  being  present  the  last  fifteen  months ;  the  black-and-white 
text-cut  (Fig.  227)  is  of  this  same  patient.  The  case  shown  in  the  lower  illustration  was 
in  a  woman,  ihe  eczematoid  symptoms  and  the  tumor  growths  presenting  about  the  same 
time,  death  following  a  year  after  their  first  appearance.  (These  cases  are  reported  in  full 
in  four.  Cutan.  Dis.,  1892.) 


GRANULOMA   FUNGOIDES 


907 


tempestuousness  of  the  skin  disturbance  and  practical  absence  of  con- 
stitutional involvement  until  a  late  stage  is,  in  most  cases,  the  most 
striking  characteristic  of  this  strange  and  essentially  fatal  malady. 
This  involvement  may,  indeed,  not  take  place  until  the  latter  end  of  the 
fungoidal  ulcerating  stage. 

This  period  has  as  its  special  feature  the  ulcerating  tumors;  these 
are  frequently  numerous,  and  result  from  the  previously  developed 
growths,  which  are  usually  somewhat  flattened  on  top,  especially  the 
largest,  the  surface  softening  and  ulceration  extending  from  the  central 
apex  portion  almost  to  the  edges.  In  some  cases,  however,  as  in  one 
reported  by  Whitfield,1  the  eczematoid  symptoms  continue  to  be  predomi- 
nant, with  but  a  scanty  admixture  of  ulcerating  fungoidal  tumors. 
Some  of  the  tumors  may  be  somewhat  pedunculated,  the  basal  portion 
being  slightly  or  markedly  smaller  in  diameter  than  the  surface  and  pro- 
jecting part.  The  destructive  tendency  extends  somewhat  into  the 


Fig.  227. — Granuloma  fungoides  in  a  male  aged  forty-seven,  of  thirteen  years'  duration. 

growth,  but  not  always  uniformly,  and  in  such  instances  there  results 
a  mushroom-like,  ulcerating  tumor,  sometimes  with  everted  edges,  or 
one  the  surface  of  which  presents  a  resemblance  to  the  surface  of  a  cut 
tomato,  and  with  a  mucoserous  or  purulent  discharge,  often  mixed 
with  blood.  The  disease  thus  continues,  the  patient  becomes  weaker 
and  weaker,  and  distinctly  cachectic,  with  symptoms  common  to  sep- 
ticemia,  and  which  lead  more  or  less  rapidly  to  death. 

Exceptionally  the  precursory  or  premycosic  stages  are  entirely  lacking, 
and  the  disease  first  shows  itself  by  the  appearance  of  the  peculiar  fun- 
goidal tumors,  which  are,  as  a  rule,  few  in  number,  and  usually  limited 
to  one  region — mycosis  d'emble'e,  of  the  French.  In  this  variety  the 
eczematoid  and  erythematous  symptoms  are  sometimes  subsequently 
added.  The  lymphatic  glandular  system  may  or  may  not  show  special 
involvement,  although  in  most  of  the  cases  enlargement  has  been  noted. 
The  course  of  the  malady  is  usually  slow,  except  in  those  cases  in  which 

1  Whitfield,  Brit.  Jour.  Derm.,  1898,  p.  153  (with  2  illustrations). 


908  NEW  GROWTHS 

active  fungoidal  ulcers  present  at  once;  the  duration  before  the  final 
end  varies  within  considerable  limits  from  several  months  (Galliard, 
Naether,  and  Debove)  to  fifteen  years  or  more;  in  one  of  my  patients 
thirteen  years. 

Etiology. — The  cause  of  the  disease  is  not  known.1  The  litera- 
ture discloses  that  it  is  much  more  common  in  males  than  females;  ac- 
cording to  Tilden's  analysis  of  30  cases,  23  of  the  former  to  7  of  the  latter. 
In  4  cases  under  my  own  observation  3  were  males  and  i  female.  It  is 
an  affection  of  middle  adult  life,  most  common  between  the  ages  of  forty 
and  fifty.  In  over  half  of  Tilden's  tabulated  cases  it  began  after  forty, 
and  in  one-fourth  under  thirty,  but  no  case  before  the  age  of  twenty. 
Demange's  patient  (quoted  by  Tilden)  was  aged  sixty-eight.  It  occurs 
apparently  among  all  nationalities,  is  entirely  independent  of  syphilis, 
tuberculosis,  and  leprosy,  and  with  no  evidence  of  heredity  or  contagion; 
2  cases  have. never  occurred  in  a  family,  and  relatives  and  nurses  fre- 
quently brought  in  contact  with  the  patients  have  remained  unaffected. 
Micro-organisms  (variously  streptococci,  diplococci,  micrococci)  have 
been  found  and  described  by  several  or  more  investigators,  notably 
Auspitz,  Rindfleish,  Hochsinger  and  Schiff,  Hammer,  DeAmicis,  Murray, 
Hatch,  and  myself,  but  there  has  been  no  striking  uniformity  in  the 
findings;  and  others,  as  Kaposi,  Payne,  Donitz  and  Lassar,  Kobner, 
Funk,  Maiocchi,  Vidal,  Brocq,  Tilden,  Ledermann,  and  a  few  others 
have  either  failed  to  find  such  organisms  or,  admitting  their  possible 
presence,  have  looked  upon  them  as  either  pyogenic  streptococci  or 
merely  fortuitous  non-pathogenic  forms.  The  inoculation  experiments 
made  by  Hatch  and  myself  on  8  guinea-pigs  and  8  rabbits  were  without 
result. 

Pathology. — There  seems  no  longer  doubt  that  granuloma 
fungoides  can  scarcely  be  considered  as  belonging  or  allied  to  the  true 
sarcomata,  as  Kaposi,  Funk,  and  some  others  believe;  although  there 
are,  as  Bowen2  and  others  have  pointed  out,  many  points  of  similarity, 
both  histologically  and  clinically,  with  multiple  sarcomatosis  of  the  pure 
type.  The  fact  that  some  of  the  growths  may  undergo  involution  is, 
according  to  the  dictum  of  Cohnheim,  a  proof  of  their  non-sarcomatous 
nature,  but  we  know  now  that  in  some  instances  of  sarcoma,  especially 
the  multiple  pigmented  sarcoma  of  Kaposi,  that  such  retrogressive 
changes  can  also  take  place.  The  premycosic  or,  as  Morrow  prefers  to 
call  it,  the  prefungoidal  stage  of  granuloma  fungoides,  taken  with  the 
whole  clinical  course,  and  to  a  less  extent  the  histologic  data,  place  it  as 
a  distinct  affection,  although  some  of  the  cases  of  the  disease  in  which  the 
tumor  stage  is  ushered  in  at  once  would  almost  point  to  connecting  or 
intermediate  examples.  French  observers  are  inclined  to  look  upon 
the  disease  as  lymphadenomatous;  the  majority  of  German  investiga- 
tors, led  by  Auspitz,  Hochsinger,  and  Schiff,  regard  it  as  granuloma- 
tous,  and  with  this  view  the  studies  of  Payne,  Hatch,  and  myself 

1  The  case  reported  by  McVeil,  Murray,  and  Atkinson,  Glasgow  Hasp.  Reps.,  1898, 
vol.  i,  p.  53 — full  abs,  in  Brit.  Jour.  Derm.,  1899,  P-  69,  in  a  farmer  aged  forty-three, 
seemed  to  follow  an  injury  on  the  temple  due  to  a  sheep  kicking  him  while  shearing  it. 

2  Bowen  ("Mycosis  Fungoides  and  Sarcomatosis"),  Jour.  Cutan.  Dis.,  1897,  p.  65 
(2  cases). 


GRANULOMA   FUNGOID ES  909 

are  in  accord.  Paltauf1  is  inclined  to  include  the  malady  in  the 
class  of  anomalies  of  vegetation  proposed  by  Kundrat,  which  com- 
prises pseudoleukemia  and  certain  forms  of  lymphosarcoma.  In  this 
connection  it  may  be  stated  that  in  3  instances  (Biesiadecki,  Philippert, 
Kaposi)  there  was  an  associated  leukemia.  In  the  Pardee-Zeit  Case 
(loc.  tit.}  although  the  clinical  picture  was  that  of  granuloma  fungo'ides, 
the  pathological  findings  pointed  to  a  true  lymphatic  leukemia.  There 
is  no  doubt,  as  Hyde  and  Montgomery  state,  that  the  premycosic  erup- 
tions are  not  truly  eczematoid,  but  are  the  initial  manifestations  and  dis- 
tinctly a  part  of  the  disease  itself.  Hardy,  Leredde,  and  others  believe, 
according  to  the  same  observers,  even  apart  from  the  visible  beginning 
symptoms,  that  the  apparently  sound  skin  is  also  at  this  early  period 
the  subject  of  characteristic  pathologic  changes.  Excepting  in  a  few 
instances  (Duhring,  Gallaird,  Riecke,  Brandweiner,  Lenoble,  and  White)2 
neoplastic  tissue  has  not  been  found  elsewhere  than  in  the  cutaneous 
and  subcutaneous  structures. 

The  various  lesional  formations,  especially  the  tumors,  have  been  his- 
tologically  studied  by  many  observers  (Kaposi,  Payne,  Paltauf,  Fordyce, 
Joseph,  Hyde  and  Montgomery,  Galloway  and  Macleod,  Hatch,  myself, 
and  many  others) ,  and  agree  in  the  main,  but,  as  already  stated,  the  inter- 
pretation placed  upon  such  investigations  has  varied.  In  the  exami- 
nations by  the  majority  of  observers  the  epidermis  was  found  thinned, 
the  rete  Malpighi  a  mere  wavy  line,  the  papillae  squeezed  out  by  the 
pressure  of  the  growth  from  below,  making  them  shorter  and  broader, 
and  the  corium  infiltrated  with  small  round  cells.  All  likewise  agree 
in  denominating  the  cells  forming  the  tumors  lymphoid,  and  many  have 
been  able  to  distinguish  a  fine  embryonal  connective-tissue  network. 
The  sections  from  the  2  cases,  taken  when  living,  investigated  by  my- 
self and  Hatch,  were  taken  from  patches  of  skin  approaching  the  normal, 
from  the  simple  erythematous  locations,  from  the  tumors  of  moderate 
size,  and  form  the  fully  developed  growths.  In  the  first,  or  almost 
normal  sections,  a  moderate  round-cell  infiltration  was  seen  in  the 
corium,  and  the  latter  was  also  thinner  than  normal.  In  those  of  the 
second  were  found  turgescence  of  the  capillaries,  with  a  diapedesis  of  the 
red  blood-corpuscles  and  considerable  round-cell  infiltration,  occurring 
in  spots;  the  epidermis  normal,  the  papillae  intact,  the  round-cell  infiltra- 
tion being  limited  above  by  the  rete  Malpighi.  In  the  section  of  tumors 
of  moderate  size  a  most  characteristic  feature  was  the  Crowding  together 
of  the  lymphoid  cells  around  the  capillaries.  In  other  respects  they  ex- 
hibited about  the  same  structure  as  the  larger  growths,  save  that  they 
presented,  in  addition,  some  of  the  elements  of  the  normal  derm.  In  the 
fully  developed  tumors  the  following  presented:  the  field  seemed  to  be 
made  up  entirely  of  lymphoid  cells,  having  much  the  appearance  of  a 

1  Paltauf  ("Lymphatic  Neoplasms  of  the  Skin"),  Vienna  Congress,  1802  (quoted  by 
Bowen). 

2  Duhring  (loc.  cit.)  and  Gallaird  found  neoplastic  tissue  in  the  walls  of  the  bladder; 
Riecke  (loc.  cit.)  in  the  kidneys,  suprarenal  glands,  retroperitoneal  glands,  and  dura 
mater;  Brandweiner  (Monatshefte,  1905,  vol.  xli,  p.  415),  nodular  masses  in  both  cere- 
bral hemispheres  (colored  illustration  given),  and  Lenoble  (Annales,  1908,  p.  349)  a 
nodule  in  the  right  lung;  C.  J.  White  (loc.  cit.)  in  peritoneal  cavity. 


910 


NEW  GROWTHS 


small  round-celled  sarcoma,  and  reposing  in  a  fine,  embryonic,  connective- 
tissue  stroma. 

Diagnosis. — The  recognition  of  the  malady  in  the  tumor  stage  is 
rarely  a  matter  of  any  difficulty,  for  the  associated  clinical  symptoms, 
usually  present,  of  eczematoid  eruptions,  small  and  large  nodules,  and 
walnut-  to  egg-sized  or  larger,  elevated,  ulcerating  growths,  generally 
of  a  fungoidal  character,  and  often  one  or  several  slightly  pigmented 
areas,  showing  the  sites  of  tumors  which  have  undergone  involution, 
taken  together  with  the  history,  make  up  a  picture  which  is  unmistakable 
and  which  also  serve  to  distinguish  it  from  sarcomata.  In  the  variety 
of  granuloma  fungoides  in  which  the  preliminary  stages  are  wanting, 
the  tumors  constituting  the  first  signs,  there  may  be  strong  clinical  sugges- 
tions of  sarcoma  and  carcinoma,  but  these  latter  usually  show  early 
glandular  involvement,  are  often  spontaneously  and  acutely  painful, 
and  rarely  tend  to  fungoidal  ulcerative  forms,  as  do  the  growths  in  the 
former  malady.  The  diagnosis  in  the  premycosic  or  prefungoid  stages 
is  not  always  possible — indeed,  in  the  earliest  period  wholly  impossible, 
as  at  that  time  the  malady  may  show  the  clinical  aspects  of  a  mixed 
urticarial,  psoriasiform,  and  eczematous  eruption,  more  usually,  how- 
ever, eczematous  in  appearance.  Inasmuch  as  Hebra  once  made  the 
diagnosis  of  eczema  in  a  case,  it  can  readily  be  seen  that  the  symptoms 
are  sometimes  clearly  of  this  character  in  appearance,  and  that  such  an 
error  might  be  unavoidable.  However,  their  persistence  and  capricious- 
ness,  the  often  circumscribed  character  of  some  of  the  areas,  with  no  tend- 
ency to  yield  more  than  temporarily  to  therapeutic  measures,  and,  in 
the  earliest  stage,  often  a  yellowish  cast  to  the  red,  are  features  which 
may  lead  to  suspicion.  To  these  later  is  added  distinct  infiltration, 
usually  of  a  more  solid  and  well-defined  nature  than  in  eczematous  or 
psoriatic  eruptions.  Later  still  the  small  tumors  appear,  some  of  which 
may  lead  rapidly  to  larger  growths,  and  the  difficulties  in  the  diagnosis 
disappear.  In  obscure  cases  a  histologic  examination  of  involved  skin, 
and  even  in  the  early  phases  of  the  disease,  will  usually  show  character- 
istic changes.1  Granuloma  fungoides  has  also  been  confused  with  lep- 
rosy, but  if  necessary  the  examination  for  the  lepra  bacilli  would  serve 
in  the  differentiation. 

Prognosis  and  Treatment — The  disease  goes  on  to  fatal 
termination,  the  duration,  as  already  stated,  varying  somewhat  widely 
from  some  months  to  fifteen  years;  after  the  active  tumor  stage  is  entered, 
the  patient  can  scarcely  live  more  than  some  months  or  one  or  two  years 
at  the  most,  depending  principally  upon  the  number  of  the  growths  and 
the  degree  of  ulcerative  tendency  displayed2  A  case  of  recovery  after 
an  accidental  migrating  erysipelas  was  recorded  by  Bazin,  one  after  the 

1  Gaudier,  Joltrain  and  Brin,  "Soc.  de  Biologic,  Seance,"  Nov.  6,  1909;  and  de 
Beurmann  and  Verdun,  Bull,  de  Soc.  fran.  de  Derm,  et  Syph.,  1909,  p.  397,  claim  that  a 
serum  reaction  test  similar  to  the  Wassermann  using  an  alcoholic  extract  of  the  mycosis 
tumors  as  the  antigen  is  of  valuable  diagnostic  aid. 

2  Elliot  (discussion),  Jour.  Cutan.  Dis.,  1910,  p.  682,  refers  to  a  case,  seen  by  him 
in  1892;  of  three  years'  duration,  in  the  erythematous  stage  with  some  tumors;  patient 
still  alive  and  well,  after  eighteen  years,  although  there  had  been  returns  of  the  tumors, 
and  the  erythematous  condition  persisted  to  a  certain  extent;  growths  were  burned 
out  with  Paquelin's  cautery  as  soon  as  they  appeared. 


LEUKEMIA    CUT  IS;   PSEUDOLEUKEMIA    CUTIS  9!  I 

administration  of  arsenic  by  Kb'bner,  and  one  by  Geber.  Constitutional 
treatment  consists  essentially  in  the  use  of  tonics  and  nutritives,  together 
with  the  continued  administration  of  arsenic,  hypodermically,  when 
possible.  Treatment  by  exposure  to  x-rays,1  using  care  not  to  have  the 
current  too  strong  or  the  exposures  too  long,  may  often  be  resorted  to 
with  benefit;2  even  cures,  as  a  rule,  but  temporary,  however,  have  re- 
sulted. Instead  of  using  one  tube,  and  treating  part  after  part  separately, 
Lawrence  employs  an  #-ray  bath,  employing  6  tubes  at  the  one  exposure. 
The  treatment  seems  especially  valuable  in  controlling  the  pruritus. 
Results  in  some  cases  occurred  without  distinct  #-ray  reaction;  in  others 
not  till  moderate  reaction  was  provoked.  Crocker  cites  a  case  in  which 
recovery  took  place  apparently  from  continued  purgation.  Hodara 
saw  improvement  from  ichthyol,  internally,  moderate  to  full  doses. 
Local  measures  have  in  view  the  maintenance  of  cleanliness.  In  the 
early  stages  the  various  antipruritic  applications  used  in  eczema  can  be 
employed.  Later,  antiseptic  applications  and  dressings  to  the  ulcers, 
and,  when  deemed  advisable,  operative  interference. 

LEUKEMIA  CUTIS;  PSEUDOLEUKEMIA  CUTIS3  <£ 

In  some  cases  of  leukemia  the  skin  either  directly  or  indirectly 
shares  in  the  malady.  The  lesions  presented,  consisting  variously  in 

1  As  to  x-ray  treatment:  Jamieson,  Brit.  Jour.  Derm.,  1903,  p.  i  (case  illustration; 
disease  disappeared  from  all  parts  treated);  Jamieson  and  Hute,  ibid.,  1904,  p.  125  (in 
prefungoid  stage;  no  traces  remained);  Stainer,  ibid.,  1903,  p.  212  (apparently  cured); 
Marsh,  Amer.  Jour.  'Med.  Sci.,  1903,  vol.  cxxvi,  p.  314  (apparently  cured);  Ormsby. 
Medicine,  1903,  vol.  ix,  p.  904,  and  Hyde  and  Montgomery,  "Diseases  of  the  Skin," 
seventh  ed.,  p.  779  (prefungoid  stage;  plaques  would  disappear  under  treatment); 
Lustgarten,  Jour.  Cutan.  Dis.,  1904,  p.  185  (case  demonstration;  patches  had  almost 
entirely  disappeared,  with  the  exception  of  a  few  unrayed  spots,  for  which  patient  was 
still  under  treatment;  "a  single  twenty-minute  exposure  will  produce  a  dermatitis  on 
any  part  of  the  body  followed  by  a  complete  disappearance  of  the  lesion";  Lustgarten 
believes  a  dermatitis  should  be  provoked  by  the  rays);  Elliot,  ibid.,  p.  187  (discussion; 
complete  disappearance  of  all  lesions);  Carrier,  Jour.  Cutan.  Dis.,  1904,  p.  73  (case 
illustration;  lesions  have  entirely  disappeared);  Bulkley,  ibid,  (case  demonstration; 
steady  improvement);  Dubois-Havenith,  Presse  med.  beige,  1904,  vol.  Ivi,  pp.  139  and 
423  (symptomatically  cured);  Belot  and  Bisserie,  Arch,  d 'electric med.,  1904,  vol.  xiii, 
p.  855,  and  translation  in  Arch  Roentg.  Ray,  1904-5,  p.  139,  and  Belot,  Annales,  1904, 
p.  588  (eruption  practically  disappeared  under  treatment);  Markley,  Jour.  Cutan.  Dis., 
1905,  p.  440  (disappeared);  Jackson,  ibid.,  1906,  p.  193  (apparent  recovery  for  more 
than  a  year — recurrence  and  death);  Lawrence,  "z-Ray  Bath,"  Jour.  Cutan.  Dis., 
1908,  p.  247;  Burnside  Foster,  ibid.,  1909,  p.  75  (case  improving). 

2  C.  J.  White,  ibid.,  p.  195,  has  recorded  an  instance  of  fatal  toxemia  apparently 
resulting  from  the  rapid  disappearance  of  the  lesions  under  ac-ray  treatment;  also  refers 
(with  resume  and  bibliography)  to  other  reported  instances  of  toxemia  following  the 
treatment  of  other  neoplastic  growths — see  also  Pancoast's  paper,  Univ.  Penna.  Med. 
Bull.,  Jan.,  1907. 

3  The  following  papers  will  be  found  to  cover  pretty  fully,  by  review  and  bibliog- 
raphy, the  literature  of  the  leukemias:  Pincus,  Archiv,  1899,  vol.  1,  pp.  37  and  177; 
Nekam,  Ueber  die  leukcemischen  Erkrankungen  der  Haul,  1899,  Vose,  Hamburg  and 
Leipsiz;  Nicolau,  Annales,  Aug.-Sept.,  1904,  p.  753,  and  also  in  Unna's  "Histopath- 
ology";  Brunsgaard,  Hautkrankheiten  bei  der  myeloiden  Leukaemia  und  der  malignent 
Granulomatose,  Arch.,  March,  1911,  cvi  (with  case  report  of  a  fatal  leukemia,  and  a 
case  of  lymph-gland  tumors  with  a  blood  picture  of  polynuclear  leukocytosis;  in  both 
cases  metastatic  skin  tumors  in  the  form  of  cutaneous  and  subcutaneous  papules 
and  nodules;  gives  a  good  critical  review  based  largely  on  the  histopathology  of  the 
various  skin  lesions  associated  with  the  leukemias  and  the  malignant  granulomata; 
Dubreuilh,  "Prurigo  lymphadenique,'M nnales,  1905,  H.  8-9  (concerning  especially  cases 


912 


NEW  GROWTHS 


the  cases  reported,  or  in  some  instances  as  a  medley  in  the  same  case, 
of  true  leukemic  tumors  (Biesiadecki,  Hochsinger  and  Schiff,  and  others), 
dry,  and,  less  frequently,  moist,  eczema-like  areas,  often  of  more  or  less 
general  distribution,  eczematous  or  lichenoid  papules,  infiltrated,  thick- 
ened, reddish,  sometimes  pale,  areas  of  skin,  with  occasionally  the  lines 
and  folds  accentuated  (when,  on  the  face  presenting  an  appearance  of 
leontiasis) ;  and  in  some  instances  the  development  of  diffuse  lymphatic 
thickening  and  hypertrophy,  with  the  formation  in  the  lower  part  of 
the  corium,  or  subcutaneously,  of  discrete,  crowded,  or  chain-like  pea 
to  cherry-sized  or  larger,  doughy  or  hard,  somewhat  flattened  nodules. 
There  is  usually  intense  itching,  and  sometimes  a  hypersensitive  skin, 
tender  upon  touch  or  pressure,  or  at  times  spontaneously  painful.  The 
eczematous  element  is  variable,  being  more  or  less  intense  at  different 
times  or  periods,  but  the  tumor-like  growths  and  infiltration  are  usually 
persistent  and  progressive;  exceptionally  the  eczematoid,  thickened 
or  lymphatic  infiltrations  give  place  to  atrophic  changes.  The  face,  head, 
arms,  and  genital  and  anal  regions  are  frequently  favorite  situations  for 
the  more  extreme  developments;  the  face  and  head  in  those  of  limited 
development.  In  some  of  the  cases — those  in  which  there  is  a  medley 
of  tumor  formations,  eczematoid  eruptions,  and  thickened,  infiltrated 
plaques — the  resemblance,  as  to  external  appearances,  to  granuloma 
fungoides  is  quite  striking,1  but  there  is  rarely  any  decided  tendency  to 
ulceration,  and  practically  none  to  the  formation  of  the  peculiar  fungoid 
growths  and  ulcers  of  granuloma  fungoides.  Exceptionally,  the  mani- 
festation may  be  suggestive  of  a  multiple  pigmented  sarcoma.2  Cases 
of  the  other  extreme — in  which  the  visible  tumor  formation  is  practically 
wanting,  and  only  the  smaller  subcutaneous  nodules,  together  with  a 
dry,  eczematoid,  somewhat  shriveled-looking,  reddened,  slightly  scaly 
skin,  are  present — may  show  some  resemblance  to  pityriasis  rubra  of 
Hebra.  Exceptionally  an  intense  pruritus  is  the  sole  associated  skin 
symptom. 

Not  uncommonly  the  eczema  or  eczema-like  eruption  is  the  first 
symptom  to  which  the  patient's  attention  is  called,  and  such  a  con- 
dition is  usually  persistent,  with  a  disposition  to  infiltrated  plaques, 
and  most  intractable  to  treatment.  The  itching  also  seems  more  or 
less  uncontrollable.  In  other  instances  the  eczema-like  symptoms  are 
lacking,  the  manifestations  consisting  of  from  several  to  large  numbers 
of  variously  sized,  slightly  to  prominently  projecting,  soft,  doughy, 
firm,  sometimes  roughly  lobulated  tumors,  over  which  the  skin  may  or 

characterized  by  pruritus  and  pruriginous  papules,  etc.,  2  cases  of  his  own;  refer- 
ences); Hazen,  "Skin  Changes  in  the  Leukaemias  and  Allied  Conditions,  "Jour.  Cutan. 
Dis.,  191 1,  p.  521  (based  upon  2  cases  under  his  own  observation  (i  case,  notes  given 
by  Dr.  Strobel),  a  review  of  recorded  cases,  omitting  doubtful  cases,  with  brief  case 
notes  and  bibliography  of  the  leukemias  and  allied  conditions — an  exhaustive  and 
helpful  paper  to  those  interested). 

1  Pelagatti,  "Mycosis  fungoides  und  Leukamie,"  Monalshefle,  1904,  vol.  xxxix,  pp. 
369  and_433  (with  histologic  cuts),  believes  granuloma  fungoides  a  leukemia  primarily, 
with  skin  manifestations  secondarily. 

2  Rolleston  and  W.  Fox,  "A  Case  of  Atypical  Myeloid  Leukemia  with  Nodular 
Infiltration  of  the  Skin,"  Brit.  Jour.  Derm.,  1909,  p.  377  (case  illustrations — 4  histoiogic 
cuts,  and  references). 


LEUKEMIA    CUTIS;   PSEUDOLEUKEMIA    CUTIS  913 

may  not  be  movable,  and  which  may  be  of  a  normal,  pale  red,  yellowish, 
or  brownish-red  color.  In  these  cases  the  general  symptoms  of  leukemia 
may  have  long  preceded  these  cutanenous  manifestations.  Later  the 
leukemia  becomes  more  profound,  and  there  may  also  be  the  de- 
velopment of  lymphatic  abscesses,  with  sometimes  a  tendency  to  a 
breaking  down  of  the  larger  growths,  exceptionally  into  gangrenous 
ulcers;  increasing  weakness  and  prostration  of  the  patient,  and  finally 
death. 

The  histologic  characters  of  the  growths  have  been  studied  by  various 
observers  (Biesiadecki,  Hochsinger  and  Schiff ,  Kreibich,  Pinkus,  NeTcam, 
Nicolau,  and  others).  There  is  found  a  cellular  infiltration  in  the  corium 
and  subcutaneous  tissue  consisting  largely,  as  is  generally  conceded,  of 
crowded  and  heaped-up  lymphocytes;  although  some  observers  believe 
the  masses  are  derived  from  the  connective-tissue  cells  in  situ,  and  others 
that  they  arise  from  the  exudation  of  leukocytes  from  the  blood-current. 

Pseudoleukemia  Cutis. — Pseudoleukemia,  known  commonly  as 
Hodgkin's  disease,  like  leukemia,  sometimes  presents  cutaneous  mani- 
festations (lymphadenoma  cutis)  closely  or  practically  similar  to  those 
observed  in  the  latter  disease,  and  already  described.  Bullous  lesions 
are  a  rather  unusual  occurrence.1  It  is  believed  by  some  observers2  that 
a  pseudoleukemia  sometimes  develops  into  a  true  leukemia. 

Diagnosis. — The  recognition  of  the  eruptions  of  the  leukemias 
depends  largely  upon  the  recognition  of  the  underlying  disease.  In- 
tractable eczematous  or  eczematoid  eruption,  especially  if  at  all  exten- 
sive, with  a  disposition  in  places  to  considerable  infiltration,  rebellious  to 
treatment,  and  with  a  troublesome,  persistent,  or  paroxysmal  itching 
difficult  to  relieve,  should  always  suggest  the  possibility  of  granuloma 
fungoides,  a  leukemia  cutis,  or  a  pseudoleukemia  cutis.  Suspicion  thus 
aroused  becomes  more  probable  or  almost  certain  if  there  is  any  associated 
tumor  formation;  and  as  to  leukemia  and  pseudoleukemia,  a  careful 
general  examination,  as  to  blood,  glands,  and  internal  organs,  will  usually 
determine  the  matter.  That  there  is  often  a  strikingly  puzzling  likeness 
in  the  clinical  cutaneous  ensemble  of  these  three  maladies  is  to  be  ad- 
mitted, so  much  so  as  to  suggest  a  possible  kinship.3 

Treatment. — Hopeless  as  to  final  outcome  as  it  usually  is,  a 
proper  general  plan  of  treatment  is  to  be  instituted.  Billings4  has  ob- 
served favorable  influence  from  benzol,  but  says  its  use  requires  caution. 
As  to  the  cutaneous  symptoms,  exceptionally  amelioration  and  in  one 
or  two  instances  complete  relief  followed  the  administration  of  arsenic, 
preferably  by  hypodermic  injection.  The  £-ray,  more  especially  in 

1  Bloch  reports,  Archiv  ("Erythema  toxicum  bullosum  und  Hodgkinische  Krank- 
heit"),  1907,  vol.  Ixxxvii,  p.  287,  a  case  of  associated  bullous  erythema  and  Hodgkin's 
disease. 

2  Linser,    "Beitrage   zur   Frage   das   Hautveranderungen   bei    Pseudoleukamie," 
Archiv,  May,  1906,  vol.  Ixxx;  Radaeli,  "Mykosis  fungoides  oder  Pseudoleukamie  cu- 
tanea,"  ibid.,  July,  1906,  vol.  Ixxx. 

3 1  have  met  with  3  such  puzzling  cases  in  recent  years  in  which  the  differentiation 
symptoms  were  so  ill-defined  that  a  positive  diagnosis  without  qualification  could 
scarcely  be  made;  all  ended  fatally.  See  also  foot-note  of  Pardee  and  Zeit  case,  under 
Granuloma  fungoides. 

4  Billings.  "Benzol  in  the  Treatment  of  Leukemia,"  Jour.  Amer.  Med.  Assoc.,  Feb. 
15,  1913,  p.  496  (with  pertinent  literature  references). 

58 


914 


NEW  GROWTHS 


pseudoleukemia,  has  given  encouraging  results.1  The  external  manage- 
ment of  the  eruption  and  tumors  is  essentially  that  advised  in  granuloma 
fungoides. 

LEPRA2 

Synonyms. — Leprosy;  Lepra  Arabum;  Elephantiasis  Graecorum;  Leontiasis; 
Satyriasis;  Fr.,  La  lepre;  Ger.,  Der  Aussatz;  Norwegian,  Spedalskhed. 

Definition. — Lepra  is  an  endemic,  chronic,  malignant,  constitu- 
tional disease,  due  to  a  specific  bacillus,  characterized  by  alterations  in 
the  cutaneous,  nerve,  and  bone  structures,  varying  in  its  morbid  mani- 
festations according  to  whether  the  skin,  nerves,  or  other  tissues  are 
predominantly  involved,  and  resulting  in  anesthesia,  ulceration,  necrosis, 
general  atrophy,  and  deformity. 

Ill-defined  records  of  the  existence  of  this  malady  are  to  be  found 
as  far  back  as  the  remotest  ages.  Although  its  primary  origin  is  unknown 
it  is  not  improbable,  that  it  was  in  its  earliest  history  limited  to  Egypt 
and  the  Orient.  Mention,  sometimes  of  an  indefinite  character,  is  made 
of  it  in  several  parts  of  the  earlier  books  of  the  Bible.3  During  the  middle 
ages  it  was  quite  rife  in  Europe,  England,  and  Scotland,  declining  in  the 
fifteenth  century  and  practically  disappearing  by  the  sixteenth.  In 
the  last  hundred  years  there  seems  to  have  been,  in  certain  places,  signs 
of  recrudescence,  and  the  malady  has  appeared  in  parts  where  it  had 

1  A  review  of  the  literature  of  x-ray  in  the  leukemias,  with  bibliography,  will  be 
found  in  a  paper  by  Pancoast,  in  Univ.  Pa.  Med.  Bull.,  Jan.,  1907;  and  Stengel  and 
Pancoast,  "The  Treatment  of  Leukaemia  and  Pseudoleukaemia  with  X-rays,"  Jour. 
Amer.  Med.  Assoc.,  Sept.,  28,  1912,  p.  1166 — in  former  over  long  bones,  in  latter  over 
glandular  enlargements. 

2  Important  general  literature:   Danielssen  and  Boeck,  Traite  de  la  Spedalskhed, 
Paris,  1848;  Vandyke  Carter,  "Leprosy  and  Elephantiasis,"   1874;  Leloir,  "Traite 
pratique  et  theorique  de  la  Lepre,"  Paris,   1886;   Thin,  "Leprosy,"  London,  1891; 
Journal  of  the  Leprosy  Investigating  Committee,  London,  1890-91;  Hansen  and  Looft, 
"Die  Lepra  vom  klinischen   und   pathologischen-anatomischen  Standpunkt,"  Bibli- 
otheca  medica,  D.  2,  H.  2;  there  is  an  English  translation  by  Walker,  London,  1895; 
Mittheilungen  und  Verhandlungen  der  Internal.  Lepra  Conferenz  zu  Berlin,  1897,  Berlin, 
1897-98;  Lepra- Bibliotheca  internationalis;  Babes,   "Die  Lepra,"  1901;   Santon,  "La 
Leprose,"  1901;  Verhandl.  v.  Inlernat.  Derm.  Cong.,  Berlin,  1904,  vol.  i.     The  transac- 
tions of  the  International  Congresses  on  Leprosy;  Lie,  Archh,  1911,  ex,  p.  473  (sta- 
tistical review,  based  on  over  1000  cases).     Other  literature  will  be  referred  to  in  the 
course  of  the  text. 

3  McEwen,  in  two  interesting  papers,  "The»  Leprosy  of  the  Bible  in  its  Medical 
Aspect."  The  Biblical  World,  No.  3,  Sept.,  1911,  and  "The  Leprosy  of  the  Bible:  its 
Religious  Aspect,"  ibid.,  No.  5,  1911,  very  properly  concludes  that  leprosy  of  the  Bible, 
as  also  believed  by  most  men  competent  to  study  the  subject,  includes  many  cutaneous 
affections: — "The  word  'leprosy'  did  not  refer  ever  and  always  to  true  leprosy,  but 
was  rather  a  generic  term  covering  various  sorts  of  inflammatory  skin  diseases,  which 
rendered  the  one  afflicted  unfit  to  associate  with  others,  not  because  his  condition  was 
contagious  as  a  disease,  but  because,  by  virtue  of  the  belief  among  the  Hebrews  in  the 
principle  to-day  known  as  'taboo,'  it  disqualified  him  for  the  worship  of  Jehovah, 
threatened  others  by  contact  with  a  like  disqualification,  and  required  ceremonial 
procedure  for  removal.     When  this  simple,  and,  we  believe,  true  explanation  of  biblical 
leprosy  is  understood  and  accepted,  a  great  step  will  be  taken  toward  the  elimination  of 
the  irrational  lepraphobia  of  to-day." 

Any  one  who  has  carefully  studied  the  subject  cannot  think  otherwise.  More- 
over, I  am  convinced  that  the  history  of  the  so-called  great  spread  of  the  disease  in 
middle  Europe,  England,  and  Scotland  during  the  middle  ages  and  in  a  century  or  two 
gradually  disappearing  is  similarly  largely  mythical,  due  to  a  hysteric  wave  of  lep- 
raphobia  and  ignorance  in  diagnosis,  which  resulted  in  placing  most  skin  disease  cases, 
among  which  doubtless  some  true  leprosy  cases,  under  this  ban — to  remain  until  fear 
had  ceased  and  knowledge  had  increased. 


LEPRA  9 I 5 

never  before  existed.  It  is  probable,  however,  that  this  alleged  increase 
or  recrudescence  is  more  apparent  than  real,  the  studies  and  activity  of 
dermatologic  workers  in  the  past  several  decades  in  regard  to  the  disease 
bringing  the  existent  cases  and  facts  more  strongly  into  the  foreground. 
Its  distribution  is,  however,  quite  extensive,  although  the  aggregated 
number  of  cases,  as  well  as  the  percentage  of  state  and  world  population, 
is  insignificant  compared  to  that  during  the  early  and  middle  ages.  It 
still  exists  to-day  to  a  variable  extent  in  Norway  and  Sweden,  Southern 
Russia,  Asia,  Japan,  along  the  coasts  of  Africa,  some  of  the  Central  and 
South  American  States,  Mexico,  Cuba,  and  the  Sandwich  Islands.  It 
is  also  found  in  some  of  the  British  Colonies,1  in  many  of  the  islands  of  the 
Indian  and  Pacific  Oceans,  New  Zealand,  Madeira,  and  the  West 
Indies.  Spain  and  Portugal,  as  well  as  Greece  and  certain  parts  of 
Italy  and  France,  furnish  a  variable  number  of  cases. 

In  the  United  States2  the  earliest  cases  were  found  in  Louisiana 
among  the  French,  and  in  Minnesota  and  other  Northwestern  States 
among  the  Norwegian  immigrants,  and  a  limited  number  in  South 
Carolina.  It  also,  as  known,  exists  in  its  colonies  recently  acquired. 
In  more  recent  years,  as  to  be  expected  from  our  nearness  to  leprous 
centers,  imported  cases,  especially  Chinese,  have  been  met  with  in 
California  and  the  other  nearby  Coast  States.  Isolated  cases  in  indi- 
viduals who  have  contracted  the  disease  elsewhere  are  also  encountered 
from  time  to  time  in  New  York,  Philadelphia,  Chicago,  and  other  cities. 

Symptoms. — Leprosy  presents  varied  and  manifold  symptoms. 
The  clinical  aspects  in  some  cases  seem  totally  different  from  those 
in  others,  and  in  others  again  are  frequently  of  mixed  character.  There 
are,  too,  in  most  instances,  several  stages  of  the  malady,  which  are, 
however,  often  ill  defined.  Owing  to  these  facts  it  is  customary,  and, 
upon  the  whole,  more  satisfactory  as  to  clearness,  to  describe  the  dis- 
tinct types  separately.  Probably  the  best  arrangement  is  a  division 
of  the  subject  into:  (i)  Period  of  incubation;  (2)  period  of  invasion; 
(3)  macular  type;  (4)  tubercular  type;  (5)  anesthetic  type;  (6)  mixed 
type.  One  form  usually  shades  slightly,  moderately,  or  decidedly  into 
another,  so  that  it  can  readily  be  understood  that  the  manifestations  of 
either  form  may  vary  considerably. 

1  See  Abraham's  paper  in  Trans.  Internal.  Leprosy  Conference. 

2  D.  W.  Montgomery,  "Leprosy  in  San  Francisco,"  Jour.  Amer.  Med.  Assoc.,  July 
28,  1894;  Dyer,  "Report  on  the  Leprosy  Question  in  Louisiana,"  Proceedings  of  the 
Orleans  Parish  Med.  Soc'y,  meeting  of  June  n,  1894;  Dyer,  "Endemic  Leprosy  in 
Louisiana,"  Philada.  Med.  Jour.,  Sept.  17,  1898;  Jones,  New  Orleans  Med.  and  Surg. 
Jour.,  1877-78,  vol.  v,  p.  673;  Morrow,  "Matters  of  Dermatological  Interest  in  Mex- 
ico and  California,"  Jour.  Cutan.  Dis.,  1889,  p.  147;  Hyde,  "The  Distribution  of  Lep- 
rosy in  North  America,"  Trans.  Cong.  Amer.  Phys.  and  Surg.,  1894  (with  full  bibliog- 
raphy); J.  C.  White,  "Leprosy  in  the  United  States  and  Canada,"  Trans.  Internal. 
Leprosy  Conference,  1897,  vol.  i;    Bracken,  "Leprosy  in  Minnesota,"  Philada.  Med. 
Jour.,  1898,  ii,  p.  1309;  D.  W.  Montgomery  (a  white  woman  who  contracted  leprosy 
in  San  Francisco),  Lepra,  Bibliotheca  inlernalionalis ,  vol.  1,  Fasc.  4,  1900;  Burnside 
Foster  (case  contracted  in  Minnesota),  Jour.  Amer.  Med.  Assoc.,  Aug.  31,  1901;  Dyer, 
Jour.  Amer.  Med.  Assoc.,  Nov.  7,  1903;  "Origin  of  Louisiana  Leprosy,"  Med.  Library 
and  Histor.  Jour.,  Jan.,  1904;  "Leprosy  in  North  America,"   Verhandl.  v.  Internal. 
Derm.  Cong.,  1904,  vol.  1;  Daland,  "Leprosy  in  Hawaiian  Islands,"  Jour.  Amer.  Med. 
Assoc.,  Nov.  7,  1903;  Ewing,  "Leprosy  as  Seen  in  the  Philippines,"  Med.  Record,  Dec. 
15,  1906;  Pollitzer,  "Historical  Sketch  of  Leprosy  in  the  United  States,"  Jour.  Cutan. 
Dis.,  May,  1911,  p.  361. 


916 


NEW  GROWTHS 


Stage  of  Incubation. — This  is,  so  far  as  inference  from  the  known 
facts  shows,  extremely  variable.  The  absence  of  a  recognizable  pri- 
mary lesion  necessarily  limits  the  field  of  observation  on  this  point. 
It  has  happened,  however,  that  in  some  instances  the  malady  can  be 
ascribed  to  exposure  consequent  upon  a  short  visit  to  a  region  where 
it  is  prevalent,  the  affection  developing  a  variable  time  after  the  return 
home — a  country  free  from  the  disease.  Such  observations  indicate 
that  the  period  of  incubation,  from  the  time  of  exposure  to  the  first 
manifestations,  may  be  short  or  long,  varying  from  several  months 
to  some  years,  depending,  doubtless,  upon  the  receptivity  and  condi- 
tion of  the  individual  and  upon  other — unknown — factors.  As  illus- 


Fig.  228. — Leprosy  of  the  maculo-anesthetic  type,  in  a  boy  of  fourteen;  with  also  a 
thickened  macular  anesthetic  patch  on  the  palm  (courtesy  of  Dr.  D.  W.  Montgomery). 

trating  the  short  extreme,  Bidenkap,  cited  by  Morrow,1  observed  an 
instance  in  which  the  disease  developed  a  few  weeks  after  the  first 
exposure,  and  Morrow  himself  had  a  case  under  his  care  in  which  the 
disease  appeared  within  ten  months  following  a  short  visit  to  the  Sand- 
wich Islands.  On  the  other  hand,  some  observers,  among  whom  Dan- 
ielssen,  Boeck,  and  Leloir,  have  recorded  cases  having  an  incubation 
period  of  ten  to  forty  years.  Doubtless  the  state  of  the  health,  the  food 
supply,  climate,  and  surroundings,  as  well  as  the  varying  resisting  power 
of  individuals,  are  responsible,  in  great  part  at  least,  for  the  great  differ- 
ences in  the  length  of  time  noted  between  exposure  and  the  appearance 
of  invasion  symptoms.  It  is  not  improbable,  however,  that  in  most  cases 
of  apparent  long  period  of  incubation  the  disease  may  have  already  been 
1  Morrow's  System,  vol.  iii  (Dermatology),  p.  566. 


LEPRA  917 

in  existence  for  some  time,  but  that  the  manifestations  are  of  such  mild 
character  that  they  escape  observation. 

Stage  of  Invasion. — This  period  varies  within  considerable  limits, 
averaging  probably  from  several  months  to  a  year.  The  prodromata 
of  leprosy  are  frequently  ill  defined,  and,  unless  occurring  in  leprous 
countries  or  districts,  and  presenting  something  characteristic,  are  often 
ascribed  to  simple  ill  health  or  considered  manifestations  of  malaria, 
tuberculosis,  or  some  other  malady.  Chilliness,  febrile  action  of  an  in- 
termittent type,  malaise,  disinclination  to  exertion,  mental  depression 


Fig.  229. — Macular  leprosy  patches,  associated  with  tubercular  infiltration  of  the  face; 
same  patient  as  Fig.  231  (courtesy  of  Dr.  L.  A.  Duhring). 

or  hebetude,  debility  and  epistaxis,  often  associated  with  pain,  altera- 
tions in  sensibility,  and  motor  weakness,  variously  present  from  time  to 
time  irregularly.  One,  several,  or  all  such  symptoms  may  be  noted,  but, 
as  a  rule,  those  most  frequently  observed  are  the  chilliness  and  febrile 
action,  lassitude  and  debility,  and  pains,  especially  in  the  extremities, 
and  of  a  more  or  less  paroxysmal  character.  Instead  of  chilliness  there 
may  be  well-defined  rigors.  The  fever,1  if  uncomplicated,  is  probably 

1  Lewers,  "A  Note  on  Leprous  Fever,"  Brit.  Jour.  Derm.,  1899,  p.  388,  gives  a 
good  brief  analytic  review  of  this  subject,  with  citations  of  opinions  from  important 
works  on  the  disease. 


pi 8  NEW  GROWTHS 

always  more  or  less  intermittent,  and  is,  as  well  as  other  symptoms,  due 
to  the  presence  of  the  bacilli  or  their  toxins.  While  often  an  early  mani- 
festation, it  is  frequently  more  pronounced  later,  along  with  the  appear- 
ance of  the  cutaneous  symptoms.  Vertigo  and  cephalalgia  are  also  not 
uncommon  manifestations  in  the  invasion  stage.  In  the  anesthetic 
variety  of  the  disease,  while  chilliness,  febrile  action,  and  some  of  the 
other  symptoms  named  present,  there  is,  as  is  to  be  expected,  a  prepon- 
derance of  those  of  a  distinctly  neurotic  character.  Morrow  considers 
itching,  often  of  a  severe  degree,  to  be  one  of  the  most  common  and  char- 
acteristic signs  of  the  invasion  period.  Formication,  sensations  of 
tingling  and  burning,  pricking  pain,  localized  soreness  or  tenderness,  a 
numb  or  dead  feeling,  heaviness,  stiffness  with  neuralgic  pain,  both  of  a 
superficial  and  deep  character,  are  also  variously  noted. 

The  import  of  such  symptoms,  as  well  as  others  of  the  invasion  stage, 
is  often  overlooked,  however,  until  cutaneous  evidences  of  the  malady 
show  themselves.  In  many  instances,  it  is  true,  these  latter  are  the 
first  signs  to  which  the  patients  give  attention,  the  earlier  symptoms 
having  been  of  a  mild  or  obscure  character  or  practically  wholly  absent. 
Recent  studies  indicate,  as  first  pointed  out  by  Morrow,  and  since  em- 
phasized by  the  observations1  of  Sticker,  Jeanselme,  and  Laurens,  that 
the  first  manifestations  are  rather  determined  toward  the  mucous  mem- 
branes of  the  pharynx  and  upper  air -passages  than  toward  the  skin; 
and  betrayed  by  alterations  of  the  voice,  such  as  husky  or  rough  phona- 
tion,  rhinitis  with  an  abnormally  free  nasal  secretion,  sometimes  epis- 
taxis,  and  an  increase  of  the  salivary  secretion. 

Macular  Type. — Macular  leprosy  (lepra  maculosa)  is  to  be  consid- 
ered more  as  a  forerunner  of  the  tubercular  form,  and  occasionally  also 
of  the  anesthetic  variety,  than  as  a  distinct  type.  The  eruptive  mani- 
festations may  or  may  not  have  been  preceded  by  several  or  more  of  the 
invasion  symptoms.  The  cutaneous  phenomena  consist  of  variously 
sized  patches,  with  or  without  infiltration,  of  a  red,  violaceous,  brownish, 
or  blackish  color.  There  may  be  an  intermingling  of  depigmented 
vitiligo-like  spots,  striae,  or  areas,  with  those  of  a  hyperpigmented  char- 
acter, and  these  all  may  be  so  ill  pronounced  as  to  give  the  integument 
a  dappled  appearance.  In  fact,  this  type  can  be  said  to  be  sometimes 
made  up  of  a  mixture  of  morphea-like  patches,  leukodermic  areas,  and 
more  or  less  pigmented  spots  and  patches.  Some  may  be  atrophic, 
others  somewhat  thickened  or  lardaceous  and  firm.  The  eruption  may 
be  slight  and  somewhat  limited,  or  in  some  instances  is  quite  extensive. 
The  color  may  be  brownish  or  mahogany  red  or  sepia  tint,  dependent 
to  some  extent  upon  the  complexion  and  race.  Occasionally  it  may  sug- 
gest an  ecchymosis.  Patches  vary  in  size  from  a  pin-head  to  a  palm  or 
larger,  as  a  rule  being  coin-  to  palm-sized.  There  is  sometimes  a  deeper 
shade  centrally,  in  others  peripherally;  if  the  latter,  the  patches  may 
assume  a  distinctly  circinate  aspect.  The  skin  involved  may  be 
otherwise  apparently  normal,  slightly  atrophic  or  thickened,  and  may 
show  slight  hyperesthesia  or  be  more  or  less  anesthetic.  Not  infre- 
quently irregularly  scattered  blebs  appear  from  time  to  time,  usually 

1  Sticker,  Jeanselme,  Laurens,  Trans.  Internal.  Leprosy  Conference,  Berlin,  1897. 


LEPRA  919 

scanty  in  number.  The  febrile  and  other  general  symptoms,  already 
referred  to,  often  present  at  intervals,  at  which  times  there  is  usually  an 
exacerbation  in  the  cutaneous  symptoms.  The  malady  may  persist 
somewhat  indefinitely  as  this  type,  with  sometimes  paralytic  motor 
symptoms  and  sensory  disturbances,  with  variable  mixture  of  more 
pronounced  evidences  of  the  anesthetic  type;  or  infiltration  and  nodula- 
tion  begin  to  present,  and  it  passes  partially  or  more  or  less  completely 
into  the  tubercular  form. 


Fig.  230. — Macular  Leprosy — showing  unusual  circinate  patches  (courtesy  of  Dr. 

Howard  Fox). 

Tubercular  Type  (Tubercular  Leprosy;  Tuberculated  or  Nodular 
Leprosy;  Lepra  Tuberculosa). — This  is  the  more  common  expression  of 
the  disease,  and  generally  the  form  which  is  noted  in  a  region  when  the 
malady  gains  its  first  foothold.  Later,  after  its  existence  in  a  community 
for  a  long  period,  the  milder  or  anesthetic  type  is  noted  to  occur  relatively 
in  greater  and  greater  frequency.  In  tubercular  leprosy  the  brunt  of 
the  malady  is  seemingly  borne  by  the  integument.  The  earliest  symp- 
toms are  usually  those  described  in  the  macular  variety,  which  latter, 
as  stated,  is  generally  to  be  considered  an  early  stage  of  the  disease. 
The  peculiar  characters  of  the  tubercular  variety  consist  in  the  appear- 


920 


NEW  GROWTHS 


ance  of  tubercles  and  nodules,  distinctly  defined,  or  as  more  or  less  ill- 
defined  areas  of  infiltration,  with  subsequent  ulceration.  The  skin, 
more  especially  of  the  face,  ears,  and  often  other  parts,  is  noted  to  be 
thickened,  seemingly  hypertrophic,  with  an  accentuation  of  the  natural 
lines.  The  region  of  the  brow,  particularly  of  the  eyebrows,  commonly 
shows  the  earliest  evident  infiltration.  Along  with,  as  well  as  often 
preceding,  these  characteristic  lesions,  scattered  blebs  and  more  or  less 
infiltrated,  hyperesthetic  or  anesthetic,  pinkish,  reddish,  or  pale-yellow- 
ish macules  make  their  appearance  from  time  to  time,  subsequently  fading 
away  or  remaining  permanently. 

When  well  advanced,  the  tubercular,  nodular,  or  infiltrated  masses 
give  rise  to  great  deformity;  the  face,  a  favorite  locality,  becomes  more 


Fig.  231. — Leprosy  of  the  tubercular  type,  associated  with  macular  variety;  the 
tubercles  not  defined,  but  consisting  of  pronounced  infiltration,  especially  about  the 
eyes  and  brow;  same  case  as  Fig.  229  (courtesy  of  Dr.  L.  A.  Duhring). 

or  less  roughly  leonine  in  appearance  (leontiasis) .  The  hands  are  also 
usually  the  seat  of  similar  lesions,  and  not  infrequently  other  regions 
likewise  present  tubercles  or  areas  of  infiltration.  As  a  rule,  however, 
the  face,  ears,  and  hands  are  the  parts  chiefly  so  involved. 

The  tubercles  are  brownish  or  brownish-yellow  in  color,  vary  in  size 
considerably,  often  attaining  somewhat  large  proportions.  They  de- 
velop in  most  instances  from  macular,  usually  slightly  or  moderately 
infiltrated,  areas,  although  also  often  arising  primarily  upon  skin  seem- 
ingly previously  unaffected.  They  persist  almost  indefinitely  without 
material  change,  or  undergo  absorption  or  ulceration;  this  last  takes 
place  most  commonly  about  the  fingers  and  toes.  Not  infrequently 


LEPRA 


921 


there  is  a  partial  or  even  complete  disappearance  of  one  crop  of  tubercles, 
to  be  succeeded  by  another,  and  ordinarily  of  more  pronounced  char- 
acter. At  such  times  the  fresh  outbreak  is  often  preceded  by  febrile 
action,  chilliness,  and  other  general  symptoms.  Others  may  undergo 
some  absorption  and  be  gradually  transformed  into  indurated,  fibrous, 
pseudokeloidal  masses.  Some  may  completely  disappear  and  leave 
behind  atrophic,  thinned,  pigmented  skin  or  cicatrices.  Many  tend, 
however,  after  a  more  or  less  indefinite  period,  to  undergo  ulcerative 
destruction,  and  this  tendency,  as  already  remarked^  is  most  frequently 
displayed  with  the  tubercles  and  nodules  of  the  extremities.  The  re- 
sulting ulcerations  are  of  a  shallow,  indolent  character,  having  a  yellow- 
ish-brown, viscid  discharge,  which  sometimes  dries  to  brownish,  thickish 


Fig.  232. — Tubercular  leprosy  of  three  years'  duration  (courtesy  of  Dr.  Howard  Fox). 

crusts.  In  some  instances  the  ulcerative  action  extends  deeply  and  may 
lay  bare  ligaments  and  bones.  Others  after  a  time  tend  to  heal,  and 
especially  if  cleanliness  is  maintained  and  antiseptic  dressings  applied. 
In  the  course  of  time,  and  more  particularly  when  ulcerative  action  is 
pronounced,  the  lymphatic  glands  of  the  neck,  groin,  and  axillae  become 
enlarged,  and  not  uncommonly  finally  break  down  and  ulcerate;  along 
with  this  is  noted  also  swelling  of  the  lymphatics  leading  to  these  glands. 
In  addition  to  the  integumentary  changes,  the  mucous  membrane 
of  the  nares,  mouth,  pharynx,  and  other  neighboring  parts  also  shows 
invasion.  The  eye  likewise  often  suffers  and  exhibits  surface  tubercles 
or  infiltration.  The  hair,  especially  of  the  regions  involved,  sooner  or 
later  shows  impaired  nutrition  and  falls  out;  this  is  frequently  noted 


922 


NEW  GROWTHS 


about  the  eyebrows.  The  scalp  hair,  however,  usually  remains,  as 
this  region  is,  according  to  almost  all  observers,  peculiarly  exempt  from 
leprous  manifestations.1  The  palms  are  likewise  rarely  invaded.2  The 
nails  do  not,  as  a  rule,  seem  to  suffer  directly,  but  their  nutrition,  as  is 
to  be  expected,  is  often  impaired,  and,  as  a  result,  there  may  be  thinning 
or  thickening,  irregularity,  brittleness,  opacity,  etc.  There  is  commonly, 
early  in  the  malady,  a  disturbance  of  the  functions  of  the  sweat  and 
sebaceous  glands;  primarily  there  is  often  increased  activity,  but  later 


Fig.  233. — Leprosy,  tubercular  variety;  lesions  are  also  shown  upon  the  cornea  (courtesy 

of  Dr.  J.  A.  Fordyce). 

there  is  a  partial  or  more  or  less  complete  arrest,  and  this  may  be  localized 
or  somewhat  general. 

Anesthetic  Type  (Lepra  Ansesthetica ;  Lepra  Nervorum. — Anes- 
thetic leprosy,  in  which  the  brunt  of  the  malady  is  borne  by  the  nervous 
system,  is  characterized  chiefly  by  anesthetic  and  atrophic  manifesta- 

1  Morrow,  "A  Case  of  Macular  Lepride  of  the  Scalp — with  Remarks  on  the  Locali- 
zation of  Leprous  Lesions,"  Jour.  Cutan.  Dis.,  1900,  p.  10,  reports  a  case  in  which  the 
scalp  showed  macular  manifestations;  Fernet,  Brit.  Med.  Jour.,  Nov.  n,  1905,  p.  1280, 
reports  2  cases  in  which  the  scalp  was  involved. 

2  D.  W.  Montgomery,  Jour.  Cutan.  Dis.,  1899,  p.  445,  noted  an  instance  with  a 
maculo-anesthetic  leprid  upon  the  palm;  a  case  with  a  similar  circinate  patch  in  this 
region,  in  addition  to  manifestations  on  other  parts,  recently  came  under  my  notice. 


LEPRA  923 

tions.  The  latter  are  usually  more  or  less  limited  to  the  hands,  feet,  and 
face.  Its  development  is  an  insidious  one,  and  it  is  not  infrequently  a 
part  of  or  a  sequence  of  the  macular  form.  Following  or  along  with  the 
precursory  symptoms  denoting  general  systemic  disturbance,  or  inde- 
pendently of  any  prodromal  indications,  a  hyperesthetic  condition,  in 
localized  areas  or  more  or  less  general,  is  observed.  As  a  rule,  febrile 
attacks,  or  the  pseudomalarial  aspect,  is  not  a  usual,  or  at  least  not  so 
constant,  accompaniment  of  this  type.  Lancinating  pains  along  the 
nerves,  particularly  of  the  extremities,  and  an  irregular,  scattered,  pemphi- 
goid  eruption  are,  however,  commonly  noted.  The  malady  may  present 
nothing  further  than  these  various  manifestations,  often  along  with 
occasional  attacks  of,  or  more  or  less  persistent,  pruritus,  for  an  indefi- 
nite time,  ordinarily  one  to  several  years.  Sooner  or  later  there  follows 
the  special  eruption,  coming  out  from  time  to  time,  and  consisting  of  sev- 
eral or  more,  usually  non-elevated,  well-defined,  pale-yellowish  patches, 
i  or  2  inches  in  diameter.  They  rarely  present  in  numbers,  but  gen- 
erally present  singly,  new  areas  appearing  from  time  to  time.  They 
are  found  most  frequently  upon  the  back,  shoulders,  dorsal  surface 
of  the  arms,  thighs,  about  the  elbows,  knees,  and  ankles.  The  face 
also  may  show  the  eruption.  There  is  often  a  symmetric  distribution. 
Leloir  noted  an  instance  of  double  zoster-like  arrangement  on  the  chest. 
As  a  rule,  they  are  at  first  neither  hyperesthetic  nor  anesthetic,  but  may 
be  the  seat  of  slight  burning  or  itching.  They  spread  peripherally,  and 
tend  to  clear  in  the  center.  The  patches  eventually  become  markedly 
anesthetic,  and  the  overlying  skin  and  the  skin  on  other  parts  as  well 
becomes  atrophic  and  of  a  brownish  or  yellowish  color.  In  many  in- 
stances when  first  appearing  they  are  of  a  sepia-brown  shade,  and  some- 
times of  a  bluish-red  color,  and  usually  more  pronounced  at  the  border 
portion.  Occasionally  if  several  are  close  together  coalescence  gradually 
takes  place,  resulting  in  gyrate  patches,  with  a  well-defined,  sometimes 
slightly  elevated,  reddish  periphery,  and  a  pale  or  leukodermic  atrophic 
central  portion.  In  fact,  instead  of  the  eruption  presenting  itself  as 
yellowish-brown  areas,  of  the  features  described,  the  earliest  patches  may 
be  of  a  vitiligo-like  character.  In  some  cases  there  is  depigmentation, 
extending  over  considerable  surface. 

The  areas  are  frequently  preceded  by  sensory  disturbance,  such  as 
formication,  burning,  or  stinging  sensations.  While  they  are  in  their 
first  appearance  sometimes  hyperesthetic,  after  a  variable  time,  usually 
soon  afterward,  there  is  anesthesia,  especially  centrally.  Not  uncom- 
monly the  central  portion  becomes  anesthetic,  while  hyperesthesia  is 
noted  in  the  spreading  border.  In  some  cases,  or  in  some  stages  of  the 
malady,  the  anesthesia  does  not  confine  itself  to  the  immediate  areas, 
but  may  involve  considerable  surface,  or  even  an  entire  region  supplied 
by  an  affected  nerve.  While  ordinarily  the  nervous  disturbance  primar- 
ily does  not  compromise  the  tactile  sense,  consisting  at  such  period  of 
hyperesthesia,  analgesia,  and  thermo-anesthesia,  later  the  sensory  func- 
tions are  wholly  abolished. 

As  the  disease  continues  and  the  nerve  involvement  becomes  more 
pronounced  atrophic  symptoms  are  noted  to  ensue.  The  subcuta- 


924 


NEW  GROWTHS 


neous  tissues,  muscle,  hair,  and  nails  undergo  atrophic  or  degenerative 
changes,  and  these  changes  are  especially  observed  about  the  hands 
and  feet.  These  parts  become  crooked,  thinned,  emaciated,  and  other- 
wise distorted.  Surface  ulcers  appear,  either  spontaneously  or  as  the 
result  of  knocks  or  other  injuries.  The  muscles  atrophy,  the  fingers 
become  drawn  up  and  flexed,  producing  the  so-called  "leper  claw." 
Finally  the  bone  tissues  are  involved,  the  phalanges  dropping  off  or  dis- 
appearing by  disintegration  or  absorption  (lepra  mutilans).  The  toes 
and  feet  are  similarly  affected,  and  not  infrequently,  especially  in  those 
who  go  barefooted,  a  deep  plantar  ulcer  forms.  The  process  may  not 
stop  at  disintegration  and  destruction  of  the  fingers  and  toes,  but  the 
hands  and  feet  may  gradually  be  wholly  lost.  The  ulnar  and  peroneal 

nerves   and   other    nerves    of 

the  extremities  seem  to  be 
especially  prone  to  the  damag- 
ing influence  of  the  bacillus 
invasion.  The  ulnar  nerve 
particularly  is  considerably 
thickened,  either  uniformly  or 
irregularly,  and  can  usually  be 
felt  as  a  thick,  tense  cord,  and 
is  often  painful  upon  pressure. 
In  addition,  owing  partly  to 
the  atrophy  of  the  glandular 
structures  and  the  consequent 
suppression  of  the  sweat  and 
sebaceous  secretions,  there  is 
often  a  thinned,  atrophic-look- 
ing  condition  of  the  skin  of  the 
arms  and  legs,  which  is  gen- 
erally of  a  dirty  yellowish  or 
brownish  color,  and  presents 
a  somewhat  tense  appearance, 
and  with  thin,  flaky,  or  branny 
scaliness.  Occasionally  the 
skin  is  somewhat  wrinkled. 
In  occasional  cases  the  skin  of 
the  trunk  likewise  exhibits  similar  changes.  The  atrophic  action  also 
often  involves  the  face,  and  along  with  the  paralytic  symptoms,  which 
sooner  or  later  presents,  give  rise  to  considerable  facial  disfigurement. 
The  face  is  sometimes  drawn  to  one  side.  The  eyelid  muscles  are  often 
involved,  and,  in  consequence,  and  also  partly  owing  to  the  loss  of 
eyelashes,  the  eyes  not  being  properly  protected,  inflammation,  ulcera- 
tion,  and  opacities  ensue. 

Ulcerations  are  not  so  common  a  feature  of  the  anesthetic  as  of 
the  tubercular  form,  and  are  chiefly  the  result  of  trophic  influence, 
arising  principally  from  dry  or  moist  gangrene,  and  from  knocks  or 
other  injuries. 

The  mucous  membrane,  especially  of  the  mouth,  soft  palate,  uvula, 


Fig.  234. — Leprosy  of  the  tubercular  type, 
on  face,  associated  with  anesthetic  type;  same 
case  as  Figs.  235  and  238. 


LEPRA 


925 


and  back  of  the  pharynx,  shows  loss  of  sensibility  and  other  nervous 
disturbance,  and  there  is  serious  interference  with  the  act  of  deglutition, 
often  giving  rise  to  regurgitation  through  the  nostrils. 

Mixed  Type. — The  mixed  form  of  leprosy  is,  as  the  name  signifies, 
characterized  by  features  of  the  several  types  described.  The  early  le- 
sions are  usually,  as  in  the  other  forms,  those  of  the  macular  type.  Later 
there  is  often  at  first  the  development  into  the  anesthetic  or  tubercular 
expression  of  the  disease,  and  which  may  persist  as  such  for  a  variable 
time,  and  then  gradually 
present  symptoms  of  the 
other  variety.  The  dis- 
tinctly anesthetic  form  of 
the  malady  may,  there- 
fore, sometimes  sooner  or 
later  have  added  tuber- 
cular and  nodular  infiltra- 
tions, and  with  subse- 
quent ulceration;  the  tu- 
bercular form  likewise  may 
present  after  a  time  fea- 
tures of  the  anesthetic 
type,  not  infrequently, 
however,  the  clinical  fea- 
tures are  of  mixed  char- 
acter from  the  beginning. 

Course.— Leprosy 
runs  a  chronic  persistent 
course,  with,  in  many 
cases,  remissions,  or  even 
temporary  or  more  or  less 
prolonged  intermissions. 
Exacerbations  in  the  cu- 
taneous phenomena  occur 
from  time  to  time,  and 
at  such  periods  there  are 
generally  preceding  and 
accompanying  constitu- 
tional symptoms  of  mal- 
aise, debility,  febrile  ac- 
tion, and  chilliness  or 
distinct  rigors.  These  are  much  less  common,  however,  in  the  anes- 
thetic variety,  and  not  infrequently  are  practically  absent.  The  in- 
tegumentary lesions  become  slowly  more  pronounced  and  numerous,  and 
while  the  tubercles  and  nodular  masses  and  infiltration  may  undergo 
absorption,  new  outbreaks  predominate  over  retrogressive  changes. 
More  commonly  these  lesions  show  ulcerative  changes.  The  nervous 
form  of  the  disease,  as  already  described,  increases,  as  a  rule,  steadily, 
but  is  much  less  rapid  in  its  progress  than  the  tubercular  form,  usually 
lasting  from  ten  to  thirty  years,  averaging  probably  twelve  to  fifteen. 


Fig.  235. — Leprosy,  showing  paralysis  and  atro- 
phy of  some  of  the  extensor  muscles,  and  the  "leper 
claw"  of  the  anesthetic  type;  faint  macular  anes- 
thetic area  shows  on  forearm;  same  case  as  pre- 
ceding, with  tubercular  type  on  face. 


926  NEW  GROWTHS 

In  tubercular  leprosy  death  results  in  almost  half  the  cases  from 
the  direct  effect  of  the  disease,  either  from  exhaustion  or  involvement 
of  the  air-passages  or  of  internal  organs.  Renal  and  lung  complications 


Fig.  236. — Anesthetic   leprosy — showing  "claw  hand"  with  ulcerations  (courtesy  of 

Dr.  J.  M.  Winfield). 

carry  off  almost  as  great  a  number.  The  remainder  die  from  anemia, 
or  enteric  complications  with  colliquative  diarrhea.  In  the  anesthetic 
form  the  end  comes  from  the  direct  action  of  the  leprous  poison,  from 


-  237. — Anesthetic  leprosy,  showing  characteristic  mutilation  (courtesy  of  Dr.  T.  M. 

Winfield). 

exhaustion,  muco-enteritis,  long-continued  digestive  disorders,  or  other 
complications.  Pulmonary  and  renal  disorders  are  not  encountered 
as  often  in  this  form  as  in  the  tubercular  variety. 


LEPRA  927 

It  is  not  improbable,  however,  that  the  pulmonary  and  enteric 
maladies  which  bring  the  fatal  end  in  leprosy  cases  are,  in  reality,  not 
complications,  as  usually  understood,  but  are  themselves  of  leprous 
character.  Arning  believes  that  the  supposed  intercurrent  pneumonia 
and  tuberculosis,  and  the  diarrhea  or  dysentery,  are  due  to  leprous 
infiltration — which  he  denominates  respectively  phthisis  leprosa  and 
enteritis  leprosa.  Beaven  Rake's1  conclusions  are  practically  the  same. 
The  culture  experiments  with  fragments  of  assumedly  phthisical  lung 
or  tuberculous  viscera  from  lepers  have,  as  he  states,2  so  far  been  unsuc- 
cessful, this  tending  to  confirm  the  view  that  these  conditions  are  lep- 
rous and  not  really  tuberculous.  As  to  kidney  complication,  this  same 
observer3  found,  in  78  autopsies,  some  form  of  nephritis  in  23  cases,  a 
percentage  of  29.4.  He  noted  a  much  longer  duration  of  life  in  these 
cases  when  occurring  in  the  anesthetic  variety  than  in  the  tubercular 


Fig.  238. — Leprosy,  with  paralysis  and  atrophy  of  extensor  muscles,  and  some  small 
ulcerations  on  toes,  and  slightly  scurfy  skin;  same  case  as  Fig.  235. 

form,  which  he  attributes  to  the  fact  that  in  the  latter  variety  the  sweat- 
glands  are  involved  earlier  and  to  a  more  serious  extent,  thus  throwing 
more  strain  on  the  kidneys. 

Etiology. — The  direct  cause  of  leprosy  is  now  accepted  to  be 
a  specific  bacillus — the  bacillus  leprae.  The  discovery  by  Hansen,  in 
1874,  has  completely  negatived  the  hereditary  theory  formerly  so  strongly 
held.  It  is  true  that  the  evidence  points  to  the  fact  that  certain  individ- 
uals or  families  may,  as  likewise  now  believed  regarding  tuberculosis,  show 
a  readier  susceptibility  when  exposed  to  invasion.  It  is  certain,  too, 

heaven  Rake,  "The  Significance  of  Visceral  Tuberculosis  in  Leprosy,"  Brit.  Jour. 
Derm.,  1890,  p.  33  (based  upon  a  study  of  90  autopsies). 

2  Beaven  Rake,  Brit.  Med.  Jour.,  Aug.  4,  1888. 

3  Beaven  Rake,  "The  Kidney  Lesions  in  Leprosy  Considered  in  Relation  to  the  Skin 
Changes,"  Brit.  Jour.  Derm.,  1889,  p.  213  (with  citation  of  the  opinion  of  others  as  to 
the  complication,  with  references). 


928 


NEW  GROWTHS 


that  the  liability  to  successful  implantation  of  the  organism  is  measurably 
increased  by  such  predisposing  influences  as  climate,  soil,  abode,  food, 
and  habits.  It  is  known  that  the  malady  is  most  prevalent  in  tropical 
and  subtropical  countries,  although  it  is  also  common  in  some  cold 
climates,  as  Norway,  Iceland,  and  elsewhere.  It  is,  moreover,  distinctly 
a  disease  of  the  coast  and  nearby  waterways;  it  also  occurs,  however, 
inland,  and  in  high  regions  likewise,  although  to  a  relatively  slight  extent. 
The  method  by  which  the  organism  gains  access  is  not  known.1 
Recent  observations  (Morrow,  Sticker,  Jeanselme,  Laurens,  Babes, 
von  Peterson,  Flugge,  Besnier,  Gliick,  Schaeffer)  indicate  that  the 
mucous  membrane  of  the  nose,  and  probably  of  the  mouth  also,  may 
be  a  not  uncommon  source  of  communication  and  infection.2  Schaeffer3 
refers  to  experiments  on  this  point.  Slides  were  placed  in  the  vicinity 
of  leprosy  patients  while  they  were  reading  aloud,  and  subsequently 
examined,  disclosing  the  presence  of  large  numbers  of  bacilli.  It  is  not 
improbable,  also,  that  entrance  may  take  place  through  some  abrasion 
in  the  skin  (Lassar,  Arning,  von  Peterson,  Ehlers,  Geill).  Geill4  calls 
attention  to  the  fact  that  in  tropical  countries,  with  the  people  who  go 
barefooted,  the  first  lesions  are  seen  frequently  upon  the  feet — in  50 
per  cent,  of  his  own  cases.  It  is  known  that  the  bacilli  can  be  found 
in  the  feces  (Boeck).5  Vaccination  has  exceptionally  been  blamed  for 
the  introduction  of  the  organisms,  but  there  is  scant  reliable  evidence 
on  this  point.6  There  is  a  growing  belief  that  the  malady  is  not  directly 
contagious  or  inoculable  from  man  to  man,  but  that  there  is  an  inter- 
mediate host,  or  insect  carrier,  as  now  generally  believed  as  to  malaria, 
and  it  is  one  that  might  explain  many  apparent  contradictions.7  Hutch- 
inson8  has  long  held,  as  is  well  known,  the  opinion  that  in  the  eating  of 
fish,  especially  raw  or  salted,  is  to  be  found  the  cause  of  the  malady; 
lately  he  has  added  the  suggestion  that  the  bacillus  may  gain  access  in 

1  See  Morrow's  interesting  paper,  "Sources  and  Modes  of  Infection  in  Leprosy," 
Trans.  Amer.  Derm.  Assoc.for  1899,  p.  113;  Mugliston,  Jour.  Trap.  Med.,  1905,  p.  209, 
suggests  that  the  itch  mite  may  possibly  be  the  means  of  communication— having  the 
leprous  bacillus  in  or  simply  on  its  tissues  when  it  enters  the  skin. 

2  Mewborn,  Jour.  Cutan.  Dis.,  1903,  p.  236,  found  numerous  bacilli  in  the  nasal 
secretion  taken  from  a  case  observed  by  Fordyce. 

3  Schaeffer,  Trans.  Internal .  Leprosy  Conference,  Berlin,  1897. 

4  Geill,  ibid. 

5  Boeck,  Festschrift,  Unna  (1910,  Bid.  i,  p,  436),  and  Dermatolog.  Wochenschr.,  Oct., 
1912,  Iv,  p.  1267  (discusses  the  possibilities  of  spread  of  disease  by  this  source). 

8  See  Baum's  paper,  "Leprosy  and  Vaccination,"  Med.  Standard,  1893,  p.  163. 

7  Goodhue  (Boston  Med.  and  Surg.  Jour.,  1906,  vol.  cliv,  p.  357)  states  that  he  has 
found  the  bacillus  in  the  bedbug  and  in  the  mosquito,  but  as  yet  this  statement  remains 
without  corroboration  by  others;  Currie,  "Mosquitoes  and  Fleas  in  Relation  to  the 
Transmission  of  Leprosy,"  Public  Health  Bull.,  1910,  Washington,  D.  C.  (full  abs. 
in  Jour.  Trop.  Med.,  May  i,  1911),  made  some  experiments  in  the  laboratory  at  Hono- 
lulu, with  the  results:  mosquito,  chiefly  culex  cubensis,  negative,  as  the  proboscis  is 
inserted  into  a  blood-vessel  obtaining  bacilli — free  blood;  domestic  flies  will  convey  the 
bacillus  from  a  discharging  leprous  ulcer  to  the  skin  of  a  healthy  person  in  the  neighbor- 
hood; Engelbreth  (Dermalolog.  Wochenschr.,  1912,  liv,  pp.  700  and  723),  in  an  interesting 
paper  on  the  origin  of  the  disease,  endeavors  to  show  that  leprosy  has  flourished  in  all 
countries  where  the  goat  flourished,  and  tends  to  disappear  where  these  give  way  to  the 
breeding  of  sheep  and  cattle;  he  believes  that  an  internal  disease  in  the  goat,  closely 
resembling  tuberculosis,  is  transmitted  to  man  (through  milk,  etc.),  and  results  in 
leprosy. 

8  Hutchinson,  "Leprosy  and  Fish-Eating,"  London,  1906. 


LEPRA  929 

this  way.  His  views  as  to  this  food-cause  are  negatived  by  the  general 
observations  of  others.  It  is  not  at  all  unlikely,  however,  that  its  en- 
trance, in  some  cases  at  least,  may  be  through  the  food. 

While  one,  upon  going  thoroughly  over  the  clinical  evidence,  must 
admit  the  communicability  of  the  disease,  yet  there  are  other  unknown 
factors  in  addition  to  the  active  one — the  bacillus — which  seem  to  be 
necessary.  Hereditary  tissue  weakness,  climate,  food,  abode,  and 
habits  are,  doubtless,  therefore  contributing.  If  its  successful  communi- 
cability depended  upon  the  bacillus  alone,  the  examples  of  the  con- 
tagiousness of  the  disease  should  be  common,  instead  of  rare.1  Its  con- 
tagiousness, under  favoring  circumstances,  is  shown  in  the  rapid  spread 
in  Hawaii,  and  more  recently  the  suggestive  increase  in  Louisiana  (Dyer).2 
But  even  in  Hawaii  the  contributing  influence  of  race,  poor  food,  and 
other  factors  is  disclosed  by  the  fact  that  the  leper  population  consists 
almost  entirely  of  Hawaiians  and  half  castes,  less  than  3  per  cent,  are 
Chinese,  with  a  few  other  foreigners — British,  American,  German,  etc. — 
not  exceeding  a  dozen.  As  von  During  well  remarks,  however,  all  nega- 
tive evidence  brought  forward  as  to  its  non-communicability  is  valueless 
in  the  face  of  one  positive  fact  to  the  contrary.  And  though  these  posi- 
tive data  are,  in  my  judgment,  relatively  scanty,  still  they  are  sufficient 
to  make  us  look  upon  the  existence  of  cases  in  our  midst  as  of  possible 
danger,  although'  this  is  in  civilized,  well-fed,  and  well-cared-f or  communi- 
ties exceedingly  remote.3 

It  is  generally  admitted  that  the  anesthetic  type  is  not  so  contagious 
as  the  tubercular;  and  it  is  also  commonly  believed  that  the  form  of  the 
disease  in  a  community  which  is  usually  primarily  tubercular,  gradually, 
after  years,  loses  its  virulent  character  somewhat,  and  that  it  subse- 
quently persists  in  the  anesthetic  form.  Zambaco4  and  a  few  others 
would  also  have  us  believe  that  its  virulence  becomes  still  further  atten- 

1  Hutchinson  states  (Brit.  Med.  Jour.,  June  29,  1889)  that  not  a  single  sporadic 
case  is  ever  now  seen  in  England;  the  cases  there  are  all  imported.     Bronson  says  (Jour. 
Culan.  Dis.,  1895,  p.  428)  of  New  York:   "we  have  had  lepers  in  this  city  for  many 
years,  and  yet  there  is  not  a  single  case  on  record  where  local  contagion  has  occurred." 
Lutz  (ibid.,  1892,  p.  477),  speaking  of  his  experience  and  observations  in  South  America 
and  the  Hawaiian  Islands,  says:   "Contagion  even  by  intimate  and  prolonged  contact 
is  by  no  means  frequent  in  families  living  in  a  civilized  way  and  in  easy  circumstances." 
Hallopeau  (Trans.  Internal.  Leprosy  Conference,  Berlin,  1897)  says  that  "in  Paris  up  to 
the  present  no  case  has  been  known  to  arise  there";  and  Besnier  (ibid.)  also  states 
that  "in  Paris,  at  the  H6pital  St.  Louis,  lepers  are  not  isolated,  and  notwithstanding 
this  no  instances  of  contagion  have  ever  occurred";  Thompson  (Lancet,  Mar.  5,  1898) 
shows  that  in  Victoria  and  Australia,  where  lepers  have  mingled  freely  with  the  com- 
munity, the  disease  is  on  the  decrease.     Kaposi  (Wiener  klin.  Wochenschr.,  No.  45, 
1898),  while  admitting  that  from  a  pathologic  point  of  view  the  malady  is  infectious, 
holds  that  clinically  it  is  not  contagious.     Zambaco,  who  is  still  a  champion  of  the  hered- 
itary nature  of  the  disease,  states  that  he  has  never  seen  a  case  originating  in  contagion. 

2  Dyer,  Philada.  Med.  Jour.,  Sept.  17,  1898. 

3  Bracken,  ibid.,  Dec.  17,  1898,  states  that  it  is  quite  possible,  judging  from  his 
own  observations,  for  leprosy  to  die  out  in  certain  favored  sections  of  our  country, 
such  as  Minnesota,  without  segregation,  provided  the  importation  of  lepers  be  dis- 
continued. 

4  Zambaco,   Trans.  Internal.  Leprosy  Conference,  Berlin,  1897;  see  also  Leloir's 
interesting  paper  on  this  point,  "Existe-t-il  dans  des  pays  reputes  non  lepreux,  en  France 
et  en  particulier  dans  la  region  du  nord  et  a  Paris,  des  vestiges  de  1'ancienne  lepre," 
Bull,  de  I'Acad.  de  Med.,  Paris,  1893,  p.  215;  a  good  abstract  in  Brit.  Jour.  Derm.,  1893, 
p.  129;  see  also  references  under  Morvan's  disease. 

59 


930 


NEW  GROWTHS 


uated,  and  that  the  disease  is  finally  exemplified  in  many  cases  of  the 
maladies  known  as  syringomyelia,  scleroderma,  morphea,  sclerodactylia, 
Raynaud's  disease,  and  progressive  muscular  atrophy  (Aran-Duchenne), 
considering  them  to  be  modified  or  weakened  forms  of  lepra. 

Pathology.: — The  bacillus  is  now  fully  accorded  the  r61e  of 
starting  and  producing  the  pathologic  changes,  and  which  has  in 
recent  years  received  considerable  study  by  many  investigators.  The 
bacillus  is  a  slender,  rod-like,  straight  or  very  slightly  curved  parasite, 
averaging  about  sinnr  inch  in  length  (from  one-half  to  three-fourths 
the  diameter  of  a  red  blood-corpuscle);  and  its  thickness  is  about  one- 
fourth  to  one-fifth  of  its  length.  According  to  Cornil,  the  longest  are 
found  in  parenchymatous  organs,  while  those  found  in  the  skin  nodules, 
owing  to  compression,  are,  as  regards  size,  less  developed.  Morpholog- 
ically they  are  very  similar  to  tubercle  bacilli,  and  their  differentiation 
is  not  always  easy.  Lepra  bacilli  are,  however,  in  relatively  greater 
abundance  in  the  tissues,  usually  occur  in  clumps,  groups,  or  masses, 
are  smaller  and  less  uniform  in  diameter  than  the  tubercle  bacilli.  They 
also  exhibit  readier  reaction  to  staining  agents,  "dependent  upon  micro- 
chemical  reaction  of  the  investing  membrane  of  the  bacillus  to  acids, 
alkaline  and  anilin  dyes."  They  are  best  demonstrated  by  staining  the 
section  of  tissue  or  de*bris  of  a  broken-down  nodule  by  Ehrlich's  process 
with  fuchsin,  and  methyl-blue  as  a  contrast  (Crocker).  While  the 
bacilli  are  sometimes  found  more  or  less  generally  distributed  in  the 
tissues,  they  have  certain  predilections.  They  are  usually  most  abundant 
in  the  diffuse  and  nodular  infiltrations,  in  the  connective  tissue  of  the 
peripheral  nerves,  in  the  lymphatic  glands  and  spaces,  and  sebaceous 
glands  (Babes  and  Unna) ;  but  are  rarely  to  be  found  in  the  true  maculo- 
anesthetic  patches,  unless  associated  with  some  infiltration.  They  are 
also  found  in  the  liver,  spleen,  kidneys,  in  the  testicles  (Neisser  and 
others),  and,  according  to  Arning,  also  in  the  ovary.  In  fact,  in  well- 
advanced  cases,  more  especially  in  the  tubercular  form,  scarcely  any 
organ  escapes.  The  physiologic  secretions  remain  free  so  long  as  the 
secreting  tissue  or  membrane  does  not  become  the  seat  of  leprous  de- 
posits. The  blood-vessels,  except  those  peripherally  involved  in  the 
leprous  infiltrations  or  in  the  last  stages  of  the  disease,  rarely  contain 
bacilli. 

The  earlier  reports  (Campana  and  Ducrey,  Hansen,  Neisser,  Carras- 
quilla,  Van  Houtum  and  Emile-Weil)  of  alleged  moderately  successful 
culture  of  the  bacillus  have  been  looked  upon  with  considerable  question ; 
but  the  later  trials  (Kedrowski,  Clegg,  Duval,  Brinckerhoff,  Currie  and 
Holman,  and  others)  seem  to  have  been  more  fortunate,  but  with  some 
slight  puzzling  diversity  in  the  results.  Duval  and  Wellman,1  from  a 

1  Duval  and  Wellman  ("A  Critical  Study  of  the  Organisms  Cultivated  from  the  Le- 
sions of  Human  Leprosy,  with  a  Consideration  of  their  Etiologic  Significance,"  Jour. 
CiUan.  Dis.,  191 2,  p.  397),  as  a  result  of  their  own  researches,  reached  the  following  con- 
clusions: (i)  From  a  bacteriologic  study  of  29  cases  of  leprosy,  an  acid-fast  bacillus  was 
discovered  in  22.  (2)  A  chromogenic  strain  similar  in  all  essentials  to  that  described  by 
Clegg  was  recovered  from  14  cases,  which  under  certain  conditions  grows  as  (a)  non- 
acid-fast  streptothrix,  (b)  non-acid-fast  diphtheroid,  and  (c)  an  acid-fast  bacillus.  (3) 
Eight  cases  yielded  an  organism  which  was  distinctly  different  from  Clegg's  bacillus  in 
its  biologic  character,  growing  only  upon  special  medium  and  not  producing  pigment. 


LEPRA  931 

review  of  the  subject  and  their  own  investigations,  conclude  that  two, 
possibly  three,  different  organisms  have  been  cultivated  from  the  specific 
lesions  of  leprosy,  namely:  (i)  a  non-acid-fast  diphtheroid  (Kedrowski), 
(2)  an  acid-fast  chromogenic  bacillus  (Clegg),  and  (3)  a  permanently 
acid-fast  bacillus  (Duval).  Williams  has  grown  four  different  types  of 
organisms,  including  a  Gram-positive  non-acid-fast  streptothrix,  which, 
however,  he  believes  to  be  different  phases  of  the  same  organism.  The 
earlier  experimental  animal  inoculations  (Hansen,  Kobner,  Damsch, 
Rake,  Campana,  Profeta,  Vossius  and  Melcher-Orthmann)  were,  accord- 
ing to  Neisser's  examination  of  the  question,  practically  negative;  in  a 
few  instances  there  was  a  suspicious  local  growth.  More  recently  Duval 
and  Gurd,  Sugai,  Monobe,  Bayon,  Rost  and  Williams,  and  others  seem 
to  have  succeeded  in  producing  the  disease,  or  at  least  conditions  simulat- 
ing it,  in  the  Japanese  dancing  mice,  white  mice,  rats,  and  monkeys — 
in  most  of  these  later  instances  the  inoculating  material  consisted  of  the 
cultured  organism.1  According  to  Duval  and  Gurd  the  bacilli  may  live 
for  more  than  a  year  outside  of  the  body.  The  reported  successful  inocu- 
lation (Arning)  some  years  ago  in  man  must  be  viewed  with  suspicion, 
inasmuch  as  the  subject  belonged  to  a  leprous  family. 

If  a  section  of  recent  nodule  is  examined,  it  is  observed  to  consist 
(Neisser)  of  a  cell-mass  separated  by  sparse  fibrillary  intermediate 
tissue;  the  cellular  elements,  mostly  rounded  in  form  and  primarily  like 
lymph-corpuscles,  undergo  increase  in  size  and  reach  four  or  five  times 
their  original  volume,  constituting  the  so-called  lepra  cells  and  the  giant- 
cells  found  in  leprous  tissue.  The  nucleus,  likewise,  shows  similar  in- 

(4)  Animal  experiments  undertaken  for  the  purpose  of  differentiating  the  two  types 
removed  from  the  human  leprous  lesion  and  to  fix  their  etiologic  status  were  not  re- 
garded as  conclusive.  (5)  Serologic  tests,  especially  those  performed  with  highly 
immune  sera,  suggested  that  the  bacillus  of  Clegg  was  not  related  to  Duval's  non- 
chromogenic,  slow-growing  culture  of  leprosy.  (6)  The  r61e  played  by  the  chromogenic 
bacillus  of  Clegg  in  the  production  of  leprosy  was  unsettled.  (7)  The  non-chromogenic 
strain,  while  behaving  according  to  most  of  our  notions  of  a  pathogenic  organism,  had 
not  yet  been  proved  to  be  the  cause  of  leprosy,  although  it  was  probable  that  it  might 
be  so,  and  the  writers  considered  that  it  deserved  more  serious  attention  than  any  strain 
cultivated  from  the  human  leprous  lesion.  (8)  The  wide  variation  in  morphology  and 
staining  reactions  for  certain  cultures  which  subsequently  become  rapid  growers  and 
chromogenic  explained  that  interpretation  of  European  writers,  that  the  Bacillus  leprae 
is  a  bacterium  of  such  pleomorphism  that  it  can  be  recognized  as  a  diphtheroid,  a 
streptothrix,  and  an  acid-fast  bacillus. 

1  The  reader  desirous  of  pursuing  further  the  subject  of  cultures  and  inoculation 
experiments  is  referred  to  the  following  additional  contributions:  Macleod,  "A  Brief 
Survey  on  the  Present  State  of  Our  Knowledge  of  the  Bacteriology  and  Pathologic 
Anatomy  of  Leprosy,"  Brit.  Jour.  Derm.,  1909,  p.  309;  Sugai,  Lepra,  1909,  viii,  p.  203; 
Clegg,  Philippine  Jour.  Sci.,  1909,  iv,  p.  403;  Duval  Jour.  Exper.  Med.,  1910,  xii,  p. 
649,  and  1911,  xiii,  p.  365;  and  "The  Experimental  Production  of  Leprosy  in  the  Mon- 
key (Macacus  rhesus),"  with  review,  Penna.  Med.  Bull.,  1911,  p.  665;  Duval  and  Gurd, 
Arch.  Int.  Med.,  1911,  vii,  p.  230,  and  "Experimental  Leprosy  and  Its  Bearing  on 
Serum  Therapy,"  Jour.  Cutan.  Dis.,  1911,  p.  274;  Currie,  Clegg,  and  Holman,  "Studies 
upon  Leprosy:  Cultivation  of  the  Bacillus  of  Leprosy,"  Public  Health  Bulletin,  Sept., 
1911,  No.  47,  Washington,  D.  C.,  p.  3,  (chronologic  review  of  literature  and  their 
own  work);  Bayon,  Jour.  London  School  Tropical  Med.,  1911,  i,  p.  45;  and  Brit.  Med. 
Jour.,  Feb.,  24,  1912;  Alderson,  "Artificial  Cultivation  of  Lepra  Bacillus  in  Hawaii," 
California  State  Med.  Jour.,  1911,  ix,  No.  3;  Rost  and  Williams,  "Scientific  Memoirs  of 
Gov't.  of  India,"  1911,  No.  42 — abs.  in  Brit.  Jour.  Derm.,  1912,  p.  164;  Williams, 
Indian  Med.  Gaz.,  "Review  Editorial."  Lancet,  I9i2,clxxi,  No.  4584;  Monobe,  Japan- 
ische  Zeitsch.  fiir  Derm,  und  Urol.,  Feb.,  1912,  xii,  No.  2,  p.  8 — abs.  in  Jour.  Cutan. 
Dis.,  1912,  p.  449. 


932 


NEW  GROWTHS 


crease,  and  some  cells  may  contain  several  nuclei.  The  cells  are  most 
plentiful  in  the  neighborhood  of  the  blood-vessels,  which  are  numerous 
and  the  vascular  supply  abundant.  Leprous  growths  are,  however,  less 
vascular  than  ordinary  granulation  tissue,  and  therefore  undergo  retro- 
gressive changes  more  slowly.  The  epidermis  is  not  involved  in  the 
specific  morbid  process,  and  never  contains  the  parasites.  The  his- 
topathologic  changes  are  especially  noted  in  the  papillary  layer,  in  the 
main  body  of  the  corium  and  the  subjacent  tissue.  According  to  Neisser 
and  others,  a  lepra  tubercle  or  nodule  is  primarily  composed  of  granula- 
tion cells.  The  deepest  cellular  layer,  that  in  the  subcutaneous  tissue, 
is  noted  to  contain,  along  with  many  unchanged  lymph-cells,  the  smallest 
and  most  recent  tumor  cells,  and  but  relatively  few  bacilli.  The  cells 
show  gradual  enlargement  in  the  higher  layers.  The  oldest,  topmost, 
layers  are  divided  from  the  rete  by  a  stratum  of  subepidermal  connective 
tissue;  the  epithelial  layer,  except  as  to  the  disappearance  of  its  inter- 
papillary  dippings,  is  otherwise  normal,  although  showing  increased 
pigmentation.  More  especially  in  the  upper  layers  of  the  tumor  are 
seen  peculiar  large,  rounded,  sharply  circumscribed  accumulations,  the 
so-called  "globi,"  composed  of  cells  very  densely  infiltrated  with  bacilli 
and  their  products,  and  undergoing  degeneration.  Besides  the  large 
lepra  cells  there  are  small  cells  apparently  identical  with  migratory 
cells;  and  small  connective- tissue  cells  which  show  here  and  there  en- 
largement from  infiltration  with  bacilli. 

There  is  a  difference  of  opinion  as  to  whether  the  bacilli  lie  within 
or  without  the  cells.  Virchow,  Neisser,  and  almost  all  others  consider 
that  they  are  almost  exclusively  within  the  large  round  lepra  cells, 
whereas  Unna,1  Herman,2  and  a  few  others  maintain  that  they  are 
chiefly  found  in  lymph-spaces,  Unna  asserting  that  the  lepra  cell  is 
nothing  more  than  a  gloea-like  mass  formed  by  degeneration  of  the  bacilli. 
It  is  now  recognized  that  a  large  proportion  of  the  bacilli  found  in  the 
tissues  are  dead;  that  even  in  young  newly  formed  lepromata  dead 
bacilli  occur,  while  in  older  lesions  the  majority  of  the  bacilli  are  dead 
(Macleod).  Virchow  believed  the  fixed  connective-tissue  cells  to  be 
the  mother-cells  of  the  subsequent  granulation  tumor.  Thin  and 
Neisser  hold  the  view  that  the  lepra  cells  develop  from  emigrated  white 
blood-  and  lymph-corpuscles. 

In  the  anesthetic  variety  the  chief  changes  are  in  the  nerves.  Vir- 
chow, Neisser,  and  others  place  the  primary  pathologic  process  in  the 
peripheral  and  cutaneous  nerves,  due  to  leprous  new  formation,  leading 
to  compression  and  atrophy  of  the  sensory  and  trophic  fibers.  The 
nerves  most  frequently  affected  are  the  ulnar,  median,  radial,  musculo- 
cutaneous,  intercostal,  humeral,  and  peroneal.  It  is  generally  believed 
that  these  changes  are  practically  limited  to  the  peripheral  nerves, 
Hansen,  Hillis,  Leloir,  Neisser,  and  others  finding  the  spinal  cord  and 
brain,  in  the  cases  examined  by  them,  normal.  In  more  recent  years, 
however,  several  observations  seem  to  point  to  the  possibility  of  central 

1  Unna,  Histopathology. 

2  Herman,  "The  Bacillus  of  Leprosy  in  the  Human  System  at  Different  Periods  of 
its  Growth,"  Trans.  Internal.  leprosy  Conference,  1897. 


LEPRA  933 

nerve  involvement ;  Chassiotis1  found  in  one  instance  investigated  by  him 
bacilli  in  the  spinal  cord. 

Diagnosis. — The  recognition  of  a  well-developed  case  of  lep- 
rosy of  either  type  is,  as  a  rule,  not  attended  with  difficulty.  It  is  an 
entirely  different  matter,  however,  in  many  instances  in  the  earlier 
stages,  or  in  those  of  advanced  period  if  the  disease  is  atypical.2  In  the 
invasion  and  early  eruptive  stage  the  prodromal  symptoms  of  chilliness, 
febrile  action,  with  subsequent  free  perspiration,  so  often  observed  in 
the  tubercular  form,  may  be,  and  often  are,  confounded  with  those  of 
malaria.  The  erythematous  areas  may  be  confused  with  simple  ery- 
thema, although  they  are  commonly  larger,  frequently  tend  to  show  in- 
filtration, and  are  slow  in  undergoing  involution.  If  to  these  symptoms 
could  be  added  sensory  disorders,  usual  in  anesthetic  leprosy,  together 
with  a  history  of  exposure,  a  strong  suspicion  could  be  entertained,  and 
probably  a  positive  opinion  reached. 

In  the  anesthetic  variety  the  prodromal  symptoms  are  also  usually 
of  variable  character  and  intensity,  and  the  pain  and  motor  weakness 
often  attributed  to  rheumatism  or  neuralgia;  the  other  disorders  of  sen- 
sation, such  as  hyperesthesia,  sensations  of  burning,  tingling,  numbness, 
formication,  and  pruritus,  one  or  several  of  which  may  be  present,  are 
often  wrongly  interpreted  as  pointing  to  neurasthenia  or  other  nervous 
disorders.  When,  however,  such  a  patient  is  living  or  has  been  living 
in  a  district  where  the  disease  prevails,  the  possibility  of  leprosy  is  to  be 
borne  in  mind.  This  would  be  materially  strengthened  by  the  presenta- 
tion of  erythematous  patches  of  a  dull  red  color,  and  of  persistent  char- 
acter, with  a  tendency  to  clear  centrally  while  extending  at  the  border, 
the  central  part  generally  becoming  whiter  than  normal  and  anesthetic. 
Such  areas  are,  however,  to  be  distinguished  from  those  of  morphea  and 
vitiligo. 

Later  in  the  course  of  the  malady  the  tubercular  form  is  to  be  differ- 
entiated mainly  from  lupus  vulgaris,  the  tubercular  syphiloderm,  and 
granuloma  fungoides.  In  the  first  the  eruption  is  usually  quite  limited, 
at  least  relatively,  and  most  commonly  confined  to  a  portion  of  the  face, 
is  of  slow  development,  and  frequently  spreads  from  one  center.  More- 
over, it,  as  a  rule,  lacks  the  infiltration  generally  noted  in  leprosy.  The 
tubercular  syphiloderm  is  also  a  limited  eruption,  and  differs  materially 
from  that  of  leprosy  by  the  fact  that  it  tends  to  occur  in  segmental, 
crescentic  groups  or  serpiginous  tracts — a  formation  rarely,  if  ever, 
noted  in  leprous  infiltrations  or  tubercles.  Both  lupus  and  syphilis  are, 
moreover,  ordinarily  wanting  in  any  suspicious  prodromal  symptoms. 
Granuloma  fungoides  and  well-marked  tubercular  leprosy  have  also 
sufficient  in  common  to  give  rise  to  possible  confusion,  but  the  early 
eczematoid  manifestations  of  the  former,  with  the  usually  accompanying 
itchiness,  its  more  general  distribution,  the  brighter  red  color,  often  serve 
to  differentiate;  in  the  later  stage  the  peculiar  fungoidal  ulcers  would  be 
distinctive. 

•  l  Chassiotis,  "Ueber  die  bei  der  anasthetischen  Lepra  in  Ruckenmarke  vorkom- 
mendcn  Bacillen,"  Monatschefte,  1887,  vol.  vi,  p.  1039. 

2  Thin  (loc.  cit.)  cites  numerous  examples  of  errors  in  diagnosis  by  observers  experi- 
enced in  dermatology. 


934 


NEW  GROWTHS 


The  anesthetic  form  in  the  more  advanced  stages  is  to  be  distin- 
guished chiefly  from  syringomyelia,  to  which  it  sometimes  bears  a 
striking  similarity.  The  various  sensory  disorders,  however,  when 
taken  together  with  the  lesions  of  the  bones  and  joints  of  the  extrem- 
ities, with  the  mutilations  and  deformities,  commonly  observed  in  ad- 
vanced stages  of  leprosy,  with  the  history,  often,  of  preceding  pem- 
phigoid  eruption,  and  vitiligo  or  morphea-like  patches,  are  quite  char- 
acteristic. 

In  cases  of  doubtful  nature,  whatever  the  type  of  the  malady,  the 
final  decision  is  often  to  be  based  upon  the  presence  of  the  special  bacillus, 
as  determined  by  repeated  examinations.  Shepherd1  advises,  when 
the  question  of  immediate  diagnosis  is  one  of  great  urgency,  cutting 
down  on  the  ulnar  nerve,  removing  a  portion,  and  examining  for  bacilli. 
It  is  commonly  believed  that  leprous  patients  give  a  positive  Wasser- 
mann,  but  there  are  exceptions  to  this.2 

Prognosis. — The  outlook  for  leprosy  patients  is  unfavorable,  a 
fatal  termination,  with  occasional  exceptions,  being  the  rule,  although 
the  end  may  not  be  reached  for  a  number  of  years.  The  tubercular  form 
is  the  most  grave,  the  mixed  variety  the  next,  and  the  anesthetic  the 
least.  The  statistics  of  the  Trinidad  Asylum,  according  to  Rake,3  show 
that  the  average  duration  is  eight  and  one-half  years.  In  some  instances, 
especially  of  the  anesthetic  variety,  it  may  be  fifteen  to  twenty  years 
or  more.  Patients  are  not  infrequently  carried  off  by  intercurrent 
disease,  although,  as  already  referred  to,  apparently  independent  organic 
affections  are  often,  in  fact,  due  to  leprous  invasion  and  infiltration. 
Under  the  most  favorable  conditions  much  can  be  done,  and  doubtless 
an  occasional  cure — a  symptomatic  cure  at  least — brought  about. 

There  seems  scarcely  question  that  mild  or  abortive  types  occur, 
though  doubtless  but  rarely.  Hansen  and  Looft,  in  quoting  Daniels- 
sen's  observations  as  to  the  Norwegian  hospital,  "that  the  results  of 
treatment  were  nothing  to  boast  of,  but  show  that  leprosy  at  its  com- 
mencement can  be  cured,"  add  the  reservation  "that  the  cure  is  not  due 
to  the  treatment,  but  to  the  natural  development  of  the  disease."  One 
cannot  go  over  the  literature  without  recognizing  the  fact  that  in  excep- 
tional instances  patients  recover,  or  at  all  events  the  malady  remains 
permanently  quiescent.  Impey4  is  strongly  of  the  opinion  that  some 
cases,  especially  the  anesthetic,  undergo  spontaneous  cure,  and  believes 
that  in  many  so-called  lepers  the  malady  has  already  run  its  course,  and 
that  the  effects  alone  remain,  and  may  go  on  from  the  damage  done  the 
nerves.  He  quotes  Hansen's  studies  as  showing  that  the  latter  observer 
"had  never  found  bacilli  in  the  nerves  of  a  chronic  case,  .  .  .  and  that 

1  Shepherd,  "Notes  on  a  Rapid  Method  of  Diagnosis  in  Leprosy,"  Jour.  Cutan.  Dis., 
1003,  p.  476. 

2  Bloombergh,   "The  Wassermann  Reaction  in  Syphilis,  Leprosy,  and  Yaws," 
Philippine  Jour  Sci.,  Oct.,  1911,  p.  335  (doubts  a  positive  reaction  in  leprosy,  add  thinks 
before  accepting   the   same  present  or  antecedent  frambesia  and  syphilis  must  be 
excluded — of  decided  importance  in  countries  where  these  diseases  prevail;  references 
to  pertinent  papers  are  given). 

3  Rake,  Report  on  Leprosy  in  Trinidad,  1885. 

4  Impey,  "The  Non-Contagiousness  of  Anesthetic  Leprosy,"  Trans.  Internal.  Lep- 
rosy Conference. 


LEPRA  935 

he  had  examined  the  bodies  of  many  of  these  patients  after  death,  and 
found  no  bacilli  in  any  organ."  Thin,  D.  W.  Montgomery,  G.  H.  Fox, 
Ehlers,  Hallopeau,  Dyer,  and  others1  have  in  recent  years  reported  cures 
of  the  disease,  spontaneously  or  as  the  result  of  treatment. 

Under  the  most  favorable  circumstances  of  change  of  residence  to 
a  non-leprous  district,  improved  hygiene,  good  food,  supporting  and 
tonic  treatment,  cleanliness,  and  aseptic  applications,  it  seems,  there- 
fore, not  improbable  that  exceptionally  cases  get  well,  or  at  least  the 
disease  ceases  to  be  active. 

Treatment. — The  management  of  leprosy  naturally  includes  a 
consideration  of  the  means  of  prevention.  There  are  still  great  dif- 
ferences of  opinion  as  to  the  necessity  of  segregation,  and  each  side  of 
the  question  has  much  in  its  support.  The  conclusions  of  the  Inter- 
national Leprosy  Conference  at  Berlin,  1897,  were,  upon  the  whole, 
in  favor  of  this,  with  certain  qualifications  as  to  its  practice,  depending 
upon  local  conditions.2  It  is  generally  recognized  that  the  anesthetic 
cases  are  much  less  dangerous  to  a  community  than  the  tubercular  form, 
and  segregation  less  urgent.  The  necessity  of  segregation  in  districts 
where  the  cases  are  sparse,  with  no  tendency  to  spread,  and  where  lepers 
can  be  properly  cared  for  at  their  homes,  is  questioned  by  many  of  con- 
siderable experience.  As  already  stated,  the  imported  cases  in  Paris, 
London,  Vienna,  Berlin,  New  York,  Chicago,  Philadelphia,  and  other 
places  where  the  disease  is  not  endemic  have  never  given  rise  to 
others. 

The  treatment  of  leprosy  has  first  in  view  the  maintenance  of  the 
patient's  general  health  by  hygienic  and  other  measures,  and  the  em- 
ployment of  such  tonics  as  may  seem  demanded.  The  value  of  change 
of  abode  to  a  non-leprous  country,  when  possible,  has  already  been 
alluded  to,  and  will  in  some  instances  stay,  and  probably  always  delay, 
the  progress  of  the  malady.  There  are  certain  remedies  for  which 
special  claims  have  been  made  from  time  to  time  by  different  observers.3 
The  most  important,  and  those  which  have  received  the  greatest  support, 
are  Chaulmoogra  oil  (Le  Page),  gurjun  oil  (Dougall),  and  mix  vomica  or 
strychnin. 

Chaulmoogra  oil  (oleum  gynocardiae,  from  the  seeds  of  the  Gyno- 
cardia  odorata)  is  given  in  doses  varying  from  5  minims  (0.33)  to  i| 
drams  (6.)  or  more  three  times  daily.  It  is  administered  in  milk,  in 
emulsion,  or  in  capsules.  As  a  rule,  its  good  effects  are  obtained  only  by 
the  larger  doses,  and  these  cannot  always  be  reached,  owing  to  the  fact 
that  the  oil  is  so  prone  to  disturb  digestion,  some  persons  being  intolerant 

1  Thin,  Brit.  Med.  Jour.,  May  4,  1901,  p.  1074;  D.  W.  Montgomery,  Med.  Record, 
April  19,  1902  (spontaneous;  6  cases);  Hallopeau,  Annales,  1903,  p.  32;  Dyer,  Med. 
News,  July  29,  1905. 

2  As  especially  bearing  upon  the  control  in  our  own  country  see  papers  by  J.  C. 
White,  "The  Contagiousness  and  Control  of  Leprosy,"  Boston  Med.  and  Surg.  Jour., 
Oct.  25,  1894,  and  Morrow,  "Prophylaxis  and  Control  of  Leprosy  in  this  Country," 
Trans.  Amer.  Derm.  Assoc.for  1909;  and  Dyer,  "The  Sociological  Aspects  of  Leprosy 
and  the  Question  of    Segregation,"  Jour.  Cutan.  Dis.,  1911,  p.  268,  and  discussion 
(Brinckerhoff,  C.  J.  White,  Schamberg,  Pusey,  Morrow,  and  G.  H.  Fox),  ibid.,  p.  282. 

3  See  papers  and  discussions  in  Trans.  Internal.  Leprosy  Conference  for  full  details 
of  the  claims  and  experimental  trials  of  the  various  special  remedies. 


936 


NEW  GROWTHS 


even  of  small  quantities.  As  less  irritating  to  the  stomach,  the  active 
principle  of  the  oil,  gynocardic  acid,  has  been  also  commended,  usually 
in  the  form  of  magnesium  or  sodium  gynocardate,  in  the  beginning  dose 
of  \  grain  (0.033),  and  increasing  gradually  to  3  grains  (0.2)  three  times 
daily.  Unna1  makes  a  soap  of  the  oil  with  soda,  and  gives  this  coated 
in  pill  form,  and  states  that,  according  to  his  observations  so  far  made, 
in  this  method  of  administration  there  is  no  disturbing  influence  on  di- 
gestion. Conjointly  with  the  internal  administration  it  can  also  be 
prescribed  by  inunction.  For  this  purpose  it  is  mixed  with  5  to  15  parts 
of  olive  or  cocoanut  oil,  or  as  a  50  per  cent,  ointment  with  lard.  It  is  to 
be  rubbed  in  thoroughly,  and,  when  possible,  one  to  two  hours  daily. 
Before  each  fresh  application  the  skin  is  washed  with  soap  and  water 
or  by  means  of  a  warm  bath.2  Under  the  favorable  influence  of  this  drug 
the  various  disease  manifestations  abate,  sometimes  slightly,  in  others, 
but  relatively  few,  quite  decidedly,  and  exceptionally  the  malady  is 
halted  in  its  progress. 

Gurjun  oil  (gurjun  balsam,  wood-oil,  from  the  Dipterocarpus  tur- 
binatus)  has  had  the  warm  support  of  Dougall,  Hillis,  and  some  others. 
It  is  usually  administered  in  emulsion,  composed  of  3  to  5  parts  of  lime- 
water  to  i  of  the  oil,  and  of  which  the  dose  is  2  to  4  drams  (8.-i6.)  two 
or  three  times  daily.  It  is  also  usually  to  be  conjointly  prescribed  by 
inunction,  with  i  to  3  parts  of  lime-water  or  olive  oil,  and  thoroughly 
rubbed  in  one  to  two  hours  daily.  Strychnin,  or  nux  vomica  (formerly 
as  Hoang  nan,  powdered  bark  of  Strychnos  gaultheriana) ,  is  another 
remedy  which  has  had  considerable  reputation.  It  is  frequently  pre- 
scribed with  one  of  the  above  oils.  Piffard  and  G.  H.  Fox,  of  our  own 
country,  observed  in  one  or  two  instances  practical  recovery  under  their 
conjoint  use.  Morrow  also  speaks  well  of  the  action  of  this  drug.  These 
three  remedies,  together  with  others  which  may  be  demanded  by  general 
indications,  supported  by  hygienic  measures,  frequent  baths,  good  food, 
open-air  life,  and,  when  possible,  change  of  climate,  will  often  accomplish 
much  toward  at  least  retarding  the  progress  of  the  malady. 

Many  other  remedies  or  plans  of  treatment  have  been  variously 
tried  or  advocated,  more  especially  in  recent  years.  Unna  has  spoken 
well  of  ichthyol  internally  conjointly  with  external  applications  of  re- 
ducing agents,  to  be  again  referred  to.  Sodium  salicylate  and  salol 
have  also  had  favorable  mention,  and  arsenic  has  long  been  considered 
of  possible  value.  Although  mercury  has  been  more  or  less  considered 
as  detrimental  in  the  disease,  lately  Haslund  and  Crocker  have  reported 
markedly  beneficial  influence  in  several  instances,  the  drug  being  ad- 
ministered by  hypodermic  injection  deeply  into  the  muscular  tissue. 
Crocker  employed  the  perchlorid  of  mercury,  using  \  grain  (0.016)  in 
20  minims  (1.33)  of  distilled  water  twice  weekly.  Carreau,  and  also 
Dyer,  believe  that  good  effects  are  sometimes  obtainable  by  increasing 
doses  of  potassium  chlorate,  an  observation  previously  made  by  Chis- 

1  Unna,  Monatschefte,  1900,  vol.  xxx,  p.  139. 

2  Tourtoulin  Bey,  Mon-alshefte,  1905,  vol.  xl,  p.  88,  commends  the  administration  of 
the  oil  by  subcutaneous  injections,  preferably  into  the  subcutaneous  tissues  of  the  fore- 
arm or  leg — dosage,  75  minims  (5.). 


LEPRA 


937 


holm.  Montesant1  and  Wellman2  have  reported  favorable  influence 
from  salvarsan  intravenously  administered.  Wilkinson3  reports  a  few 
apparent  cures  from  #-ray  treatment.  In  recent  years  various  attempts 
have  been  made  with  treatment  with  serum  (Carrasquilla) ,  antivenene, 
or  attenuated  snake  poison  (Calmette,  Dyer,  Woodson),  tuberculin 
(Yamamoto),  and  various  vaccines — leprolin,  nastin,  etc.  (Rost,  Deycke, 
Rost  and  Williams,  Wise,  Minnett,  Gottheil,  Whitmore,  Clegg,  Duval 
and  Gurd,  and  others),  but  while  at  times  favorable  influences  were 
noted,  the  results  have  been,  as  a  whole,  as  yet  disappointing.4 

The  external  treatment  consists  essentially  in  the  maintenance  of 
cleanliness  and  an  aseptic  condition  of  the  general  surface,  in  order,  so 
far  as  possible,  to  avoid  the  suppurative  complications  due  to  infection 
by  pyogenic  cocci.  Frequent  baths,  the  use  of  boric  acid,  formalin, 
carbolic  acid,  and  resorcin  lotions,  and  sometimes  sulphur  baths,  are 
some  of  the  measures  to  this  end.  Certain  remedies  have,  however, 
been  employed  with  alleged  special  influence,  such  as  Chaulmoogra 
and  gurjun  oils,  already  mentioned,  the  inunctions  of  which,  in  addition, 
however,  have  in  view  absorption  and  some  constitutional  action. 
Cashew-nut  oil  has  been  similarly  employed,  both  externally  and  inter- 
nally. In  the  opinion  of  some  the  good  effects  of  these  oils  externally 

1  Montesant,  Munchen.  Med.  Wochenschr.,  1910,  No.  9,  and  1911,  No.  n. 

2  Wellman,  Jour.  Amer.  Med.  Assoc.,  Nov.  16,  1912. 

3  Wilkinson,  "Leprosy  in  the  Philippines  with  an  Account  of  its  Treatment  with 
the  X-rays,"  Jour.  Amer.  Med.  Assoc.,  Feb.  3,  1906. 

4  "Carrasquilla  Serum,"  discussion,  Trans.  Internal.  Leprosy  Congress,  Berlin,  1897. 
"Antivenene,"  Dyer,  ibid.,  vol.  iii,  p.  500,  and  New  Orleans  Med.  and  Surg.  Jour., 

Oct.,  1897,  and  Woodson,  Philada.  Med.  Jour.,  Dec.  23,  1899. 

"Tuberculin,"  latest  report  by  Yamamoto,  JapanischeZeitschr.f.  Dermalologie  und 
Urol.,  Aug.,  1912 — abs.  in  Jour.  Cutan.  Dis.,  1912,  p.  739 — treated  a  series  of  30  cases 
with  old  tuberculin,  with  alleged  remarkable  improvement  in  many. 

"Leprolin,"  Rost,  Indian  Med.  Gaz.,  May,  June,  and  Dec.,  1904,  made  from  the 
culture  of  the  bacillus;  Rutherford,  Indian  Med.  Gaz.,  Feb.  1913,  p.  61,  32  cases  treated 
with  leprolin,  20  followed  throughout,  questionable  results,  while  taking  it  more  deteri- 
orated than  improved. 

"Nastin,  B."  Deycke,  Lepra,  1907,  p.  174,  made  from  culture  of  a  streptothrix 
found  by  him  in  a  nodular  leprosy,  from  which  he  extracted  a  neutral  fat  which  he  called 
nastin;  this  he  combined  with  benzol  chlorid  in  oily  solution  and  called  it  nastin  B.; 
this  latter  is  usually  employed,  nastin  sometimes  giving  rise  to  alarming  reaction; 
Brinckerhoff  and  Wayson,  "Studies  in  Leprosy,  U.  S.  Gov.  Printing  Office,"  1909 — 6 
cases,  disappointing;  Wise,  Jour.  London,  Trap.  School  of  Med.,  1911,  p.  63, — abs.  in 
Brit.  Jour.  Derm.,  1912,  p.  82 — in  118  cases  of  various  degrees  "nastin"  treatment 
seemed  only  successful  in  3  cases,  the  results  approximating  recovery;  70  patients  were 
placed  on  an  injection  of  benzol  chlorid  in  mineral  oil  (the  nastin  process  without 
the  nastin),  and  the  results  as  a  whole  were  rather  better  than  with  the  nastin;  Wise 
and  Minnett,  Jour.  Trap.  Med.,  Sept.  2,  1912,  p.  259,  summary  of  244  cases  treated 
with  nastin,  at  first  thought  to  be  encouraging,  but  proved  at  the  most  only  a  slight 
temporary  check;  Gottheil,  Jour.  Cutan.  Dis.,  1911,  p.  239,  i  case,  some  improvement. 
Editorial  review,  Indian  Med.  Gaz.,  Feb.,  1913,  p.  71,  regarding  nastin  treatment,  by 
Harris,  Megraw,  and  Barnardo,  states  action  doubtful. 

Other  vaccines:  Whitmore  and  Clegg,  Philippine  Jour.  Sci.,  Dec.,  1910,  p.  559, 
treatment  with  glycerin  extract  and  soap  solution  made  from  vaccine  which  Clegg  had 
cultivated  from  an  acid-fast  bacillus  from  the  spleen  and  from  the  nodules  from  a  num- 
ber of  leprosy  cases — results  negative;  nastin  B.  in  17  cases  negative;  Rost,  Indian 
Med.  Gaz.,  July,  1911,  vaccine  prepared  from  cultivation  of  the  leprosy  streptothrix, 
reports  5  of  12  cases  treated  as  symptomatically  cured — injected  weekly  i  c.c.  of  a  i: 
400  dilution  of  dried  culture  or  the  equivalent  thereof  and  i  c.c.  of  a  sterilized  six  weeks 
broth  culture;  Rost  and  Williams  (loc.  cit.),  vaccine  prepared  from  a  culture  of  leper 
bacillus  in  a  medium  consisting  of  distilled  volatile  alkaloid  of  rotten  fish,  lenco  broth 
(without  salt  or  peptone),  and  milk;  obtained  hopeful  results. 


938  NEW  GROWTHS 

used  lie,  in  great  part,  in  the  associated  prolonged  rubbing.  Unna  has 
strongly  commended,  along  with  the  internal  administration  of  ichthyol, 
the  local  applications  of  ointments  containing  the  reducing  agents, 
resorcin,  pyrogallol,  chrysarobin,  salicylic  acid,  and  also  ichthyol;  a 
compound  formula  recently  advised  by  him,  consisting  of  salicylic  acid, 
2  parts;  ichthyol  and  chrysarobin,  each,  5  parts;  vaselin,  100  parts. 
To  limited  areas  the  pyrogallol  can  be  added  in  the  same  quantity  as  the 
chrysarobin,  or  can  be  substituted  for  the  latter.  In  some  instances 
excision  and  curetting  of  the  nodules  and  infiltrations  have  been  practised, 
but  the  results  are  scarcely  such  to  justify  such  heroic  measures.  Ulcera- 
tions  should  be  kept  thoroughly  cleansed,  and,  so  far  as  possible,  aseptic, 
by  the  use  of  hydrogen  dioxid  washings,  weak  corrosive  sublimate  solu- 
tions, boric  acid  lotions,  and  similar  applications.  As  ointments  for  apply- 
ing to  open  lesions  may  be  mentioned  those  containing  aristol,  resorcin, 
salicylic  acid,  ichthyol,  balsam  of  Peru,  and  the  like.  Robertson1  com- 
mends applications  of  formalin,  using  it  diluted  to  open  wounds  and  pure 
to  other  lesions.  For  the  relief  of  the  painful  neuralgias,  sometimes 
of  severe  character,  Rake  and  others  have  reported  good  results  from 
nerve-stretching.  Electricity  has  been  employed  with  some  benefit 
to  anesthetic  areas. 

1  Robertson,  Jour.  Trap.  Med.,  1904,  p.  26. 


CLASS  VII— NEUROSES 

HYPERESTHESIA 

THIS  condition  is  characterized  by  morbidly  acute  sensitiveness  to 
external  impressions.  The  painful  phenomena  occurring  in  hyper- 
esthesia  are  started  by  external  factors,  while  in  dermatalgia  they  arise 
spontaneously.  Like  anesthesia,  it  may  be  idiopathic  or  symptomatic, 
although  the  far  greater  number  of  cases  belong  to  the  latter  category. 
As  a  rule,  only  a  small  or  a  large  area  of  the  skin  surface  may  be  affected, 
but  the  condition  may  become  general.  The  attacks  excited  may  be 
only  of  a  mild  character,  or  they  may  become  exceedingly  agonizing. 
They  have  been  compared  to  electric  shocks,  and  described  as  pricking, 
darting,  and  burning  sensations.  Hyperesthesia  is  usually  unaccom- 
panied by  any  local  change  of  temperature.  There  are  a  number  of 
possible  causes:  it  may  be  dependent  on  functional  disturbance  or  some 
pathologic  change  in  the  brain  and  spinal  cord  or  other  deranged  condi- 
tion of  the  nervous  system ;  it  is  frequently  met  with  in  hysteria  and  neu- 
rasthenia. In  well-marked  cases  the  cutaneous  surface  is  sensitive  to 
an  abnormal  degree,  and  even  contact  with  the  clothes  and  the  air  gives 
rise  to  decided  discomfort.  It  varies  in  duration ;  it  may  be  only  tempo- 
rary or  may  become  chronic.  Occasionally  cases  of  hyperesthesia  present 
themselves  in  which  it  is  difficult  or  impossible  to  determine  the  fans  et 
origo  mail;  such  instances  belong  to  the  idiopathic  variety. 

The  prognosis  and  treatment  will  depend  wholly  upon  the  character 
of  the  underlying  condition. 

Meralgia  Paraesthetica. — This  peculiar,  rare  condition  involving  the 
skin  of  the  outer  lower  two-thirds  of  the  thigh,  to  which  some  neurolo- 
gists and  White1  have  recently  called  attention,  is  characterized  by 
perverted  sensations  somewhat  varied  in  the  same  case  and  sometimes 
different  in  different  cases.  The  most  common  sensations  seem  to  be 
those  of  tingling,  formication,  heat,  and  cold.  Less  frequently  there 
have  also  been  noted  pain,  numbness,  tension,  constriction,  distention, 
hyperesthesia,  anesthesia,  imaginary  movements  and  pruritus,  and 
rarely  a  sense  of  throbbing.  They  are  not,  as  a  rule,  constant,  and 
usually  occur  when  the  patient  is  standing  or  walking.  Various  causes 
have  been  assigned,  such  as  neuritis,  rheumatism,  gout,  alcoholism,  and 
as  following  infectious  diseases,  severe  colds,  etc.  The  area  involved 
seems  to  be  that  supplied  by  the  external  femoral  cutaneous  nerve. 
Treatment  is  usually  without  effect,  although  massage  has  given  partial 
and  temporary  relief  in  some  cases,  and  #-ray  exposures  may  lessen  the 
frequency  of  the  attack  (White) .  Goldenberg  had  prompt  cure  in  a  case 
from  the  wearing  of  a  metal  plate  in  the  shoe  for  the  relief  of  a  flat-foot. 

1  J.  C.  White,  "Meralgia  paraesthetica,"  Jour.  Cutan.  Dis.,  1906,  p.  160;  Sherwell, 
ibid.,  1910,  p.  281,  reports  a  case — patient  being  himself. 

93P 


940 


NEUROSES 


DERMATALGIA 


Synonyms. — Neuralgia  of  the  skin;  Rheumatism  of  the  skin;  Fr.,  Dermalgie;  Ger., 
Nervenschmerz  der  Haut. 

Definition. — Dermatalgia,  or  dermalgia,  is  characterized  by  pain 
in  the  skin  independent  of  any  structural  lesion. 

The  pain  is  usually  localized;  it  may,  however,  be  more  or  less  general. 
Various  sensations  are  experienced,  such  as  burning,  stinging,  pricking, 
shooting  pains,  which  are  generally  aggravated  during  the  night.  It 
is  spontaneous,  and  constant  or  intermittent  in  character,  insignificant 
or  severe.  Motion  and  the  slightest  contact  may  give  rise  to  a 
severe  attack.  It  is  seated  more  commonly  in  hairy  portions  of  the 
body,  and  is  most  frequently  seen  in  middle-aged  females.  It  is  often 
associated  with  hyperesthesia,  more  or  less  pronounced.  It  is  usually 
confined  to  the  superficial  layers  of  the  skin,  which  present  no  perceptible 
changes,  being  to  aU  appearances  normal  in  thickness,  coloration,  and 
temperature. 

It  is  a  difficult  matter  to  decide  in  a  given  case  whether  the  pain  is 
idiopathic  or  attributable  to  some  pathologic  change  in  the  nerve-centers. 
Rheumatism  would  seem  to  act  as  an  exciting  cause  in  quite  a  number 
of  cases;  exposure  to  cold,  chlorosis,  and  hysteria  are  also  factors.  Sys- 
temic disorders,  as  syphilis,  diabetes,  etc.,  and  pathologic  alterations  of 
the  nervous  system,  as  in  locomotor  ataxia,  play  an  important  role  in 
its  production. 

Causalgia,  which  is  characterized  by  a  burning  pain  with  pain  and 
tenderness  at  various  neighboring  points,  and  accompanied  with  a  glossy 
state  of  the  skin  in  the  area  of  a  nerve  that  has  been  injured,  may  be 
regarded  as  an  allied  affection. 

From  neuralgia  and  muscular  rheumatism  it  may  be  differentiated 
by  having  its  seat  usually  in  circumscribed  areas  of  the  skin  and  by 
being  more  superficial  in  character.  In  pruritus  pain  is  absent  and 
itching  is  a  prominent  feature;  in  dermatalgia,  moreover,  the  area  in- 
volved is  generally  limited. 

Treatment. — This  will  be  governed  by  the  underlying  cause 
and  whether  we  have  to  deal  with  a  symptomatic  or  idiopathic  variety  of 
dermatalgia.  The  general  health  must  be  carefully  looked  after,  and 
if  a  gouty  or  rheumatic  history  is  disclosed,  the  appropriate  remedies 
should  be  prescribed.  In  chronic  cases  careful  search  must  be  made 
for  any  existing  disease  of  the  nerve-centers.  Local  applications  may  be 
resorted  to,  such  as  blistering  the  part;  tincture  of  aconite  root  and 
diluted  tincture  of  belladonna  or  galvanism  may  be  applied  to  the  sensi- 
tive area.  As  a  rule,  however,  external  remedies  fail  to  accomplish  very 
much.  Quite  frequently,  after  several  weeks,  the  pain  disappears 
spontaneously. 


ER  YTHR  OMELAL  GIA  94 1 

ERYTHROMELALGIA 

Under  this  title  Weir  Mitchell1  described,  in  1878,  a  peculiar  con- 
dition of  the  extremities  characterized  by  burning,  aching,  and  neuralgic 
pain,  and  associated  with,  subsequently,  the  development  of  redness  of 
the  affected  parts.  Since  then  other  contributions  on  the  subject  have 
been  made  by  Lannois,2  Senator,3  Gerhardt,4  Bernhardt,5  Dehio,6  Eulen- 
berg,7  Staub,8  Pezzoli,9  Carslaw,10  and  others.  The  malady  may  involve 
one  or  both  hands  or  feet  or  all  four  extremities,  and  may  be  limited  to 
one  or  several  of  the  toes  or  ringers.  It  begins  usually  in  a  limited  area, 
and  gradually,  but  as  a  rule  slowly,  extends.  The  temperature  of  the 
affected  part  is  generally  increased,  and  there  is  sometimes  an  exagger- 
ated sensibility  or  hyper esthesia,  while  in  other  instances  this  is  intact. 
The  pain  is  noted  to  be  augmented  when  the  part  is  warm.  In  extreme 
development  the  parts  are  somewhat  swollen,  and  may  present  a  pseu- 
dophlegmonous  appearance,  and,  especially  during  the  pain  attacks, 
there  may  be  noticed  venous  engorgement  and  arterial  throbbing  felt. 
The  paroxysms  may  come  on  suddenly,  and  sometimes  are  excited  by 
pressure  or  a  knock.  There  is  no  regularity,  however,  as  to  painful 
attacks  nor  to  their  duration;  sometimes  frequent,  and  lasting  from 
several  minutes  to  an  hour  or  more,  exceptionally  more  or  less  con- 
tinuous. In  occasional  instances,  as  in  a  case  reported  by  Morel- 
Lavallee,11  nutritive  disturbances  of  the  nails  of  the  affected  part  were 
noted.  In  some  cases  attacks  of  local  sweating  are  noticed. 

Etiology  and  Pathology.— The  malady  is  rare,  and  may  effect 
either  sex  and  almost  all  ages.  Lannois'  analysis  shows  a  marked  pre- 
ponderance of  males.  According  to  Hallopeau  and  Leredde,12  it  is  much 
more  common  during  adolescence  and  youth.  It  is  apparently  in  some 
cases  an  idiopathic  affection,  in  others  a  part  or  symptom  of  central  ner- 
vous disease.  Machol13  saw  it  in  a  paralytic,  and  in  Gelpe's14  case  symp- 
toms of  meningitis  and  cardialgia  had  already  presented.  Collier's  study15 
shows  multiple  sclerosis  in  6  cases,  tabes  in  2,  myelitis  in  i,  and  traumatic 
necrosis  in  i ;  and  he  cannot,  therefore,  from  his  observation  as  well  as 
an  examination  of  the  literature,  accept  the  view  of  its  being  an  idio- 
pathic vasomotor  neurosis,  but  is  of  the  opinion  that  it  is  merely  a  symp- 
tom of  central  nervous  disturbance.  This  conclusion  is  not,  however, 

1  Weir  Mitchell,  Philadelphia  Med.  Times,  1872,  pp.  81  and  113,  and  Amer.Jour. 
Med.  Sci.,  1878,  vol.  Ixxvi,  p.  17  (presentation  of  a  number  of  cases  and  discussion  of 
its  relation  to  allied  conditions). 

2  Lannois,  Paralysie  vasomotrice  des  extremites  ou  Erythromelalgie,  Paris,  1880  (with 
citations  and  references). 

3  Senator,  Berlin,  klin.  Wochenschr.,  1892,  p.  1127. 

4  Gerhardt,  ibid.,  p.  1125. 

5  Bernhardt,  ibid.,  p.  1129. 

6  Dehio,  ibid.,  1896,  p.  817. 

7  Eulenberg,  Deutsche  med.  Wochenschr.,  1893,  p.  1325. 

8  Staub,  Monatshefte,  1894,  vol.  xix,  p.  10  (with  some  references). 

9  Pezzoli,  Wiener  klin.  Wochenschr.,  1896,  p.  1263. 

10  Carslaw,  Glasgow  Med.  Jour.,  1898,  vol.  1,  p.  438. 

11  Morel-Lavallee,  Annales,  1891,  p.  708. 

12  Hallopeau  and  Leredde,  Dermatologie,  1900,  p.  769. 

13  Machol,  Berlin,  klin.  Wochenschr.,  1892,  p.  1319. 

14  Gelpe,  Carres pondenzbl.  f.  Schweitzer  Aerzte,  1899,  p.  14  (case  demonstration). 

15  Collier,  Lancet,  1898,  vol.  ii,  p.  401  (10  cases). 


942 


A'EUXOSES 


in  accord  with  Mitchell  and  Spiller's1  study  and  histologic  examination 
of  the  tissues  in  one  instance,  who  found  in  this  case  that  the  malady 
could  be  ascribed  to  a  peripheral  neuritis,  with  degenerative  changes  in 
the  nerves,  although  they  also  state  that  it  may  have  its  origin  in  involve- 
ment of  the  sensory  fibers  anywhere  between  the  peripheral  ramifica- 
tions and  the  spinal  cord.  Morel-LavalleVs  case  was  associated  with  a 
mild  type  of  Raynaud's  disease.2 

It  is  not  improbable  that  the  division  of  the  cases  of  erythromelalgia 
into  three  groups,  made  by  Lewin  and  Benda,3  is  justified  by  the  clinical 
and  etiopathologic  facts:  (i)  Central  organic  disease;  (2)  central  func- 
tional disturbance;  (3)  peripheral  irritation  or  disease;  the  last  repre- 
senting the  idiopathic  erythrodermias  with  purely  local  symptoms. 

Prognosis  and  Treatment.— The  outlook  for  the  malady  is 
not  a  very  favorable  one,  although  in  some  cases  the  symptoms  are 
slight  and  not  very  troublesome.  Treatment  is  purely  expectant. 
Cooling  applications,  such  as  menthol  and  salicylate  of  methyl,  give 
variable  relief;  favorable  influence  from  faradization  (Duchenne,  Siger- 
son,  Brocq)  and  from  the  continued  current  (Eulenberg)  has  also  been 
observed.  Weir  Mitchell  tried  stretching  and  cutting  the  nerves  sup- 
plying the  affected  part,  and  amputation  of  the  involved  toe,  but  with 
variable  result;  the  former  curing  in  one  instance,  but  in  another  gan- 
grene resulted.  Sloughing  followed  amputation  in  one  case,  with  partial 
eventual  recovery  as  to  the  local  symptoms.  Of  internal  remedies, 
some  influence  is  reported  from  sodium  salicylate,  antipyrin,  acetanilid, 
and  suprarenal  substance.4  Kanoky  and  Sutton5  gave  relief  in  a  case 
with  brief  z-ray  exposures,  using  a  soft  tube. 

PRURITUS 

Definition. — Pruritus  is  a  functional  affection  of  the  skin,  having 
as  its  sole  symptom  itching,  burning,  or  pricking  sensations. 

Symptoms. — Pruritus,  or  itching,  as  an  associated  symptom  of 
other  cutaneous  diseases  attended  by  structural  changes,  is  entirely 

'Weir  Mitchell  and  Spiller,  Amer.  Jour.  Med.  Sci.,  1899,  vol.  cxvii,  p.  i  (with 
histologic  cuts,  review  of  the  subject,  and  full  references). 

_2  There  is  sometimes  considerable  similarity  in  the  cutaneous  symptoms  of  these 
various  vasomotor  and  other  nerve  disorders.  Erythromelia  is  another,  which,  as  Pick 
C'Ueber  Erythromelie,"  Erganzungsband  (Kaposi's  Festschrift),  Archiv,  1900,  p.  915, 
with  colored  plate  and  references  to  other  cases)  states,  has  in  the  objective  and  patho- 
logic characters  a  slightly  suggestive  relationship  to  erythromelalgia,  although  quite  dis- 
tinct. This  peculiar  affection,  which  is  rarer  than  erythromelalgia,  Pick  summarizes  as 
a  symmetric,  painless,  cutaneous  condition,  more  or  less  circumscribed,  with  progressive 
livid  redness  radiating  from  the  central  part  toward  the  periphery,  and  seated  on  the 
extensor  surfaces  of  the  legs  and  arms,  showing  venous  dilatation,  but  with  no  further 
changes  in  the  skin;  Klingmiiller  and  Rille  (quoted  by  Pick)  have  observed  retrogressive 
atrophy,  and  others  have  noted  a  partial  disappearance  of  the  malady. 

3  Lewin  and  Benda,  Berlin,  klin.  Wochenschr.,  1894,  pp.  53,  87,  117,  and  114  (a 
critical  review  with  references);  Voorhees,  "Erythromelalgia:  A  Study  of  70  Cases  Re- 
ported in  the  Literature,"  Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlviii,  p.  1837,  believes,  as 
Lewin  and  Benda,  that  it  is  not  an  independent  disease,  but  a  symptom-complex,  which 
may  have  either  a  central  or  peripheral  origin. 

4Moleen,  Jour.  Amer.  Med.  Assoc.,  Aug.  17,  1912,  p.  532  (with  review  and  refer- 
ences) . 

6  Kanoky  and  Sutton,  Jour.  Amer.  Med.  Assoc.,  Dec.  19,  1908,  p.  2157. 


PRURITUS  943 

distinct  from  the  affection  under  consideration.  In  this  malady  it  is 
the  sole  and  essential  symptom,  with  no  other  sign  or  feature  except 
those  which  may  sometimes  arise  secondarily.  There  are,  therefore, 
no  primary  structural  lesions,  but  in  severe  and  persistent  cases  the 
parts  sometimes  become  so  irritated  by  continued  scratching  and  rub- 
bing to  which  the  pruritus  gives  rise  that  secondary  lesions,  such  as  fol- 
licular  papules  and  slight  thickening  and  infiltration  may  result.  As  a 
rule,  however,  excepting  often  evidences  of  scratching,  pruritus  remains 
the  only  recognizable  feature  of  the  malady.  The  character  of  this 
symptom  varies  somewhat  in  different  individuals  and  sometimes 
from  time  to  time  in  the  same  individual.  Most  commonly  it  consists 
purely  of  itching  of  variable  degree,  from  slight  to  intense,  occasionally 
of  almost  intolerable  severity.  In  others  it  is  a  feeling  of  tingling,  prick- 
ing, stinging,  heat,  or  burning.  In  exceptional  cases  it  is  described  as 
similar  to  formication,  as  though  insects  were  crawling  over  or  in  the 
ikinr  It  is  occasionally  constant,  with  but  slight  intermitting  abate- 
ment, but  is  usually  more  or  less  paroxysmal,  and,  as  a  rule,  much 
worse  toward  evening  and  the  early  part  of  the  night.  The  desire  to 
scratch  is  often  irresistible,  and  in  consequence,  as  already  remarked, 
a  variable  degree  of  irritation  may  in  some  instances  finally  be  pro- 
voked, although  commonly  nothing  more  than  slight  hyperemia,  trifling 
harshness  or  roughness,  with  few  or  many  linear  scratch-marks  or 
punctate  jags  made  by  the  finger-nails.  It  is  to  be  said,  however,  that 
in  the  vast  majority  of  cases  the  skin  remains  free  from  lesions,  except 
possibly  scattered  excoriations.  It  is  by  far  more  frequent  in  those  of 
advanced  years  (pruritus  senilis),  especially  those  whose  integument 
begins  to  show  some  of  the  old-age  changes.  The  itching  may  be  more 
or  less  general  (generalized  pruritus;  pruritus  universalis) ,  or  it  may  be 
localized  or  limited  in  extent  (local  pruritus;  pruritus  localis).  It  is 
rather  exceptional  to  find  it  involving  the  whole  surface,  but  is  quite 
frequently  found  confined  to  a  large  region,  such  as  the  trunk,  limbs, 
and  especially  the  legs.  Sometimes,  on  the  other  hand,  it  is  limited  to 
a  small  area,  such  as  the  nose,  the  ear,  the  palms  or  soles,  and  other 
locations  to  be  referred  to. 

It  is  not  at  all  uncommon  to  find  it  restricted  to  the  genital  region. 
In  men  the  scrotum  may  be  its  only  seat  (pruritus  scroti),  sometimes 
extending  along  the  perineum;  or  it  exceptionally  restricts  itself  to  the 
urethral  orifice.  It  is  probably  more  frequent  during  active  adult  life. 

In  women  the  whole  vulvar  region  (pruritus  vulvae)  may  be  subject 
to  paroxysmal  or  more  or  less  persistent  itchiness,  sometimes  chiefly 
or  wholly  limited  to  the  labia,  clitoris,  or  even  the  outer  end  of  the 
vaginal  canal.  It  may  be  met  with  in  young  children,  due  to  the  pres- 
ence of  intestinal  worms,  but  it  is  usually  observed  in  women  of  middle 
or  advanced  life.  The  itching  is  often  most  distressing,  the  desire  to 
scratch  frequently  irresistible,  so  that  such  patients  are  often  obliged 
to  shun  society.  In  persistent  and  severe  cases,  from  the  constant 
scratching  or  rubbing,  a  veritable  eczema  sometimes  eventually  develops. 

Another  locality  often  the  site  of  pruritus  is  the  anus  (pruritus  ani), 
and  here  it  is  often  of  an  intense  character,  but,  as  a  rule,  more  or  less 


944  NEUROSES 

paroxysmal.  The  anus  often  has  a  sodden  look,  that  is  usually  associ- 
ated with  a  foul-smelling  secretion  (Bronson).  It  is  not  infrequently 
associated  with  hemorrhoids  (itching  piles).  All  ages  and  both  sexes  are 
liable,  but  it  is  more  common  in  active  adult  life  and  advanced  years  and 
in  males.  In  marked  cases  of  pruritus  ani  Adler1  states  that  a  charac- 
teristic condition  of  the  disease  is  the  loss  of  the  natural  pigment  of  the 
part.  In  all  probability,  however,  this  is  merely  coincidental. 

In  addition  to  the  several  local  varieties  named,  a  few  others  should 
be  mentioned.  Pruritus  hiemalis  (winter  itch,  frost  itch),  to  which 
Duhring2  originally  and  subsequently  others  (Hutchinson,  Payne, 
Porras,  Corlett)3  called  attention,  is  a  somewhat  peculiar  type.  It  is 
commonly  confined  to  the  lower  extremities,  although  occasionally  in- 
volving the  arms  also,  arid  exceptionally  other  parts.  It  is  observed, 
as  a  rule,  only  in  adults,  and  presents  in  the  beginning  cool  weather,  in 
October  or  November,  and  often  persists  until  late  spring.  It  is  not 
constant,  but  usually  comes  on  at  night,  when  the  patient  is  disrobing, 
after  having  undressed,  or  just  after  retiring.  The  itching  varies  in 
different  cases,  but  it  is  frequently  quite  intense,  and  the  desire  to  scratch 
cannot  usually  be  restrained.  After  a  variable  paroxysm,  lasting  some 
minutes  to  an  hour  or  more,  during  which  time  the  patient  often  scratches 
and  rubs  considerably,  relief  finally  comes.  The  next  night  the  paroxysm 
recurs,  and  so  on,  in  most  instances  nightly.  In  some  cases  there  may  be 
a  recurrence  when  the  patient  rises,  and  exceptionally  it  may  be  more  or 
less  persistent  during  the  whole  night.  It  is  rarely  present  or  troublesome 
at  other  times.  As  a  result  of  the  rubbing  and  scratching  the  legs,  in 
severe  instances,  become  somewhat  rough,  hyperemic,  and  excoriated, 
the  hairs  often  torn  or  broken  off  close  to  their  follicles,  and  in  rare  ex- 
amples the  parts  may  finally  present  a  slightly  eczematous  aspect. 
The  malady  often  varies  in  severity,  and  its  intensity  is  lessened  during 
periods  of  milder  weather,  and  sometimes  disappears  entirely  during 
such  times,  to  reawaken  as  soon  as  the  weather  becomes  colder.  So  it 
continues  in  most  cases  all  winter,  finally  disappearing  as  late  spring 
approaches,  and  remains  in  abeyance  until  the  following  autumn.  In 
other  instances  it  continues  for  several  weeks  and  then  becomes  milder 
and  finally  disappears. 

It  is  believed  that  some  of  the  cases  of  so-called  "prairie  itch,"  "swamp 
itch,"  "lumberman's  itch,"  "Ohio  scratches,"  "Texas  mange"  etc.,  are 
examples  of  pruritus  hiemalis,  possibly  modified  or  aggravated  by  the  cold 
and  windy,  hard  outdoor  life,  and  the  rough  and  often  dyed  character 
of  the  cheap  woolen  underwear.4  Others  of  this  group  prove  to  be  cases 
of  scabies,  but  probably  the  largest  number  are  cases  of  dermatitis  due 
to  the  small  mite,  pediculoides  ventricosus  (q.  v.) ,  occasionally  found  with 

1  Adler,  "Etiology,  Symptomatology,  and  Treatment  of  Pruritus  Ani,"  Philada. 
Polyclinic,  1895,  Nos.  39,  43,  and  50  (review  of  the  subject,  with  references). 

2  Duhring,  Philada.  Med.  Times,  Jan.  10,  1874. 

3  Hutchinson,  Brit.  Med.  Jour.,  1875,  ii,  p.  773;  Payne,  ibid.,  May  7,  1887;  Morago 
Porras,  Trans.  Internal.  Cong.  Derm,  and  Syph.,  1889,  p.  911;  Corlett,  Jour.  Culan. 
Dis.,  1891,  p.  41. 

4  Hyde,  "On  the  Affections  of  the  Skin  Induced  by  Temperature  Variations  in  Cold 
Weather,"  Chicago  Med.  Jour,  and  Exam.,  March,  1885,  and  Feb.,  1886;  also  Hyde  and 
Montgomery,  Diseases  of  the  Skin,  fifth  edit.,  p.  758. 


PRURITUS  945 

straw  and  grain — the  dermatitis  variously  known  as  "straw  itch," 
"grain  itch,"  "grain-mite  dermatitis,"  etc. 

Another  variety  of  pruritus  (bath  pruritus)1  is  that  associated  with 
baths,  a  number  of  examples  of  which  have  come  to  my  notice  from  time 
to  time.  The  itching  or  burning  immediately  follows  a  bath.  The 
sensation  varies  greatly  even  in  the  same  individual,  sometimes  being 
relatively  slight,  at  other  times  intense.  The  feeling  is  one  of  pricking, 
burning,  or  almost  intolerable  itching.  It  is  usually  aggravated  if  the 
patient  yields  to  the  desire  to  rub  or  scratch  violently.  While  it  may  ex- 
ceptionally be  general,  it  is  commonly  seated  in  the  legs,  from  the  hips 
down,  and  occasionally  in  the  forearms  also.  The  attack  lasts  from  sev- 
eral minutes  to  half  an  hour  or  longer,  becoming  increasingly  intense 
and  then  gradually  subsiding.  It  is  usually  of  longer  duration  when  the 
patient  goes  directly  from  the  bath  to  his  bed;  if  his  clothing  is  immedi- 
ately donned,  the  pruritus  will  generally  be  less  unbearable,  less  marked, 
and  of  much  shorter  duration,  especially  if  he  walks  about,  so  as  to  get 
the  soothing  effect  of  the  gentle  rubbing  of  the  underwear.  It  is  met 
with  in  adolescence  and  adult  life,  and,  according  to  my  observations, 
chiefly  in  males,  and  in  those  having  an  irritable  and  dry  skin. 

Utiology. — The  most  common  factors  to  be  considered  as  of 
probable  import  in  more  or  less  generalized  pruritus  are  digestive  and 
intestinal  derangements,  hepatic  disorders,  intestinal  worms,  uric  acid 
excess  or  saturation,  Blight's  disease,  ovarian  or  uterine  functional  or 
organic  diseases,  diabetes  mellitus,  carcinoma,  tuberculosis,  gestation, 
and  a  depraved  state  of  the  nervous  system.  Of  these,  the  first  two  are 
most  frequently  causative.  It  has  long  been  recognized  that  pruritus 
is  often  associated  with  jaundice.  Certain  dietetic  and  medicinal  agents, 
such  as  named  as  sometimes  etiologic  in  urticaria,  are  also  occasionally 
provocative.  Especially  opium  and  its  alkaloids,  and  cocain  are  among 
the  drugs  most  apt  to  give  rise  to  pruritus  and  particularly  in  those  ad- 
dicted to  hypodermic  abuse  of  morphia  and  cocain;  the  latter  drug 
not  only  giving  rise  to  pruritus,  but  to  sensations  of  insects  burrowing 
and  crawling  in  the  skin.  In  those  of  advancing  years  (pruritus 
senilis),  as  already  stated,  the  degenerative  changes  which  the  skin 
undergoes  are  doubtless  an  important  factor  in  these  patients.  Ac- 
cording to  Bronson,2  who  has  given  the  subject  careful  consideration, 
"Of  the  general  conditions  that  act  as  predisposing  causes  of  pruritus, 
whether  it  occur  as  an  essential  disease  or  is  predominated  by  some  other 
disease  of  which  it  is  a  symptom,  by  far  the  most  important  is  hyperes- 
thesia.  This  may  be  either  congenital  or  acquired,  and  either  local  or 
general.  It  may  be  acquired  through  diseases  that  affect  the  economy  at 
large,  or  that  are  localized  in  the  skin.  The  general  diseases  producing 
it  may  be  idiopathic  neuroses,  such  as  hysteria  or  hypochondriasis  and 
other  affections  of  the  nervous  centers,  or  general  nutritive  diseases 

1  Stehvagon,  "Bath  Pruritus,"  Philada.  Med.  Jour.,  Oct.  22,  1898. 

2  Bronson,  "Etiology  of  Itching,"  Med,  Record,  Oct.  24,  1891,  and  "Itching;  Its 
Occurrence  Both  as  a  Concomitant  and  Cause  of  Disease,  and  Treatment,"  Med.  News, 
April  18,  1903.     See  also  papers  by  McCall  Anderson  and  Brooke,  on  "The  Pathology 
and  Treatment  of  Pruritus,"  Brit.  Jour.  Derm.,  1895,  pp.  292  and  294. 

60 


946  NEUROSES 

affecting  the  nervous  system  secondarily,  such  as  arthritism  or  diabetes 
mellitus.  In  all  the  cases  the  primary  effect  of  the  general  disease  is 
simply  greatly  to  heighten  the  susceptibility  of  the  peripheral  nerves, 
causing  exaggerated  sensations  from  the  slightest  contacts.  The  exciting 
causes  consist  of  irritations  that  may  be  either  indirect  and  conveyed  to 
the  skin  from  the  interior  of  the  body,  or  direct,  in  which  case  the  ex- 
citation is  produced  by  local  irritants,  whether  arising  from  extraneous 
sources  or  from  sources  that  are  intracutaneous." 

The  causes  of  localized  forms  of  pruritus  have  in  part  been  incidentally 
referred  to.  Pruritus  vulvae  in  children  may  be  due  to  intestinal  worms, 
especially  ascarides  in  the  rectum,  and  exceptionally  even  in  the  vagina 
itself.  The  same  causes  are  possible,  although  less  likely  in  women. 
Leukorrheal  discharge  is  also  sometimes  provocative.  Any  irritation 
or  derangement  of  the  utero-ovarian  system  may  likewise  serve  as  a 
reflex  cause.  Diabetic  urine,  by  its  local  irritating  action,  is  sometimes 
responsible  for  a  vulvar  pruritus,  although,  as  a  rule,  in  most  instances 
the  itching  is  merely  a  part  of  an  eczema  which  has  been  thus  provoked. 
It  is  not  at  all  uncommon  at  the  time  of  the  menopause,  during  which 
period  it  may  be  a  reflex  condition  brought  about  by  some  nearby  irrita- 
tion of  the  utero-ovarian  apparatus,  or  a  part  of  a  general  neurosis.  In 
both  sexes  this  localized  pruritus  is  sometimes  to  be  attributed  to  some 
geni to-urinary  disease,  such  as  vegetations  or  polypi  or  other  irrita- 
tion or  stricture  (Bangs)  of  the  urethra,  and  to  vesical  calculi.  Pruritus 
ani,  in  addition  to  being  frequently  associated  with  hemorrhoids,  as 
already  stated,  may  also  be  due  to  a  fissure,  fistula,  or  to  hyperidrosis 
of  the  part.  Constipation,  ascarides  in  the  rectum,  varicose  condition 
of  the  veins  of  this  part  of  the  bowel,  and,  in  occasional  instances,  the 
use  of  harsh  or  printed  substances  for  toilet  purposes  may  excite  the 
malady  by  the  variable  irritation  thus  produced  (Adler). 

In  pruritus  hiemalis  cold  weather  is  the  essential  factor,  although, 
according  to  my  observations,  it  is  to  be  observed  chiefly  in  those  whose 
skin  sweats  but  slightly  and  is  lacking  in  the  natural  oiliness.  Added 
to  these  are  to  be  mentioned  gouty  tendency  and  defective  digestion,  and 
the  irritation  of  rough  woolen  underwear.  In  bath  pruritus  the  actual 
cause  is  the  water,  although  certain  factors,  in  some  cases  at  least,  have 
an  influence.  Strong  soaps  tend  to  aggravate  it,  and  mild  soaps,  if  used 
in  too  great  freedom  or  if  not  fully  rinsed  off,  seem  also  to  have  a  damaging 
effect.  Long  continuance  in  the  water  will  usually  promote  and  aggra- 
vate an  attack.  Very  hot  or  very  cold  water  is  also  an  aggravating 
influence  in  some  individuals,  although,  as  a  rule,  the  active  factor  is  the 
bath  itself,  independently  of  the  temperature  of  the  water.  It  is  observed 
chiefly,  if  not  entirely,  in  those  who  have  a  naturally  dry,  harsh,  and 
irritable  skin.  Those  affected  are  distinctly  those  of  a  nervous  tempera- 
ment, weak  digestion,  and  lithemic  tendencies. 

Pathology. — The  disease  is  a  sensory  neurosis.  There  is  nerve 
disturbance,  without  associated  appreciable  structural  change,  and  the 
provocative  irritation  may  be  either  of  reflex  origin  or  direct,  and  may 
have  its  seat  at  any  part  of  the  nervous  system  from  center  to  periphery. 
The  tissues  remain  unaltered  throughout  the  entire  course  of  the  malady, 


PRURITUS  947 

except  so  far  as  secondary  conditions  are,  in  some  instances,  brought 
about  by  the  persistent  scratching  and  rubbing. 

Diagnosis. — The  subjective  symptom  of  itching  without  the  pres- 
ence of  structural  lesions  is  diagnostic.  In  those  severe  and  persistent 
cases  in  which  excoriations  and  papules  have  resulted  from  the  scratch- 
ing, the  history  of  the  case,  together  with  its  behavior  and  course,  must 
be  considered.  Care  should  be  taken  not  to  confound  it  with  pedicu- 
losis, which  is  possible  in  those  instances  of  the  latter  showing  relatively 
slight  reactionary  irritation;  in  most  cases  of  pediculosis,  however,  the 
excoriations,  often  with  intermingled  papules  and  pustules,  and  their 
peculiar  distribution,  being  most  abundant  on  those  parts  of  the  body 
with  which  the  clothing  comes  in  contact,  as  especially  across  the  shoul- 
ders, upper  part  of  the  back,  around  the  wrist,  and  outer  aspects  of  the 
limbs  are  quite  characteristic.  In  suspected  cases  inner  garments,  and 
especially  the  seams,  particularly  of  the  neck-band,  should  be  examined 
for  pediculi.  The  lesions  of  scabies  and  the  distribution  will  prevent 
confusion  as  to  this  malady.  The  possibility  of  itchiness  being  due  to 
other  parasites,  such  as  bed-bugs,  fleas,  gnats,  etc.,  must  be  borne  in 
mind,  but  in  such  instances,  as  in  the  other  parasitic  affections  already 
named,  the  presence  of  bites,  lesions,  distribution,  and  history  will 
usually  suffice  to  prevent  error.  Urticaria  can  be  distinguished  by  the 
presence  or  history  of  wheals  and  its  capricious  character. 

In  pruritus  of  the  genital  region  the  first  essential  is  to  exclude  its 
being  due  to  pubic  lice.  In  this  latter  malady  (pediculosis  pubis),  in 
addition  to  excoriations,  various  lesions,  such  as  papules  and  pustules, 
are  commonly  to  be  found,  and  a  careful  search  will  discover  ova  on  the 
hair-shafts,  and  the  parasites  near  or  on  the  skin,  usually  grasping  a  hair. 
Pruritus  can  scarcely  be  confounded  with  eczema,  as  the  lesions,  redness, 
and  infiltration  of  the  latter  are  wanting.  The  mistake  is  most  likely  to 
occur  when  about  the  vulva  or  anus,  as  here  it  is  not  uncommon  for  the 
rubbing  and  scratching  to  bring  about  some  infiltration;  in  fact,  in  some 
instances  a  veritable  eczema  may  be  thus  provoked. 

Prognosis. — This  depends,  in  great  measure,  upon  the  discovery 
of  the  causes  and  the  possibility  of  their  removal  or  modification.  The 
malady  is  usually  troublesome  and  often  rebellious,  although  in  the 
majority  of  cases  the  condition  responds  to  proper  treatment.  Pruritus 
of  the  vulva  is  always  obstinate,  likewise  that  of  the  anus.  Pruritus 
hiemalis  can  at  the  best,  as  a  rule,  be  only  palliated  or  kept  in  abeyance, 
but  disappears  spontaneously  toward  the  advent  of  mild  weather. 
Bath  pruritus  permits  usually  of  palliation,  but  absolute  relief  can  scarcely 
be  promised  without  considerable  qualification.  Temporary  relief  can, 
however,  in  all  varieties,  always  be  given  by  external  applications. 

Treatment. — In  the  treatment  of  this  disorder  the  various  pos- 
sible etiologic  factors  of  digestive  and  intestinal  disturbance,  hepatic 
disorders,  diabetes  mellitus,  the  uric  acid  diathesis,  renal  and  utero- 
ovarian  diseases,  and  a  low  state  of  the  nervous  system  must  all  be  con- 
sidered. The  constitutional  treatment,  if  deemed  advisable,  will  there- 
fore depend  upon  the  conclusion  reached  from  a  study  of  the  individual 
case.  The  diet  should  be  plain  and  unstimulating,  and,  when  neces- 


948  NEUROSES 

sary,  adapted  to  any  special  etiologic  conditions  which  may  exist.  Alco- 
holic drinks  are  usually  harmful.  In  many  instances  a  saline  laxative 
in  the  morning,  with  a  dose  of  an  alkali  after  each  meal,  will  do  much 
toward  relieving  the  patient.  Moderately  large  doses  of  sodium  salicylate, 
salophen,  or  of  the  lithia  salts  will  aid  in  cases  dependent  upon  gouty  or 
rheumatic  conditions.  In  many  instances,  it  is  true,  it  is  difficult  to 
recognize  any  etiologic  factor;  in  such,  constitutional  treatment  must 
be  wholly  experimental,  quinin  in  large  doses,  pilocarpin,  belladonna, 
strychnin,  cannabis  indica,  lupulin,  calcium  chlorid  (Savill),  and  even 
arsenic  being  tried.  Cannabis  indica,  in  the  form  of  the  tincture,  10  to 
30  minims  (0.65-2.)  three  times  daily,  as  commended  by  Bulkley,  and 
subsequently  by  Crocker,  can  be  tried  in  rebellious  cases.  Schamberg 
commends  moderate  to  full  doses  of  carbolic  acid.  In  those  in  which 
the  itching  is  intense  and  not  sufficiently  controlled  by  external  applica- 
tions anodynes  must  be  given  internally — potassium  bromid,  chloral, 
sulfonal,  cannabis  indica,  phenacetin,  acetanilid,  and  antipyrin  being 
variously  prescribed.  The  opium  preparations  are,  as  a  rule,  not  well 
borne,  tending  usually,  after  the  narcotic  effect  has  passed  off,  to  in- 
crease the  itching.  General  galvanization,  static  insulation,  and  the 
application  of  static  electricity  by  the  roller  electrode  down  the  spine 
furnish  relief  in  occasional  instances. 

The  external  treatment  of  pruritus  is  of  great  importance,  and, 
indeed,  essential  in  almost  all  cases.  In  most  patients  unirritating 
underwear,  such  as  cotton,  lisle  thread,  silk,  or  linen,  should  be  worn 
next  to  the  skin,  as  woolen  garments  are  frequently  an  additional  ex- 
citing factor  in  these  cases.  Among  remedial  applications  lotions  are, 
as  a  rule,  most  satisfactory,  although  in  some  patients  the  itching  seems 
to  be  due  to  a  lack  of  oiliness  of  the  skin,  and,  in  this  latter  class,  oint- 
ments even  of  an  extremely  negative  character  often  give  relief.  The 
most  commonly  prescribed  local  remedial  agent  is  carbolic  acid;  this  is 
applied  usually  in  the  form  of  a  lotion  as  follows: 

If.     Acidi  carbolici,  5j-iij  (4.-I2.); 

Glycerini,  fSij  (8.); 

Alcohol,  fgj  (32.); 

Aquae,  q.  s.  ad  Oj  (500). 

Or,  and  more  especially  in  the  local  varieties  of  pruritus,  in  an  ointment 
or  oil,  from  5  to  20  grains  (0.33-1.33)  to  the  ounce  (32.)  of  petrolatum 
or  rose-water  ointment  or  liquid  petrolatum.  Bronson  prefers  the  use 
of  this  drug  in  oil,  and  employs  it  in  12.5  to  25  per  cent,  proportion,  which 
he  states  may,  with  proper  precautions,  be  used  with  perfect  impunity, 
provided  the  area  to  which  it  is  applied  is  of  moderate  extent.  His 
favorite  formula  is  i  to  2  drams  (4--8.)  of  carbolic  acid,  i  dram  (4.) 
liquor  potassae,  and  i  ounce  (32.)  of  linseed  oil,  to  which  a  few  drops  of 
bergamot  oil  can  be  added.  Dyer1  commends  a  combination  of  car- 
bolic acid,  menthol,  camphor,  and  chloral,  which  results  in  an  oily  sub- 
stance, and  diluting  with  any  of  the  simple  oils.  Thymol  is  another 
valuable  application,  used  as  an  ointment,  from  5  to  20  grains  (0.33- 
1  Dyer,  Jour.  Arkansas  Med.  Soc'y.,  Aug.,  1912. 


PRURITUS  949 

1.33)  to  the  ounce  (32.),  or  as  a  lotion,  from  8  to  16  grains  (0.52-1.) 
to  the  pint  (500.)  of  water,  with  sufficient  alcohol  and  glycerin  for  its 
solution.  Resorcin  is  also  valuable  as  a  wash,  from  3  to  10  grains  (0.2- 
0.65)  to  the  ounce  (32.),  with  a  few  minims  of  glycerin  and  alcohol. 
Liquor  carbonis  detergens,  with  from  3  to  20  parts  of  water;  and  liquor 
picis  alkalinus,  from  i  to  3  drams  (4.-!  2.)  to  the  pint  (500.)  of  water, 
are  both  of  service  in  some  cases. 

To  all  these  lotions  the  addition  of  3  to  10  minims  (0.2-0.65)  °f 
glycerin  to  the  ounce  (32.)  is  often  an  advantage,  as  many  of  these 
patients  have  rather  dry  skin;  it  should  not  be  used,  however,  in  large 
proportion. 

Alkaline  baths,  with  from  i  to  4  ounces  (32.-I28.)  of  sodium  car- 
bonate, bicarbonate,  or  borate  to  the  30  gallons  of  water,  in  which  the 
patient  lies  for  from  ten  to  thirty  minutes,  are,  more  especially  in  those 
with  oily  or  not  too  dry  a  skin,  not  infrequently  useful;  after  the  bath 
the  patient  taps  himself  dry  with  a  soft  towel,  and  applies  a  small  quan- 
tity of  petrolatum,  cold  cream,  or  a  bland  oil,  plain  or  medicated,  as  may 
seem  to  be  demanded;  following  this  a  dusting-powder  of  starch,  rice- 
flour,  or  corn-starch  is  to  be  freely  dusted  on.  This  should  be  repeated 
every  two  or  three  days.  In  place  of  the  bath,  alkaline  lotions  contain- 
ing one  of  the  several  alkalis  named,  of  the  strength  of  from  ^  grain 
to  2  grains  (0.033-0.13)  to  the  ounce  (32.),  may  be  used,  also  to  be  fol- 
lowed up  with  an  oily  application.  A  compound  lotion,  such  as  the 
following,  although  smacking  strongly  of  polypharmacy,  has  acted  well 
in  some  cases:  ty.  Acidi  carbolici,  3ij  (8.);  thymol,  gr.  xvj  (i.);  resorcini, 
5ss-j  (2.~4.);  sodii  boratis,  3ss  (2.);  glycerini,  f3ij  (8.);  alcohol,  f5j  (32.); 
aquae,  q.  s.  ad  Oj  (500.).  In  some  instances  acid  lotions  seem  to  act 
well,  consisting  of  i  part  of  ordinary  vinegar  to  5  or  10  parts  of  water, 
or  of  acetic  acid  i  part  to  from  20,  30,  or  more  parts  of  water.  In  other 
cases  the  free  use  of  a  dusting-powder  alone  seems  to  protect  the  skin 
from  the  air,  and  in  this  manner  probably  gives  relief;  powder  applica- 
tions may  also  be  used  as  supplementary  to  lotions. 

In  the  local  varieties — pruritus  vulvas,  pruritus  scroti,  and  pruritus 
ani — the  various  remedial  applications  already  named  often  suffice  to 
give  relief.  All  possible  etiologic  factors  should  be  considered,  and 
any  indicated  treatment  instituted.  In  addition  to  the  applications 
referred  to,  however,  and  probably  of  greater  benefit,  may  be  mentioned 
menthol,  applied  as  an  ointment  or  in  a  bland  oil,  from  5  to  20  grains 
(0.33-1.33)  to  the  ounce  (32.);  an  ointment  or  solution  of  cocain, 
from  i  to  10  grains  (0.065-0.65)  to  the  ounce  (32.);  anointment  made 
up  of  from  \  to  i  dram  (2. -4.)  each  of  chloral  and  camphor  to  the 
ounce  (32.)  of  simple  cerate  or  petrolatum;  and  one  consisting  of  from 
\  to  i  dram  (2.~4.)  of  chloroform  to  the  ounce  (32.)  of  simple  cerate  or 
petrolatum.  Tarry  ointments,  although  disagreeable,  are  sometimes 
quite  serviceable  in  pruritus  ani;  after  thoroughly  rubbing  in,  the  part 
is  wiped  off  and  a  simple  dusting-powder  applied.  A  free  action  of  the 
bowels  should  be  maintained  in  pruritus  ani,  as  well  as,  in  fact,  in  all 
varieties;  in  this  form  the  salines  or  fluidextract  of  cascara  sagrada  can 
be  employed,  and  sulphur  as  a  laxative  is  also  often  valuable  in  these 


950 


NEUROSES 


cases.  In  pruritus  vulvae,  especially  in  cases  due  to  irritating  discharges, 
astringent  applications  and  injections  of  alum,  tannic  acid,  or  zinc 
sulphate,  in  the  strength  usually  employed  for  vaginal  injections,  will  be 
found  of  service.  Hot-water  injections,  repeated  once  or  twice  daily, 
will  also  prove  useful  in  some  instances.  Another  plan  of  treatment  which 
has  done  good  in  some  cases  of  the  local  forms  of  pruritus  is  the  applica- 
tion of  a  sinapism  or  small  blister  over  the  lower  lumbar  region  (Crocker). 
An  occasional  painting  of  the  region  with  a  2  to  5  per  cent,  solution  of 
silver  nitrate  in  sweet  spirits  of  niter  is  of  service  in  some  instances. 
As  a  temporary  expedient  to  bridge  over  an  intense  paroxysm,  dousing 
the  part  with  hot  water,  as  hot  as  can  be  borne,  can  be  resorted  to. 
The  x-ray  has  proved  of  value  in  some  cases  of  these  localized  forms  of 
pruritus.  In  persistent  inveterate  cases  of  pruritus  vulvae  resection  of 
the  supplying  sensory  nerves  has  been  exceptionally  practised  (Hirst, 
Deaver1). 

In  that  variety  of  pruritus  due  to  temperature  changes  (pruritus 
hiemalis)  the  several  applications  already  enumerated  may  be  tried; 
in  many  instances  the  skin  is  dry  and  harsh  and  needs  oil,  and  in  such 
the  daily  application  of  a  plain  ointment  will  give  relief ;  or  the  addition 
of  10  grains  (0.65)  of  salicylic  acid  to  the  ounce  (32.)  will  be  found  valu- 
able; or  a  weak  glycerin  lotion,  from  4  to  8  drams  (i6.~32.)  to  the  pint 
(500.)  of  water,  may  also  act  well.  A  combination  that  has  served  me 
in  some  of  these  cases  consists  of  equal  parts  of  lanolin,  petrolatum,  and 
benzoated  lard,  with  10  grains  (0.65)  of  salicylic  acid  to  the  ounce  (32.); 
and  in  others  the  addition  of  from  3  to  10  grains  (0.2-0.65)  °f  menthol. 
Underwear  of  non-irritating  character  is  esp  ecially  necessary  in  this  form 
of  the  malady,  with  sufficient  outer  woolen  covering,  however,  for  suffi- 
cient warmth;  cold,  especially  if  combined  with  high  winds,  being  dis- 
tinctly etiologic. 

In  bath  pruritus,  as  to  the  matter  of  treatment,  unfortunately  very 
often  but  little  more  than  palliation  can  be  accomplished.  The  water 
used  should  be  between  tepid  and  warm,  neither  hot  nor  cold.  Excep- 
tions to  this  rule  will  be  observed,  and  some  patients  find  the  attack 
slight  or  less  severe  after  a  cold  bath  and  some  after  a  hot  bath.  Soaps 
should  be  mild  and  used  sparingly,  and  be  thoroughly  rinsed  off.  The 
parts  should  be  wiped  or  preferably  tapped  gently  dry  with  a  soft  towel; 
it  seems  that  if  the  skin  is  allowed  to  dry  itself  or  is  incompletely  wiped 
or  tapped  dry  the  itching  is  usually  much  worse.  In  some  cases  the 
introduction  of  some  substance  into  the  bath,  such  as  salt,  in  order  to 
bring  it  up  to  the  specific  gravity  of  the  blood,  is  of  value.  The  bath 
should  be  of  short  duration.  Application,  by  gently  rubbing  in,  of  a 
glycerin  lotion  or  of  an  ointment  of  cold  cream  and  lanolin,  with  or 
without  a  minute  quantity  of  carbolic  acid  or  thymol,  will  frequently 
lessen  the  severity  of,  or  exceptionally  abolish,  the  attack.  The  free 
use  of  a  dusting-powder  following  the  bath  has  also  at  times  a  palliative 
influence.  The  attack  will  be  less  unbearable  if  the  bath  is  taken  at  such 
time  as  the  patient  immediately  dresses  and  stirs  about.  Weak  alkaline 

1  B.  C.  Hirst,  Amer.  Medicine,  1903,  vol.  v,  p.  785;  Deavcr  (Discussion),  Proceed- 
ings of  the  Philada.  County  Med.  Soc'y,  April  30,  1903,  vol.  xxiv.  No.  4. 


ANESTHESIA  95 1 

baths  are  sometimes  less  exciting  than  plain  or  soap-and-water  baths. 
The  Turkish  bath  is  not  so  likely  to  be  followed  by  the  pruritic  attack 
(Hall1).  Constitutional  treatment  should  be  advised,  especially  if  there 
seems  to  exist  any  of  the  predisposing  factors  mentioned.  The  bowels 
should  be  kept  free,  a  plain  diet  enjoined,  the  digestion  carefully  looked 
after,  and  the  nervous  system  kept  in  proper  tone.  In  some  of  the  cases 
antilithemic  remedies,  especially  moderate  doses  of  sodium  salicylate, 
seem  of  positive  value.  A  physician2  reports  the  control  of  the  affection 
in  himself  by  fair  doses  of  arsenic. 

ANESTHESIA 

This  condition — strictly  speaking — belongs  to  the  domain  of  the 
neurologist ;  as  it  plays  a  not  important  role,  however,  in  some  cutaneous 
maladies,  it  may  be  briefly  referred  to.  Cutaneous  anesthesia  is  central 
or  peripheral  in  origin.  There  may  exist  structural  change  in  the  skin, 
or  this  may  be  absent.  It  may  be  local  or  general;  usually  it  is  limited 
to  certain  areas,  or  it  may  affect  only  one,  or  even  both,  sides  of  the  body. 
There  exists  numbness  in  the  areas  involved,  or  the  sense  of  feeling  may 
be  entirely  lost.  The  sense  of  touch  is  also  quite  frequently  impaired, 
sometimes  partially,  but  probably  more  commonly  completely.  It  may 
affect  only  a  single  nerve-tract,  or  several  may  be  involved.  In  the  con- 
dition known  as  analgesia  dolorosa  of  Romberg  there  is  acute  pain  in  the 
part,  yet  sensibility  is  lost.  It  may  be  idiopathic  or  symptomatic,  and 
due  to  causes  acting  from  without  or  within.  The  most  usual  external 
causes  are  cold,  the  local  application  of  ethyl  chlorid,  cocain,  chloroform, 
etc.  The  effects  of  the  administration  of  internal  anesthetics,  such  as 
chloroform,  ether,  nitrous  oxid,  etc.,  are  too  well  known  to  require  more 
than  simple  mention.  Lesions  of  the  nervous  system  and  pathologic 
conditions  of  the  brain  and  cord  are  to  be  regarded  as  important  factors. 
It  occurs  in  such  diseases  as  syphilis,  scleroderma,  and  leprosy.  The 
variety  known  as  hysteric  anesthesia  is  not  uncommon. 

Prognosis  and  treatment  of  this  condition  will  manifestly  de- 
pend on  its  nature  and  underlying  cause. 

1  Hall,  Philada.  Med.  Jour.,  Dec.  24,  1898. 
zlbid.,  Jan.  7,  1899. 


CLASS  VIII— DISEASES  OF  THE  APPENDAGES 

IN  the  class  of  diseases  of  the  appendages  of  the  skin  it  is  convenient 
and  customary  to  include  not  only  affections  of  the  appendages  proper, — 
the  hair  and  nails,— but  also  those  of  the  glandular  structures  as  well. 
They  can  be  considered  under  four  heads:  i.  Diseases  of  the  nails.  2. 
Diseases  of  the  hair  and  hair-follicles.  3.  Diseases  of  the  sebaceous 
glands.  4.  Diseases  of  the  sweat-glands. 


i.  DISEASES   OF   THE   NAILS 
ONYCHAUXIS1 

Synonym. — Hypertrophy  of  the  nail. 

Definition. — An  overgrowth  of  the  nail  in  any  direction. 

Symptoms.- — The  affection  may  be  congenital  or  acquired, 
usually  the  latter.  One  or  all  of  the  nails  may  share  in  the  process, 
and  the  hypertrophy  may  take  place  in  one  or  all  directions,  and  this 
increase  may  be,  and  often  is,  accompanied  by  changes  in  shape,  color, 
and  direction  of  growth.  It  is  not  uncommon,  too,  to  find  conjointly 
atrophic  changes  in  some  nails  or  parts  of  one  or  more  nails,  along  with 
the  hypertrophic  growth.  Supernumerary  nails,  though  scarcely  to  be 
considered  an  example  of  hypertrophy,  are  occasionally  noted.  In  ex- 
ceptional instances  nail-formation  has  taken  place  on  the  stump  ends  of 
amputated  fingers,  etc. 

Congenital  hypertrophic  changes  are  rare.  Nicolle  and  Halipre2 
had  under  observation  a  patient  with  congenital  hereditary  malforma- 
tion of  the  nails,  with  an  associated  atrophic  condition  of  the  hair.  All 
the  nails  of  both  hands  and  feet  were  involved  and  presented  hypertrophic 
growth,  friability,  and  tendency  to  split  and  crack,  and  in  some  atrophic 
changes;  there  also  existed  disposition  to  paronychia.  A  diseased  con- 
dition of  the  nails  could  be  traced  through  six  generations,  involving  36 
members  out  of  55.  White3  reports  a  somewhat  similar  interesting  series, 

1  Literature  of  diseases  of  the  nails:  Heller,  Die  Krankheiten  der  Nagel,  Berlin, 
1900  (a  most  admirable  monograph,  with  many  illustrations  and  a  complete  bibliog- 
raphy); Shoemaker,  Jour.  Cutan.  Dis.,  1890,  pp.  334,  388,  419,  and  476  (with  references 
and  abstracts  of  interesting  cases);  Hutchinson,  Arch,  of  Surgery,  1891,  p.  237;  D.  W. 
Montgomery,  "Diseases  of  the  Nails,"  Twentieth  Century  Practice,  vol.  v  (Diseases  of 
the  Skin);   Schwimmer,   "Nagelkrankheiten,"  Eulenberg's  Real-Enclydopadie,  1898, 
vol.  xvi,  p.  371;  Pollitzer  (inflammatory  affections),  Zeisler  (trophic  affections),  Grin- 
don  (parasitic  diseases),  and  Hardaway  (treatment),  Jour.  Cutan.  Dis.,  1901,  pp.  503- 
527;  Leisseur,  ibid.,  1902,  p.  502;  C.  J.  White  (clinical  study  of  485  cases),  Boston 
Med.  and  Surg.  Jour.,  Nov.  13,  1902;  Jackson,  Jour.  Cutan.  Dis.,  April,  1905,  p.  153; 
Hyde,  "The  Egg-Shell  Nail,"  Jour.  Cutan.  Dis.,  1906,  p.  145  (illustrated). 

2  Nicolle  and  Halipre,  Annales,  Aug.-Sept.,  1895,  pp.  675  and  804  (with  illustration). 

3  C.  J.  White,  Jour.  Cutan.  Dis.,  1896,  p.  220  (with  illustrations). 

952 


ONYCHAUXIS  953 

presenting  both  hypertrophic  and  atrophic  changes,  with  subungual  in- 
flammation, and,  in  one  nail,  paronychial  inflammation.  In  this  in- 
stance, too,  with  an  occasional  break,  four  generations  had  been  affected 
— in  some  congenital  absence  or  malformation,  in  others  changes  taking 
place  later.  The  thin,  downy,  sparse  hair  was  also  noted,  as  in  Nicolle 
and  Halipre's  case.  Eisenstaedt1  met  with  a  somewhat  similar  series 
of  cases — five  generations.2  A  congenital  case  of  upward  projecting, 
thickened,  claw-like  nails  has  been  recorded  by  Sympson,3  in  which,  too, 
there  was  an  occasional  disposition  to  soreness.  In  this  instance  there 
was  no  hereditary  tendency. 

Acquired  onychauxis  is,  in  its  milder  phases,  not  uncommon;  its 
extreme  type  is  somewhat  rare.  The  overgrowth  sometimes  consists 
of  simple  thickening,  which  may  be  quite  marked,  or  there  may  be  a 
hypertrophic  tendency  toward  lateral  growth,  which  sometimes  results 
in  producing  a  periungual  inflammation — paronychia.  This  latter  may 
be  slight  and  consists  of  trifling  inflammatory  redness,  or  there  may  be  a 
good  deal  of  swelling  and  purulent  discharge.  Many  cases,  however, 
are  seen  in  which  no  tendency  to  underlying  or  surrounding  inflammation 
is  observed.  In  occasional  instances  the  nail  thickens  enormously  and 
becomes  relatively  compressed  laterally,  so  that  it  consists  of  a  thick, 
horny  growth,  somewhat  flattened  basal  part,  and  more  or  less  rounded 
on  the  upper  side,  and  either  projects  upward  toward  the  distal  end, 
downward  like  talons  (claw-nails) ,  or  may  be  slightly  or  markedly  twisted, 
like  a  horn — onychogryphosis.  The  large  toe-nail  is  one  especially  liable 
to  malformed  overgrowth.  It  is  also  seen  on  the  fingers,  and  may  in- 
volve one,  several,  or  more  nails;  a  typical  example  of  the  latter  has  been 
reported  by  Ricketts4  In  some  cases  the  hypertrophied  nail  is  hard 
and  horny,  in  others  more  or  less  friable  and  easily  breakable  in  part  or 
throughout.  The  luster  is  usually  lost,  the  nail-substance  becomes 
opaque,  the  surface  often  rough  and  irregular,  and  the  color  a  dirty  yel- 
low, brown,  or  even  blackish. 

Unna5  describes  a  persistent  condition  of  the  nails  which  I  have 
occasionally  seen,  and  which  he  terms  "scleronychia,"  characterized  by 
thickening,  inelasticity,  hardness,  roughness,  and  by  being  opaque  and 
of  a  yellowish-gray  color,  with  disappearance  of  the  lunula;  there  often 
appear  longitudinal  furrows,  or  the  surface  may  be  made  up  of  protuber- 
ances and  depressions;  the  anterior  border  is  rough  and  irregular,  but 
there  is  no  tendency  to  chipping  or  breaking;  it  usually  involves  all  the 
finger-nails  simultaneously,  and  sometimes  the  toe-nails  as  well.  Mod- 
erate degrees  of  onychauxis  are  not  uncommon  in  tuberculosis,  the  nails 
being  slightly  or  moderately  thickened,  broadened,  with  a  tendency  to 
curve  over  the  finger-ends.  Invasion  of  the  nails  by  the  vegetable  fungi 
(onychomycosis)  of  ringworm  and  favus  bring  about,  in  some  instances, 
increase  in  size,  along  with  the  granular  and  friable  condition  noted. 

1  Eisenstaedt,  Jour.  Amer.  Med.  Assoc.,  Jan.  4,  1913,  p.  27  (with  illustrations). 

2  An  interesting  fact    concerning  these   three  series  (Nicolle  and  Halipre,  C.  J. 
White,  Eisenstaedt)  of  cases  is  that  the  subjects  were  French  or  of  French  extraction. 

3  Sympson,  Lancet,  1888,  i,  p.  772  (with  illustrations). 

4  Ricketts,  Cincinnati  Lancet-Clinic,  1887,  i,  p.  302. 
6  Unna,  Histo pathology,  p.  1051. 


954  DISEASES   OF  THE  APPENDAGES 

The  various  Inflammatory  diseases,  such  as  psoriasis,  eczema,  etc.,  in- 
volving the  finger  and  nail  regions,  are  often  responsible  for  a  slight  degree 
of  onychauxis.  Very  often,  however,  a  thickening  of  the  nail  is  more 
apparent  than  real,  the  seeming  increase  in  thickness  being  due  to  under- 
lying accumulation  of  epithelium  or  scaliness.  A  condition  of  this  kind, 
independent  of  any  cutaneous  inflammatory  disease,  and  involving  most 
of  the  finger-nails,  was  observed  by  Hallopeau  and  Le  Damany,1  who 
designated  it  as  a  generalized  parakeratosis  of  the  nails,  the  thickness 
being  due  to  imperfect  keratinization  of  the  lower  layer.  Sometimes  the 
nails,  especially  in  their  distal  half,  are  decidedly  raised  from  the  nail-bed 
by  a  growth  of  horny  material  beneath  them.2 

In  onychauxis  knocks  and  even  the  free  use  of  the  parts  sometimes 
lead,  owing  to  the  unyielding  characters  of  such  nails,  to  tenderness 


Fig.  239. — A  chronic  condition  of  onychia  and  paronycbia  with  atrophic  (and  some- 
times associated  hypertrophic)  nail  changes,  slight  bulbous  swelling  of  the  finger-ends; 
occasionally  seen  as  an  idiopathic  affection,  but  more  usually  associated  with  eczema  of 
the  fingers,  and  occurring  most  commonly  in  women,  and  more  particularly  in  those 
who  have  their  hands  in  water  a  great  deal.  Occasionally  this  condition  is  seen  in  asso- 
ciation with  or  following  impetigo  contagiosa,  or  independently  as  a  staphylococcic 
infection  of  the  nail-beds  and  nails;  sometimes  doubtless  of  streptococcic  origin.3  It 
may  be  occasionally  accompanied  with  arthritis  of  the  distal  joints.* 

or  a  variable  degree  of  inflammation  of  the  nail-bed  (onychia)  and  the 
surrounding  tissue  (paronychia,  whitlow).  Onychia  may  exist,  however, 
primarily  and  lead  to  atrophic  or  hypertrophic  nail  change;  the  matrix 
is  often  considerably  inflamed,  and  is  sometimes  accompanied  with  a 
seropurulent  undermining,  but  more  frequently  the  nail-bed  and  peri- 
ungual  tissue  both  share  in  the  inflammatory  action.  The  onychial  in- 

1  Hallopeau  and  Le  Damany,  Annales,  1895,  p.  538. 

2  Malcolm  Morris,  Brit.  Jour.  Derm.,  1901,  p.  8,  exhibited  a  striking  case  of  this 
kind,  a  boy  of  twelve,  and  A.  G.  Wilson,  ibid.,  Jan.,  1905,  p.  13  (with  illustrations  and 
references),  has  reported  cases  of  similar  character  as  a  hereditary  affection — three  gen- 
erations. 

3  Adamson,  Brit.  Jour.  Derm.,  1904,  p.  165,  describes  a  case  following  impetigo, 
with  references. 

4  Hartzell,  "Diseases  of  the  Nails,  Accompanied  by  Arthritis  of  the  Distal  Joints  of 
the  Fingers  and  Toes,"   Univ.  Med.  Bull.,  Oct.,  1904  (with  two  illustrations). 


ONYCHAUXIS  955 

flammation  may  be  of  a  malignant  character,  with  destruction  of  tissue 
and  involvement  of  the  lymphatics;  the  nail  is  cast  off,  and  discloses  a 
markedly  inflamed,  suppurative  tissue.  The  affection  rarely  involves 
more  than  one  or  two  nails. 

Simple  paronychia  is  often  independent  of  hypertrophic  nail  changes, 
and  is  commonly  seen  about  a  toe-nail,  being  simply  the  result  of  lateral 
pressure  of  a  normal  nail  produced  by  tight-fitting  shoes,  or  from  a  slight 
overgrowth  laterally  (ingrowing  nail).  It  is  likewise  observed,  however, 
about  the  finger-nails,  and  here  the  paronychial  inflammation  may  be 
extremely  sluggish,  quite  superficial,  consisting  of  redness  and  slight, 
sometimes  scarcely  perceptible,  swelling,  and  with  little,  if  any,  tendency 
to  purulent  formation  or  accumulation;  in  such  cases  several  or  more  of 
the  fingers  are  involved,  and  this  type  of  the  affection  is  usually  observed 
in  those  who  are  obliged  to  have  their  hands  in  water  a  great  deal.  A 
mild  degree  of  onychia  may  be  present.  It  is  also  observed  in  association 
with  eczema  of  the  fingers.  In  other  instances  the  inflammatory  action 
is  more  intense,  with  considerable  pain,  swelling,  and  pus-accumulation. 
The  nutrition  of  the  nail  often  suffers. 

Both  in  onychia  and  paronychia  the  involved  area  may  exception- 
ally be  small,  consisting  of  only  a  part  of  the  nail  region,  usually  forward 
and  laterally,  and  may  so  persist,  unless  treated,  indefinitely,  sometimes 
gradually,  but  scarcely  perceptibly,  from  day  to  day,  extending. 

Etiology  and  Pathology.— The  etiology  of  onychauxis  has 
been  already  incidentally  touched  upon.  The  condition  is  more  com- 
mon in  advancing  years.  Pressure  and  warmth,  doubtless,  are  of  eti- 
ologic  importance  in  hypertrophy  of  the  toe-nails.  Lack  of  proper  care 
is  probably  contributory.  The  various  chronic  inflammatory  cutaneous 
diseases  are  sometimes  responsible  both  for  hypertrophic  and  atrophic 
changes.1  Local  irritation  or  injuries,  constitutional  disorders,  gout, 
rheumatism,  and  diseases  of  the  nervous  system,  or  injuries  involving 
the  nerves,  as  in  Bowlby's  case,2  may  also  be,  to  a  varying  degree,  pro- 
vocative of  hypertrophy.  Thickened  and  enlarged  nails  are  sometimes 
seen  in  acromegaly,  and  may  also  be  observed,  in  some  cases  of  leprosy, 
syringomyelia,  and  similar  affections,  although  atrophic  conditions  are 
probably  more  common.  An  explanation  of  why,  in  some  cases,  the 
overgrowth  should  take  one  direction,  in  other  cases  another,  and  in  still 
others  a  twisted,  horn-like  form  and  character  is  difficult  to  find;  pressure 
is,  it  is  true,  a  directing  influence  in  some  instances,  but  not  in  all. 

Onychia  is  probably  often  idiopathic,  due  to  slight  traumatism  or 

1  C.  J.  White,  he.  cit.,  found  404  out  of  485  cases  to  be  due  to  or  associated  with 
6  diseases:  eczema  (107),  trauma  or  felon  (72),  paronychia  (68),  psoriasis  (67),  occupa- 
tion dermatitis  (62),  and  syphilis  (28).     Among  comparatively  new  occupations  which 
may  have  a  damaging  influence  on  the  nails,  as  well  as  the  skin,  may  be  mentioned  that 
having  to  do  with  the  handling  of  formalin.    Galewsky  (Munch,  med.  Wochenschr.,  Jan. 
24,  1905,  vol.  Hi,  No.  4,  calls  particular  attention  to  the  seeffects,  which  sometimes,  as 
regards  the  nails,  may  not  follow  till  weeks  or  a  few  months  after  exposure.     The  condi- 
tion is  often  accompanied  with  a  burning  or  boring  sensation  in  the  ends  of  the  fingers 
and  the  nails.     A  few  instances  of  such  occurrence  among  surgeons  and  nurses  have 
come  under  my  own  observation. 

2  Bowlby,  "Some  Trophic  Lesions  Following  Injuries  of  Nerves,"  Illustrated  News, 
1889,  vol.  iv,  p.  25  (with  colored  plate  showing  marked  hypertrophy  and  transverse 
furrows). 


956  DISEASES   OF  THE  APPENDAGES 

persistent  or  repeated  irritation  from  a  hypertrophied  nail,  which  serves 
to  give  chance  to  a  localized  pyogenic  infection.  Syphilis  and  tubercu- 
losis are  also  factors  in  some  cases.  The  essential  causes  in  paronychia 
are  pressure,  and  possibly  a  variable  but  mild  local  pyogenic  infection. 
Unskilled  manicuring  and  infected  manicuring  instruments  may  also 
play  a  part. 

Treatment. — The  result  of  treatment,  especially  as  to  perma- 
nency, in  these  various  conditions  will  depend  upon  a  proper  recognition 
of  the  essential  causative  element.  A  coexisting  disease,  cutaneous  or 
systemic,  will  often  be  the  clue  which  indicates  the  line  of  constitutional 
treatment.  Cod-liver  oil,  tonics,  and  mercurials,  with  potassium  iodid, 
may,  therefore,  be  variously  needed.  Arsenic  is  valuable  in  some  cases, 
but  it  must  be  persisted  in  to  get  a  result.  Unna  found  it  curative, 
though  slowly,  in  scleronychia.  In  some  cases  the  cause  is  found  to  be 
purely  an  external  one,  and  the  treatment,  therefore,  wholly  local.  In 
others,  again,  the  disease  seems  idiopathic,  so  far  as  our  knowledge  goes, 
and  exists  without  any  demonstrable  reason,  and  in  such  cases  the  man- 
agement is  purely  empirical,  usually  local  and  general.  For  ordinary 
onychauxis  of  one  or  two  nails,  local  measures  alone  are  called  for. 
Proper  care  and  cutting  of  the  nails,  the  avoidance  of  pressure,  either 
from  tight-fitting  shoes  or  gloves,  are  essential.  Even  slight  injuries  or 
traumatisms  with  manicuring  implements  should  be  guarded  against.  The 
excessive  nail-growth  should  first  be  thoroughly  softened  by  soaking  in 
hot  water,  in  which  a  little  sodium  bicarbonate  or  borax  has  been  dis- 
solved, and  then  carefully  cut  or  filed  away.  Subsequent  overgrowth 
can  usually  be  kept  under  control  by  a  fine  file  rather  than  with  the  scis- 
sors or  knife.  If  there  is  a  tendency  to  stony  hardness  and  brittleness, 
a  slight  soaking  nightly,  or  every  second  or  third  night,  in  hot  water, 
with  or  without  the  addition  of  the  alkali,  is  advisable,  the  part  being 
subsequently  enveloped  over  night  with  a  plain  ointment,  such  as  cold 
cream  or  vaselin. 

Onychia,  if  of  mild  character,  can  sometimes  be  managed  by  frequent 
washings  of  the  parts  with  saturated  solution  of  boric  acid  and  continuous 
applications  of  a  25  to  50  per  cent,  ointment  of  ichthyol.  Salicylic  acid 
ointment,  with  equal  parts  of  lanolin  and  cold  cream,  3  to  10  per  cent, 
strength,  is  also  valuable.  If  the  nail  is  hard  and  inelastic,  occasional 
softening  by  soaking  in  a  warm  solution  of  sodium  bicarbonate,  4  or  5 
grains  to  the  ounce,  is  advisable.  Occasionally  painting  thoroughly 
both  around  and  under  the  edges  of  the  nail  with  a  2  to  5  per  cent,  solu- 
tion of  silver  nitrate  in  sweet  spirits  of  niter  proves  serviceable;  if  done 
carefully,  the  solution  can  be  well  insinuated  ("flowed  in")  under  the 
ends  and  sides  of  the  nails,  and  thus  come  in  contact  with  a  great  part  of 
the  diseased  area.  Not  infrequently,  however,  removal  of  the  nail 
may  be  necessary.  If  there  is  undermining  suppuration,  incisions  are 
advisable,  the  subsequent  applications  being  the  same  as  above.  In 
these  latter  cases,  instead  of  ichthyol  ointment,  after  washing  with  the 
boric  acid  solution  the  part  can  be  enveloped  in  a  thick  layer  of  boric 
acid  powder.  The  dressings  should  be  changed  two  or  three  times  daily. 
In  obstinate  cases,  especially  those  of  distinctly  suppurative  or  pyogenic 


A  TR  OP  HI  A    UNGUIUM  957 

type,  both  as  to  onychia  and  paronychia,  x-ray  treatment  can  some- 
times be  used  to  advantage. 

Paronychia  is  to  be  managed  in  the  same  manner  as  onychia  as  re- 
gards the  applications.  Unhealthy  granulations,  if  present,  can  be 
modified  or  destroyed  by  applications  of  silver  nitrate — stick  or  solu- 
tion. If  due  to  apparent  side  pressure  of  the  nail,  the  center  of  the  nail 
should  be  filed  somewhat  thin,  and  a  small  tuft  of  cotton  or  lint,  wet  with 
boric  acid  solution,  gently  insinuated  under  the  lateral  nail-edges  to  re- 
move the  pressure.  Occasional  softening  with  bicarbonate  of  sodium 
solution  is  also  of  value.  In  most  cases,  those  of  mild  character,  these 
measures  will,  if  faithfully  carried  out,  usually  suffice.  If  there  is  con- 
siderable lateral  pressure,  due  to  nail  overgrowth,  the  side  edges  can  be 
carefully  trimmed  off;  or  if  the  case  is  a  severe  one,  avulsion  of  the  nail 
may  be  necessary.  In  operations  about  the  nails  complete  or  relative 
anesthesia  can  be  produced  by  cocain.  In  the  milder  types,  those  of 
sluggish  and  persistent  character,  observed  about  the  finger-nails,  the 
several  applications  referred  to,  along  with  general  tonic  treatment  when 
needed,  and  keeping  the  hands  out  of  water,  will  often  bring  the  affair 
to  an  end.  Arsenic  is  useful  in  some  of  these  cases.  Cooks,  laundresses, 
etc.,  continuously  obliged  to  have  their  fingers  wet  a  considerable  part 
of  the  time,  should  have  recourse  to  rubber  gloves  while  at  such  work. 

ATROPHIA  UNGUIUM1 

Synonyms. — Atrophy  of  the  nails;  Onychatrophia. 

Symptoms. — In  atrophy  of  the  nails  these  appendages  may  show 
various  conditions;  they  may  be  soft,  thin,  and  brittle,  splitting  easily, 
opaque  and  lusterless,  and  sometimes  with  a  worm-eaten  appearance. 
But  one  of  these  characters  may  be  present,  or  several  or  all  may  be 
exhibited.  It  may  be  congenital  or  acquired. 

Congenital  cases  are  rare,  and  in  such  instances  it  is  not  uncommon 
to  find  imperfect  growth  or  absence  of  the  hair,  and  also  defective  forma- 
tion of  the  phalanges.  In  some  of  these  instances  the  nails  are  entirely 
wanting,  as  in  Eichhorst's2  case,  although  the  nail-bed  and  fold  were  well 
developed,  hair  and  teeth  normal,  and  no  hereditary  history.  In  the 
congenital  hypertrophic  cases3  recorded  by  Nicolle  and  Halipre  and  C.  J. 
White,  especially  in  the  series  reported  by  the  latter,  in  addition  to  hy- 
pertrophy, atrophic  changes  were  also  noted.  Hutchinson4  had  under 
observation  2  cases — brother  and  sister — with  congenital  alopecia  and 
born  without  nails;  at  the  age  of  eight  and  seven  respectively,  the  nails 
had  grown,  but  the  hair  was  still  exceedingly  defective. 

Acquired  nail  atrophy  in  some  of  its  forms  is  quite  frequent.  Thin- 
ning, with  a  marked  tendency  to  splitting  of  the  free  borders,  is  often 
observed  along  with  various  chronic  inflammatory  and  squamous  skin 
diseases,  and  in  consequence  of  some  constitutional  disturbance,  or  in- 

1  For  general  literature  references  see  Onychauxis. 

2  Quoted  by  D.  W.  Montgomery,  Twentieth  Century  Practice,  vol.  v  ("Diseases  of 
the  Skin"),  p.  617. 

3  Referred  to  under  hypertrophy  of  the  nails. 

4  Hutchinson,  Arch,  of  Surgery,  1891,  p.  237. 


958  DISEASES   OF  THE  APPENDAGES 

dependently,  and  without  assignable  cause.  Occasionally  one  or  two 
nails  are  noted  to  be  somewhat  thin,  especially  at  the  free  border,  and 
with  a  persistent  central  crack  or  fissure  extending  upward.  In  fevers 
and  other  diseases  there  is  not  infrequently  an  intermittent  transverse 
thinning,  forming  transverse  furrows.  Exacerbations  of  fevers  and 
other  severe  constitutional  maladies  are  sometimes,  as  pointed  out  by 
Vogel,  Longstreth,1  and  others,  often  marked  by  transverse  atrophy, 
either  by  furrows  (furrowed  nails)  or  white  bands.  Wilks2  and  Hartzell3 
have  both  observed  transverse  atrophic  depressions,  resulting  from  sea- 
sickness, marking  the  time  of  its  occurrence.  Zeisler4  noted  in  his  own 
case,  following  a  fracture  of  the  thigh,  that  the  nails  of  the  foot  of  the 
affected  leg  did  not  grow  at  all  for  six  or  eight  weeks,  and  subsequent 
observation  showed  that  a  deep  ridge  marked  the  division  between  the 
new-growing  part  and  the  old  nail,  slowly  moving  forward,  dividing  it 
into  two  portions — a  distal  one  which  was  thin  and  clearly  atrophic, 
and  a  proximal  strong  and  thick  one.  As  Zeisler  states,  the  line  of  de- 
marcation indicated  that  the  nails,  from  the  moment  of  the  fracture, 
had  evidently  ceased  to  grow  for  some  weeks,  the  arrest  of  growth  appar- 
ently resulting  from  the  malnu- 
trition and  general  atrophy  of  the 
leg  due  to  its  constriction  by  dress- 
ings and  its  horizontal  position. 
The  nails  of  the  other  foot  ex- 
hibited normal  growth.  In  fact, 
it  is  now  well  known,  and  the  ob- 
servation has  been  made  by  many 
physicians,  that  in  depression  in 
the  general  health,  if  at  all  pro- 
nounced, the  nails  thus  show  par- 
ticipation in  the  disturbance  to 
nutrition.  Longitudinal  striae  of 
scarcely  perceptible  degree  are  ap- 
parently normal,  but  sometimes 
Fig.  240. — Atrophy  of  the  nails.  distinct  atrophic  longitudinal  fur- 

rows are  observed,  but  their  import 

is  not  understood.  Another  form  of  atrophic  thinning  is  that  known  as 
the  spoon-naU,  in  which  the  sides,  and  to  a  less  extent  the  free  margin 
also,  become  everted,  making  a  central  spoon-like  depression  or  scoop. 
Crocker5  describes  such  cases,  and  refers  to  several  observed  by  others. 
It  is,  however,  rare,  and  usually  occurring  in  wasting  diseases,  although 
in  other  instances  without  explainable  reason. 

An  atrophic  friable  or  crumbly  condition  of  the  nails  is  most  com- 
mon, sometimes  involving  one,  several,  or  all  the  finger-nails,  and  some- 

f    l  Longstreth,  "On  the  Changes  in  the  Nails  in  Fever,  etc.."  Trans.  Coll.  Physicians 
of  Philadelphia,  1877,  p.  113. 

2  Wilks,  Trans.  Palhol.  Soc'y,  London,  1870,  p.  409. 

3  Hartzell,  discussion  on  Disease  of  the  Nails,  Trans.  Amer.  Derm.  Assoc.for  igoi. 

4  Zeisler,  "Trophic  Dermatoses  Following  Fractures,"  Jour.  Cutan.  Dis.,  1808,  p. 
3°S- 

5  Crocker,  Diseases  of  the  Skin. 


ATROPHIA    UNGUIUM 


959 


times  the  toe-nails  also,  although  this  latter  is  not  so  frequent.  It  may 
begin  in  any  portion — ordinarily,  however,  at  the  basal  portion.  The 
nails  break  and  crack  readily.  Poor  health,  chronic  digestive  disturb- 
ances, diseases  of  the  nervous  system,  possibly  traumatisms,  and  invasion 
by  the  vegetable  fungi  of  favus  and  ringworm  are  factors  in  different 
cases. 

Shedding  of  the  nails  occurs  sometimes  after  fevers  and  nervous 
diseases.  It  has  been  occasionally  observed  conjointly  with  alopecia 
areata  and  general  defluvium  capillorum.  It  is  also  seen  in  diabetes, 
scarlatiniform  erythema,  and  dermatitis  exfoliativa,  but  in  other  in- 
stances without  apparent  cause.  In  some  cases  it  is  hereditary  and  even 
congenital.  Montgomery1  reported  a  case  of  a  man  in  whom  there  had 
been  a  constant  shedding  of  the  finger-nails  since  birth,  with  a  history 
of  a  similar  affection  in  some  of  his  ante- 
cedents. Apparently  in  certain  nervous 
disorders,  diabetes,  etc.,  the  great  toe-nail 
most  frequently  suffers  in  this  respect. 

Leukopathia  unguium  (achromia  un- 
guium;  leukonychia;  flores  unguium; 
white  spots;  white  nails;  gift  spots, 
etc.),  in  its  mildest  type,  is  not  infre- 
quent, the  chalky  whiteness  being  either, 
and  most  usually,  in  the  form  of  spots 
or  in  the  form  of  transverse  bands,  the 
nails  otherwise  being  quite  normal. 
They  appear  near  the  lunula,  and  gradu- 
ally move  forward  with  the  growth  of 
the  nail.  Unna,2  Giovannini,3  Long- 
streth,4  Morison,5  Stout,6  Heidingsfeld,7 
and  others  report  marked  instances  of 
the  band  type;  Longstreth  observed 
white  transverse  bands  on  his  own  finger- 
nails after  an  attack  of  relapsing  fever; 

the  several  bands  marking  the  time  of  the  relapses.  Giovannini's  case 
followed  typhoid  fever,  and  Unna's  case  was  apparently  congenital,  and 
associated  with  partial  ringed  hair.  Morison's  patient,  a  young  woman, 
was  in  good  health,  the  bands  appearing  without  apparent  cause;  they 
had  practically  disappeared  for  a  time  one  summer.  In  Stout's  case,  a 
mulatto,  in  addition  to  involvement  of  the  finger-nails,  a  number  of  the 
toe-nails  exhibited  a  similar,  but  slightly  less  marked,  condition;  and  so 

1 D.  W.  Montgomery,  Jour.  Cutan.    Dis.,  1897,    p.   252   (with  some  literature 
references). 

2  Unna,  International  Atlas,  plate  xix,  1891. 

3  Giovannini,  ibid. 

4  Longstreth,  loc.  cit. 

5  Morrison,  Archiv,  1888,  p.  3  (with  colored  plate). 

6  Stout,  Medical  News,  Feb.  24,  1894  (with  illustrations  and  some  literature  refer- 
ences) . 

7  Heidingsfeld  (7  cases),  Jour.  Cutan.  Dis.,  1900,  p.  490  (with  illustrations  and 
bibliography);  Sibley,  Brit.  Jour.  Derm.,  1911,  p.  281,  records  a  case,  and  also  a  case 
of  yellow-ochre  color  in  a  syphilitic  subject  while  under  antisyphilitic  treatment  (with 
a  review  of  the  literature  with  references). 


"M^^^^tfflH^^ttftfc^tfflHS  dfet 

Sr^? 

__^_ i^— ~- 

npP 


Fig.  241. — Leukopathia  ungui- 
um (the  transverse  band  type); 
patient  manicured  herself  about 
every  seven  to  ten  days. 


960  DISEASES   OF   THE  APPENDAGES 

far  as  could  be  ascertained  was  probably  congenital.  Lawrence,1  quoted 
by  Stout,  observed  an  example  of  finger-nail  bands  in  a  healthy  man  aged 
forty-five,  apparently  congenital,  and  whose  child,  aged  five,  likewise 
presented  a  similar  appearance,  though  not  so  distinctly  marked. 

Htiology  and  Pathology. — The  causes  of  these  various  atrophic 
and  other  described  conditions  have  in  part  been  incidentally  referred 
to.  So  far  as  observation  goes,  the  same  etiologic  factors  responsible 
for  the  production  of  hypertrophy  may  also  lead  to  atrophic  changes. 
The  various  inflammatory,  and  especially  scaly,  skin  diseases,  more 
particularly  when  involving  the  hand  and  fingers,  are  often  etiologic; 
constitutional  diseases,  nervous  disorders,  glossy  skin  (Weir  Mitchell), 
traumatism,  vegetable  parasites,  etc.,  are  therefore  variously  found  in 
the  different  cases;  as  already  stated,  heredity  is  a  demonstrable  factor 
in  some  of  the  cases.  In  many,  however,  it  must  be  confessed,  it  is 
difficult  to  find  an  adequate  explanation  for  the  often  persistent  and 
rebellious  atrophic  manifestation.  The  immediate  factor,  exclusive 
of  the  parasites,  is  doubtless  trophic  in  character,  but  that  is  about 
as  far  as  one  can  get  in  many  instances,  and  that  is  more  of  a  cloak  for 
lack  of  knowledge  than  a  satisfying  explanation.  Nutritive  disturbance 
of  the  matrix  naturally  is  followed  by  imperfect  nail-formation,  and 
this  part  shares  in  all  general  enfeebling  diseases,  especially  if  profound 
and  long  continued. 

The  white  spots  and  bands  are  in  most  cases  either  due  to  general 
disease,  such  as  fevers,  nervous  disorders  (Bielschowsky)  ,2  or  to  local 
traumatisms.  In  many  instances,  however,  as  in  that  of  complete  in- 
volvement in  Joseph's3  patient,  there  is  no  assignable  cause.  The  striated 
form  is  rare,  although  Heidingsfeld's  observation  of  7  well-marked  cases 
in  a  comparatively  short  time  indicates  that  it  is  not  so  rare  as  it  ap- 
parently seems  from  the  scant  literature  of  the  subject.  Six  of  his 
patients  were  young  women  who  assiduously  manicured  their  nails,  and 
his  studies  would  indicate  that  the  cuticle  knife  is  a  possible  cause  of  these 
white  formations.  He  gives  an  illustration  of  i  case,  showing  the  nails 
one-half  (new-growing  part)  normal  after  disuse  of  the  cuticle  knife  for 
forty  days.  As  yet  there  is  some  difference  of  opinion  as  to  the  origin  or 
production  of  the  white  appearance.  Most  of  the  various  writers  named 
and  other  observers  consider  it  due  to  infiltration  of  air,  filling  the  minute 
interstitial  spaces  between  the  loosened-up  epithelial  strata.  This  is  the 
accepted  view.  Heidingsfeld,  who  made  careful  microscopic  examina- 
tions of  the  affected  nails,  was  not  able  to  corroborate  this,  and  he  con- 
sidered that  his  researches  justified  the  following:  Leukoplakia  unguium 
is  the  result  of  some  pathologic  change  of  structure  of  a  plane  of  nail- 
cells,  approximating  a  failure  of  the  affected  cells  to  undergo  normal 
physiologic  keratinization ;  the  causes  may  be  trauma,  malnutrition, 
febrile  diseases,  neuroses,  or  any  agency  which  disturbs  the  growth, 
development,  or  keratinization  of  matrix  cells  in  their  change  to  nail 

1  Lawrence,  Australian  Med.  Jour.,  Oct.  15,  1893. 

1  Bielschowsky  (following  multiple  neuritis),  Neurologisches  Centralblatt,  1890,  p. 
74i. 

*  M.  Joseph,  "Leukonychia  totalis,"  Dermatolog.  Zeitschr.,  1894,  p.  657. 


ON  YCHOM  YCOSIS  96 1 

structure;  an  infiltration  of  air  is  not  present,  and  there  is  no  rational 
physiologic  basis  for  such  a  theory. 

Treatment. — The  management,  in  a  general  way,  of  nail  atrophy 
is  essentially  the  same  as  described  in  treatment  of  hypertrophy  of  these 
structures.  A  recognition  of  the  causative  factor  is  important  for  suc- 
cess, but  this  often  seems  impossible.  In  the  absence  of  underlying 
factors  which  will  give  indication  of  constitutional  treatment  when 
necessary  an  empirical  plan  is  the  only  resort.  Arsenic,  and  also  cod- 
liver  oil,  often  have  a  favorable  influence  if  persevered  in.  Small  doses — 
2  or  3  grains  (0.135-2.)  three  times  daily — of  sulphur  in  some  instances 
appear  to  have  an  alterative  effect.  The  local  management  consists 
in  the  protection  of  the  parts  from  traumatism  and  from  contact  with 
disturbing  materials,  such  as  water,  other  liquids,  and  irritating  sub- 
stances. When  necessary,  disinfection  with  boric  acid  solution  and  appli- 
cations of  the  milder  salves,  such  as  prescribed  in  eczema,  and  those  named 
in  the  treatment  of  nail  hypertrophy  are  useful.  In  cases  of  nail-splitting, 
enveloping  the  part  with  salve  nightly,  and  wearing  over  the  finger-end 
a  piece  of  a  glove-finger,  and  keeping  the  free  end  of  the  nail  closely  cut 
or  filed,  will,  if  persisted  in,  often  get  rid  of  the  trouble. 

In  white  nails  the  treatment  is  purely  upon  general  indications, 
with  a  trial  of  arsenic  in  chronic  cases,  and,  if  necessary,  the  conceal- 
ment of  the  blemishes  by  some  indifferent  stain;  for  this  latter  purpose 
occasionally  touching  the  spots  with  a  5  or  10  per  cent,  resorcin  lotion 
will  bring  about  slight  discoloration  and  render  the  blemish  less  conspicu- 
ous. The  treatment  of  atrophic  nails  due  to  the  ringworm  and  favus 
fungi  will  be  elsewhere  considered  (see  Onychomycosis). 

ONYCHOMYCOSIS 

Synonyms. — When  due  to  ringworm  fungus:  Onychomycosis  trichophytina; 
Tinea  trichophytina  unguium;  Trichophytia  unguium;  Ringworm  of  the  Nails;  Fr., 
Onychomycose  trichophytique;  Trichophytie  ungueale;Ger.,  Onychomycosis  tonsurans. 
When  due  to  favus  fungus:  Onychomycosis  favosa;  Tinea  favosa  unguium;  Favus  of  the 
nails;  Fr.,  Onychomycose  favique;  Favus  des  ongles;  Ger.,  Favus  des  Nagels. 

Definition. — A  crumbly,  friable,  grayish-colored,  granular-looking 
condition  of  the  nail,  due  to  invasion  by  the  ringworm  or  favus  fungus. 

Symptoms. — Rarely  more  than  one  or  two  nails  are  involved, 
and  most  commonly  the  finger-nails.  The  invasion  is,  as  a  rule,  in- 
sidious, and  the  development  of  the  malady  extremely  slow.  Usually 
the  lateral  distal  edge  shows  the  first  signs,  the  part  becoming  somewhat 
brittle  and  friable,  grayish  or  grayish-yellow  in  color,  and  often  some- 
what crumbly.  It  may  be  thus  limited,  scarcely  involving  more  than 
one-fourth  of  its  substance,  and  remain  so  sometimes  almost  indefinitely. 
In  other  instances  the  greater  part  of  this  nail  is  sooner  or  later  invaded, 
and  it  may  encroach  upon  the  posterior  portion,  although  most  com- 
monly involving  the  anterior  half  or  two-thirds.  In  exceptional  cases, 
however,  the  whole  nail  is  implicated.  Beneath  the  distal  portion  there 
is  often  a  variable  accumulation  of  epithelial  matter  and  debris,  of  a 
dirty-gray  or  grayish-yellow  color,  and  in  some  instances  sufficiently 
great  in  quantity  to  lift  this  part  of  the  nail  up  from  its  bed  in  an  irregular 

61 


g62  DISEASES   OF   THE  APPENDAGES 

manner.  In  occasional  cases  the  malady  seems  to  be  more  or  less  re- 
stricted to  this  underlying  part,  the  horny,  or  nail  substance  proper, 
showing,  at  first  at  least,  but  little  involvement,  although  usually  slightly 
changed  in  color.  While  the  free  edge  or  the  immediately  adjacent  side 
more  commonly  shows  the  earliest  effects,  not  infrequently  the  first 
involvement  is  with  the  lateral  or  posterior  portion,  and  this  probably 
more  frequently  from  the  ringworm  fungus  than  from  the  favus  fungus. 
The  changes  produced  by  these  fungi  vary  but  little,  although  in  the  dis- 
ease due  to  that  of  favus  the  evidences  first  presenting  consist  in  some 
cases  of  yellowish,  pin-point  to  pin-head,  grain-like  bodies.  While  the 
nail  of  any  finger  or  fingers  may  be  attacked,  the  thumb,  the  first,  and  the 
second  are  apparently  most  frequently  involved,  and  this  is  especially  so 
in  favus.  The  toe-nails  are  relatively  seldom  invaded,  but  much  more 
commonly  by  the  ringworm  fungus  than  with  that  of  favus;  Vidal, 
Zeisler,  and  a  few  others  have  noted  instances  in  which  the  latter  attacked 
these  parts  primarily.  In  exceptional  instances  the  affected  nails,  more 


Fig.  242. — Onychomycosis  due  to  the  favus  fungus — favus  of  the  nails — in  a  Russian 
girl  aged  seventeen.  One  year's  duration;  favus  of  the  scalp  since  twelve  years  old 
(courtesy  of  Dr.  F.  J.  Leviseur). 

especially  those  of  the  toes,  are  increased  in  volume  and  become  quite 
hard  and  horny,  sometimes  gryphotic  and  distorted  (Geber,  Censi).1 
Etiology  and  Pathology.— The  cause,  as  already  stated,  is 
either  the  ringworm  or  favus  fungus;  the  latter  much  less  frequently, 
and  when  etiologic,  the  malady  is,  as  a  rule,  contracted  from  the  erup- 
tions elsewhere  on  the  surface,  usually  from  the  disease  on  the  scalp. 
This  is  true  in  great  measure  also  with  that  due  to  the  ringworm  fun- 
gus, although  it  is  not  uncommon  to  find  the  nails  the  primary  and  sole 
part  involved,  having  been  contracted  from  others  who  may  have  the 
disease  on  the  non-hairy  or  hairy  parts.  It  may  itself  be  the  source 
of  contagion  to  others.2  Both  the  nail  and  subjacent  derma  are  in- 
vaded by  these  fungi.  According  to  Sabouraud,  only  the  trichophyton 
endothrix  (almost  always  trichophyton  acuminatum  or  trichophyton 

1  Geber,  Ziemssen's  Handbook  of  Skin  Diseases,  p.  487;  Censi',  "Clin.  dermosif.  d. 
R.  Univ.  di  Roma,"  abs.  in  Brit.  Jour.  Derm.,  1898,  p.  423,  records  2  instances  of 
onychomycosis  trichophytina  of  the  toe-nails,  in  which  the  nail  was  thickened,  curved, 
and  nodular,  shaped  like  a  bird's  claw  or  a  ram's  horn. 

2  Fournier,  Jour.  mal.  cutan.,  1889,  p.  3,  has  recorded  an  instance  of  contraction  of 
ringworm  by  several  members  of  a  family  from  a  servant  who  had  onychomycosis. 


ONYCHOMYCOSIS  963 

violaceum)  is  found  in  the  nails,  the  other  varieties  of  ringworm  fungus 
not  attacking  these  structures;  but  this  statement  is,  it  is  believed,  too 
absolute.  The  fungus  can,  as  a  rule,  be  readily  demonstrated  in  the 
scrapings  of  the  affected  nail  substance  by  placing  on  a  slide  in  some 
liquor  potassae,  allowing  it  to  soften  for  several  minutes  to  an  hour  or 
more,  and  then  examining  with  a  power  of  400  to  500  diameters.  Ex- 
ceptionally, as  noted  by  Hutchinson  and  Crocker,  the  parasite  is  not  easily 
found,  the  scrapings  requiring  sometimes  a  soaking  of  ten  to  twenty 
hours  in  the  liquor  potassae. 

Diagnosis.— With  the  presence  of  either  ringworm  or  favus 
patches  elsewhere  upon  the  surface  the  nail  involvement  would  permit 
usually  of  a  ready  diagnosis.  A  similar,  or  closely  similar,  condition 
of  the  nails  is,  however,  seen  in  connection  with  psoriasis,  eczema,  and 
other  chronic  inflammatory  dermatoses;  and,  moreover,  not  infrequently 
occurs  independently,  sometimes  as  the  result  of  impaired  general  nutri- 
tion or  trophic  disorders,  and  likewise  in  those  of  gouty  or  rheumatic 
tendency.  The  diagnosis,  therefore,  must  often  be  based  upon  micro- 
scopic examination  of  the  scrapings.  It  is  true,  however,  that  in  the 
parasitic  disease  rarely  more  than  one  or  several  nails  are  affected,  while 
in  association  with  or  as  a  result  of  the  maladies  mentioned,  in  most 
instances,  many  or  all  are  apt  to  be  more  or  less  involved. 

Prognosis  and  Treatment.— The  malady  is  extremely  obsti- 
nate, although  finally  responsive  to  persistent  treatment.  If  let  alone, 
it  continues  indefinitely,  showing  no  tendency  to  spontaneous  cure.1 
It  usually  remains  limited,  however,  to  one  or  two  nails ;  more  than  several 
are  rarely  involved.2 

In  the  treatment  the  parts  are  to  be  repeatedly  closely  pared,  pumiced, 
or  scraped.  If  very  hard  and  brittle,  and  often  also  with  advantage  in 
other  instances,  an  occasional  soaking  in  an  alkaline  solution  will 
serve  to  soften ;  or  liquor  potassae  or  a  stronger  solution  of  caustic  potash 
can  be  painted  on  several  times.  Another  method  (Pellizzari)  of  soften- 
ing and  removing  the  involved  nail  tissue  is  by  enveloping  it  with  sapo 
viridis,  covering  it  with  a  rubber  finger-stall,  and  allowing  it  to  remain 
for  one  to  several  days,  during  which  time  it  can  be  renewed.  These 
mildly  caustic  applications  require  some  care  that  the  surrounding  tissue 
is  not  unnecessarily  acted  upon.  Along  with  the  removal  of  the  dis- 
eased nail  substance  from  time  to  time  in  the  manner  described  parasiti- 
cide applications  are  to  be  made.  One  of  the  best  plans  is  to  dip  the 
affected  finger-ends  in  a  solution  of  mercuric  chlorid,  from  i  to  3  grains 
(0.066-0.2)  to  the  ounce  (32.),  for  five  to  ten  minutes  twice  daily,  allow- 
ing it  to  dry  in,  and  then  enveloping  the  parts  with  an  ointment  of  white 
precipitate  or  calomel,  a  dram  (4.)  to  the  ounce  (32.);  or  the  finger-ends 
may  be  soaked  in  a  15  to  20  per  cent,  solution  of  sodium  hyposulphite, 
subsequently  enveloping  them  with  an  ointment  of  precipitated  sulphur, 
i  dram  (4.)  to  the  ounce  (32.).  In  cases  in  which  the  parts  are  not  sen- 

1  Crocker,  Brit.  Jour.  Derm.,  1899,  p.  331,  mentions  an  instance  in  which  one  nail 
had  apparently  been  affected  by  the  ringworm  fungus  for  forty  to  fifty  years;  Fernet, 
ibid.,  1902,  p.  16,  one  case  in  which  it  had  existed  for  twenty  to  thirty  years. 

2  Sabouraud,  Annales,  1896,  p.  33  (describes  a  case  due  to  ringworm  fungus,  involv- 
ing all  the  nails  of  the  right  hand). 


964  DISEASES   OF  THE  APPENDAGES 

sitive  or  easily  irritated  enveloping  the  nail  over  night  in  an  application 
consisting  of  the  following  may  be  advised: 

1$.     Sulphur  praecip.,  3ij  (8.); 

Ac.  salicylici,  gr.  xxx  (2.); 

Saponis  viridis,  q.  s.  ad  5j  (32.). 

Sabouraud  commends  a  lotion  composed  of  15  grains  (i.)  iodin,  30 
grains  (2.)  potassium  iodid,  and  a  quart  (1000.)  of  water;  this  is  ap- 
plied on  absorbent  cotton,  and  kept  covered  with  a  rubber  finger-stall, 
and  renewed  frequently.  It  is,  as  all  other  plans,  slow,  but  the  fungus 
development  is  completely  inhibited,  the  new-growing  nail  substance 
remaining  unaffected,  and  gradually  replacing  the  morbid  structure. 
Crocker  has  had  the  most  success  with  Harrison's  plan  of  treating 
ringworm  of  the  scalp  (q.  v.).  Norman  Walker  keeps  the  nails  soak- 
ing in  a  bath  of  Fehling's  solution  by  means  of  lint  and  finger-stall, 
for  a  day  or  two,  removing  the  softened  nail,  and  following  with  a 
continuous  dressing  of  a  3  per  cent,  copper  sulphate  solution;  Cranston 
Low1  found  both  this  and  the  Harrison  method  successful.  In  per- 
sistently obstinate  cases  complete  avulsion  of  the  affected  nail,  followed 
by  the  use  of  the  above  remedies,  may  be  required. 


2.  DISEASES  OF  THE  HAIR  AND  THE  HAIR-FOLLICLES 
HYPERTRICHOSIS2 

Synonyms. — Hypertrophy  of  the  hair;  Superfluous  hair;  Hairiness;  Hirsuties; 
Hypertrophia  pilorum;  Hyper trichiasis;  Polytrichia;  Trichauxis;  Fr.,  Foils  accidentels. 

Definition. — Excessive  or  abnormal  growth  of  hair,  either  as 
regards  region,  degree,  age,  or  sex. 

Symptoms. — Excessive  hair  growth  may  be  congenital  or  ac- 
quired, and  of  limited  (hypertrichosis  partialis)  or  general  (hyper- 
trichosis  universalis)  distribution. 

Congenital  hypertrichosis  may  be  either  partial  or  general,  although 
both  are  rare,  the  former  less  so  than  the  latter.  In  partial  cases  the 
hairiness  is  usually  a  part  of  a  pigmented  naevus — in  fact,  such  are, 
as  a  rule,  examples  of  hairy  naevi.  The  skin  is  commonly  found  pig- 
mented, and  with  a  variable  amount  of  connective-tissue  growth  (see 
Naevus  pigmentosus).  In  this  variety  of  congenital  cases  the  lower 
part  of  the  trunk,  especially  over  the  sacrum,  is  the  most  frequent  locali- 
zation. 

In  universal  hypertrichosis  the  growth  on  those  regions  where  the 
hair  is  normally  more  vigorous  is  the  most  pronounced.  The  situations 
on  which  lanugo  hair  never  grows,  as,  for  instance,  the  palms,  soles, 
etc.,  remain  free,  even  in  instances  of  markedly  excessive  general  hairi- 

1  Cranston  Low,  "Fungus  Infection  of  the  Finger  Nails,"  Edinburgh  Med.  Jour., 
Feb.,  IQII   (an  interesting  and  valuable  contribution — 19  cases  in  three  years — 16 
from  trichophyton,  2  favus  and  i  unknown  fungus). 

2  Important  literature:  Jackson,  Diseases  of  the  Hair  and  Scalp,  New  York,  1890; 
Jackson  and  McMurtry,  Diseases  of  the  Hair,  1912;  Beigel,  The  Human  Hair,  Lon- 
don, 1869;  Leonard,  The  Hair,  Detroit,  1881. 


//  YPER  TRICHOSIS  96  5 

ness.  Usually  at  birth  there  is  noted  a  perceptible  down,  with  considerable 
hairy  growth  on  the  normal  localities.  In  others  the  downy  hairs  are 
noticed  only  after  some  months  or  a  few  years.  These  gradually  increase 
in  size,  become  more  or  less  uniformly  pigmented,  and  almost  invariably 
of  the  same  color  as  the  scalp  hair.  These  cases  are  rare,  but  quite  a 
number  have  been  recorded,  a  few  of  which  have  been  of  the  female  sex. 
The  body  hairiness  is  often  variable  as  to  degree,  but  always  much  more 
pronounced  than  normally,  and  ordinarily  the  growth  is  conspicuous. 
The  face  shows  the  greatest  development  of  the  blemish,  being  more  or 
less  completely  covered.  This  general  hairiness  is  not  only  usually 
congenital,  but  there  is,  as  a  rule,  a  hereditary  history.  Examples  of 
this  condition — the  so-called  homines  pilosi,  or  hairy  people — have 
been  reported  by  various  observers.1  It  is  commonly  noted  that  these 
general  congenital  hairy  individuals  show  defective  development  of 
teeth,  as  is  also  observed  in  cases  of  congenital  absence  of  hair.  In 
Duhring's  patient,  however,  the  teeth  were  all  present  and  in  good  con- 
dition. 

Acquired  hypertrichosis,  compared  to  the  above-described  con- 
genital cases,  is  a  mild  affair,  but  often  most  harassing  to  its  subjects, 
if  of  the  female  sex,  and  these  are  the  only  subjects  who  come  profes- 
sionally under  our  notice.  Exceptionally,  however,  instances  of  general 
acquired  hirsuties  have  been  observed.2  A  variable  degree  of  hairiness 
often  develops  in  certain  families  as  adult  and  advanced  age  is  reached, 
but  more  especially  in  the  male  line,  although  it  is  not  uncommon  to  see 
moderate  development  on  some  women,  not  necessarily  the  face,  but  on 
the  usual  downy  sites  of  the  covered  parts,  especially  the  arms  and  legs. 
These  cases,  however,  rarely  seek  advice.  The  examples  of  acquired 
hypertrichosis  soliciting  professional  aid  are  those  observed  in  young 
and  middle-aged  women,  who  find  the  down  of  the  chin,  lip,  and  some- 
times the  sides  of  the  face  growing  stronger,  becoming  pigmented,  and 
thus  constituting  a  positive  blemish.  Various  degrees  and  varieties  are 
observed,  from  that  of  simple  exaggerated  down  to  a  conspicuous  growth. 
In  others,  more  frequently  in  those  of  advancing  years,  there  may  be 

1  Beigel  (loc.  cit.)  refers  to  several  instances  of  recorded  cases  (with  several  illustra- 
tions), of  which  the  most  striking  are  those  of  Julia  Pastrana  and  Shwe-Maon  (Craw- 
ford's case).     Julia  Pastrana,  a  Spanish  dancer,  not  only  had  a  fine  beard,  but  the  whole 
body  was  hairy,  and  a  daughter  displayed  the  same  anomaly.     Shwe-Maon,  one  of  his 
daughters,  and  one  of  her  sons,  all  displayed  universal  hairiness,  the  body  hairs  of  his 
daughter  being,  however,  chiefly  of  a  downy  character.     The  Russian  dog-faced  man, 
Andrian  Jeftichjew,  whose  picture  is  now  well  known,  and  his  son,  Fedor,  both  of  whom 
were  on  exhibition  in  this  country  and  elsewhere,  are  additional  examples.     Duhring 
(Arch.  Derm.,  1877,  p.  193,  with  illustration)  had  under  observation  a  "bearded  woman," 
aged  twenty-three,  in  whom  there  was  full  growth,  such  as  seen  in  men,  and  also  more  or 
less  general  hypertrichosis,  with,  however,  some  parts  entirely  free.     There  was  no 
hereditary  history,  nor  did  either  of  her  two  children  up  to  the  time  of  their  death — at 
the  ages  of  two  and  four — display  this  tendency. 

2  Erasmus  Wilson  (Lectures  on  Dermatology,  London,  1878)  refers  to  an  unmarried 
woman,  aged  thirty-three,  in  whom  general  hairiness  began  to  develop  at  puberty,  and 
covered  the  surface,  excepting  a  bald  plaque  on  the  vertex  of  scalp;  the  woman  was  a 
sufferer  from  amenorrhea.     Zarubin  (Jour.  Cutan.  Dis.,  1897,  p.  74)  records  a  some- 
what similar  case,  in  a  married  woman,  appearing  at  the  age  of  twenty-three,  after  a  mis- 
carriage with  her  second  child  and  consequent  pain  (amenorrhea)  in  the  sexual  sphere, 
the  menses  not  appearing  again  for  eleven  years;  the  general  hair  growth  was  followed 
by  scalp  baldness. 


966  DISEASES   OF   THE   APPENDAGES 

simply  a  small  number  of  large  scattered  hairs  or  one  or  two  tufts.  The 
growth  of  these  latter  is  somewhat  akin  to  the  growth  of  hairs  usually 
observed  in  old  men  about  the  nasal,  aural,  and  brow  regions.  In  ex- 
ceptional instances  (transitory  hypertrichosis)  acquired  hair  growth  on 
a  woman's  face  has  been  noted  to  disappear  spontaneously;  this  has  been 
more  especially  observed  to  occur  after  pregnancy  or  after  the  re-estab- 
lishment of  normal  menstrual  flow,  following  prolonged  amenorrhea.1 
The  hair  growth  occasionally  seen  following  local  injuries,  such  as  frac- 
tures, nerve  traumatism,  and  the  like,  sometimes  falls  out  subsequently. 

The  tendency  to  excessive  growth  of  the  beard  in  men,  and  of  the 
scalp  hair  to  extreme  luxuriance  and  length  in  some  women,  is  a  matter 
of  occasional  observation.  This  by  no  means,  especially  in  women, 
indicates  an  excessive  production  on  the  other  natural  situations.  In 
rare  instances  the  hairy  development  on  parts  other  than  the  scalp 
takes  place  early — before  puberty,  its  normal  time  for  active  growth — 
and  has  resulted  in  whiskered  boys,  associated  with  early  develop- 
ment of  the  pubic  hairs,  or  female  children  with  precociously  hairy 
pudenda.2 

In  connection  with  hypertrichosis,  the  anomaly  exceptionally  ob- 
served, two  hairs  (Giovannini)3  and  even  three  hairs  (Hemming)4 
emerging  from  a  single  follicle,  usually  on  the  bearded  parts,  may  be 
referred  to.  One  is  commonly  abortive,  although  they  may  be  equally 
developed  and  thick.  Giovannini  is  inclined  to  believe,  from  an  instance 
observed  by  him,  that  this  may  give  rise  to  a  sycosiform  inflammation. 
I  have  myself  observed  in  a  few  cases  in  isolated  follicles  the  growth  of 
two  hairs,  but  never  with  coincident  inflammation.  Doubtless  in  some 
instances  these  double  and  triple  hairs  are  simply  examples  of  hair- 
splitting. 

The  hair  has  certain  normal  directions  in  which  it  grows,  but  ex- 
ceptionally this  may  be  deviated  from.  The  most  frequent  example 
of  this  is  with  the  eyelashes,  which  may  tend  inward  against  the  eyeball 
(trichiasis)  and  give  rise  to  considerable  irritation,  and  sometimes 
opacity  of  the  cornea,  etc.  In  rare  instances  are  observed  in  this  region 
two  rows  of  lashes  (distichiasis),  a  supplementary  inner  row  curved  back- 
ward on  to  the  eye,  which  may  extend  along  the  whole  lid,  but  usually 
only  along  the  outer  third  of  the  upper  lid.  Both  trichiasis  and"  distichia- 
sis may  result  from  chronic  inflammation  of  the  lid-borders;  the  latter 

1  Gottheil  has  cited  an  instance,  which  was  also  observed  by  Jackson  (Jackson, 
Morrow's  System,  vol.  iii  (Dermatology),  p.  841),  in  which  a  woman,  after  having  borne 
several  children,  was  the  subject  of  a  persistent  amenorrhea,  during  which  time  a  growth 
of  coarse  hair  grew  on  the  face;  several  years  later  she  became  pregnant,  and,  after  the 
birth  of  the  child,  the  remaining  hairs — some  had  been  removed  by  electrolysis — sponta- 
neously disappeared. 

2  Lesser  (Carres pondenzbl.  f.  Schweitzer  Aerzte,  xxvi,  p.  355;  Jour.  Cutan.  Dis., 
1897,  p.  75)  cites  an  instance  of  a  girl  of  six  in  whom  extensive  hair  growth  began  at 
the  age  of  four,  the  child  developing  precociously  and  menstruating  when  three  years 
old.     In  addition  to  the  natural  situations  there  was,  however,  also  growth  on  face  and 
general  body  surface  (an  illustration  of  this  case  in  Lesser's  Hautkrankheiten,  tenth  edit., 
1900,  p.  220);  Beigel  (Virchow's  Archiv,  1868,  vol.  xliv,  p.  418)  also  recorded  a  six- 
year-old  girl  with  mature  pudendal  development;  and  Chowne  (Lancet,  1852,  i,  p. 
421)  a  boy  aged  eight,  with  pubic  hairs  and  a  bearded  face. 

3  Giovannini,  Archiv,  1893,  vol.  xxv,  p.  187  (with  cuts). 

4  Hemming,  Monatshefte,  1883,  p.  163. 


HYPERTRICHOSIS  967 

is,  however,  sometimes  congenital  or  develops  about  the  age  of  puberty 
(de  Schweinitz). 

Etiology. — Some  of  the  possible  causative  factors  have  been 
already  incidentally  alluded  to.  The  condition  may  be  congenital  in 
a  few  instances,  and  in  many  a  hereditary  factor  is  recognizable.  Cer- 
tain races  are  more  especially  prone  to  strong,  coarse,  and  more  than  the 
usual  quantity  of  lanugo  growth,  with  a  tendency  to  become  stronger 
and  coarser.  Those  of  dark  complexion  are  more  susceptible.  It  is 
true,  too,  that  masculine  women  are  frequently  the  subjects  of  this  blem- 
ish, but  such  individuals  are  not  very  sensitive  concerning  it  and  rarely 
seek  advice,  so  that,  according  to  my  experience,  the  large  majority  of 
women  coming  under  actual  notice  for  treatment  are  in  nowise  less 
womanly  than  those  free  from  facial  hirsuties.  In  fact,  I  should  say 
that  most  of  my  patients  have  been  exceedingly  sensitive,  refined,  frail, 
and  womanly.  In  the  larger  number  of  cases  the  growth  develops  most 
actively  at  the  climacteric  period.  It  is  a  common  observation  that  the 
growth  is  frequently  associated  with  diseases,  functional  or  organic,  of 
the  utero-ovarian  system.  On  the  other  hand,  in  many  instances  there 
is  no  apparent  cause.  It  is  known  that  local  irritation,  as  the  warmth 
of  fracture  dressings,  sinapisms,  stimulating  embrocations,  and  the  like, 
are  quite  capable  in  some  subjects  of  stimulating  hairy  development. 
There  is  a  strong  belief  among  women  that  greasy  applications  to  the  face 
favor  hirsutial  growth,  especially  the  petroleum  ointments,  but  unless 
there  is  an  underlying  tendency  I  cannot,  from  my  own  observations, 
think  this  to  be  true.  Friction  and  petroleum  ointment  conjointly 
might  in  such  subjects  have  a  stimulating  influence;  but  grease  of  any 
kind,  even  with  active  friction  or  massage,  is  often  enough,  as  we  unfortu- 
nately know,  powerless  to  stay  falling  hair  or  to  stimulate  new  growth. 
The  nervous  system  is  probably  a  factor  in  some  instances;  it  is  not  in- 
frequent in  insane  women,  although  often  in  association  with  menstrual 
irregularity  or  abeyance.1 

.Treatment. — There  is  no  treatment  for  general  hypertrichosis. 
For  cases  of  moderate  acquired  facial  hair  growth  occurring  on  women's 
faces,  and  for  which  relief  is  often  urgently  sought,  full  and  permanent 
removal  can  be  effected  by  electrolysis,  a  dermatologic  procedure  the 
profession  owes  to  Hardaway,  who  was  led  to  employ  it  by  Michel,  who 
had  been  successfully  using  it  for  the  removal  of  ingrowing  eyelashes. 
Since  then  Fox,  Jackson,  Brocq,  and  others  have  gone  over  the  details 
and  reported  results.  The  operation  is  permanent  in  its  effects,  but  as 
each  hair  must  be  treated  individually,  it  is  only  practicable  in  cases 
in  which  the  hairs  are  coarse  and  not  too  numerous.  Owing  to  the  deli- 
cate character  of  the  operation,  it  is  natural  that  a  proportion  of  failures 
— failure  to  strike  the  hair-papilla — should  occur;  and  this  experience 
proves.  With  a  good  operator,  however,  there  should  not  be  more  than 
2  or  3  papillae  missed  out  of  10.  The  position  of  the  papilla  is  usually 
indicated  by  the  direction  of  the  hair-shaft,  but  this  is  not  always  so, 
especially  under  the  chin;  the  proportion  of  failures  in  the  latter  region 

1  H.  C.  Baum,  Jour.  Amer.  Med.  Assoc.,  July  13, 1912,  p.  104,  thinks  that  in  general 
toxic  influences  are  of  some  import,  and  indican  in  the  urine  bears  a  relationship. 


968  DISEASES    OF   THE  APPENDAGES 

is  therefore  greatest.  The  surface  can  be  gone  over  a  second  time, 
however,  and  complete  removal  thus  attained.  I  have  always  declined 
to  operate  on  lanugo  growth,  and  have  always  discouraged  the  treatment 
in  extensive  cases,  as  in  the  former  the  hair  is  not  conspicuously  unsightly, 
and  it  is  possible,  just  at  such  time,  the  operation,  by  producing  irritation, 
might  stimulate  the  hair;  and  in  the  latter  the  method  seems  interminable. 
From  about  35  to  50  hairs  can  be  comfortably  operated  on  in  an  hour. 
Even  in  extensive  growth,  however,  if  the  subject  have  persistence, 
patience,  and  a  full  purse,  a  final  favorable  result  can  be  brought  about. 
The  procedure  is  somewhat  painful,  variable  as  to  degree  in  different 
individuals,  but  it  is  never  an  obstacle,  for  the  patient  is  extremely  rare 
who  cannot  sit  and  bear  the  slight  pain  of  the  operation  much  longer  than 
the  physician  can  comfortably  operate.  The  upper  lip,  especially  under 
the  nose,  is  the  most  sensitive  part.  Anodyne  applications,  usually 
without  effect,  need  not,  therefore,  ever  be  used.  A  good  light  is  re- 
quired, for  at  the  best  the  procedure  is  trying  on  the  operator's  eyes. 
The  patient  can  be  placed  on  an  ordinary  chair  with  a  head-rest,  or  a 
reclining  chair  can  be  used — it  is  most  convenient  for  the  physician,  who 
sits  at  the  side  facing  the  patient,  when  the  part  to  be  depilated  is  on  a 
level  with  his  eyes. 

The  object  of  the  electrolytic  operation  is  to  destroy  the  papilla  and 
lower  part  of  the  follicle.  For  this  purpose  are  needed  a  galvanic  bat- 
tery of  10  to  30  cells,  a  needle-holder,  an  extremely  fine  needle,  the 
ordinary  cords,  an  electrode,  a  rheostat,  and  a  milliamperemeter.  The 
strength  of  current  required  is  from  j  to  i|  milliamperes,  probably  f  of 
a  milliampere  being  the  average.  If  no  meter  is  used,  a  current  of  from 
2  to  6  freshly  charged  cells  of  a  zinc-carbon  battery  with  electropoion 
fluid,  or  from  4  to  10  Leclanche  cells,  or  from  the  same  number  of  the  or- 
dinary commercial  dry  cells,  or  from  8  to  16  silver  chlorid  cells  will  give 
the  required  strength;  it  is  better,  however,  to  have  a  large  number  of 
cells,  so  that  the  requisite  current  can  be  obtained  for  some  months,  as 
the  cells  gradually  weaken.  Moreover,  the  battery  is  then  available 
for  electrolytic  and  other  purposes  which  require  stronger  currents. 
The  needle  may  be  either  one  of  iridoplatinum,  suggested  by  Hardaway, 
and  which  I  prefer,  or  a  fine  steel  one.  Fox  and  Jackson  both  use  a 
jeweler's  steel  broach.  The  iridoplatinum  needle  can  be  bent  in  any 
direction,  a  convenience  when  operating  in  certain  regions.  The  needle- 
holder  should  not  have  an  interrupter,  although,  strange  to  say,  more  of 
these  are  sold,  the  general  practitioner  being  the  purchaser.  The  expert 
buys  the  one  without,  as  the  current  should  be  broken  at  the  positive 
electrode,  and  not  at  the  needle — the  abrupt  breakage  by  the  latter 
giving  rise  to  flashes,  and  often  giddiness.  The  holder,  with  the  needle, 
is  to  be  attached  to  the  negative  pole.  If  attached  to  the  positive  pole,  the 
needle  glues  itself  slightly  in  the  follicle,  and  if  a  steel  needle  is  used,  its 
oxidation,  which  takes  place  at  this  pole,  results  in  a  deposit  of  iron  rust 
in  the  skin.  While  a  milliamperemeter  is  not  an  absolute  necessity,  its 
employment  is  a  guard  against  the  use  of  a  too  strong  current  and 
therefore  lessens  the  risk  of  scarring. 

The  region  to  be  operated  upon  should  be  wiped  off  with  a  pledget 


HYPERTRICHOSIS  969 

of  cotton  wet  with  alcohol,  as  a  mild  preliminary  antiseptic  measure 
which,  I  believe,  lessens  the  chance  of  pustulation.  For  the  operation 
good  light  is  required;  a  magnifying  lens  or  a  pair  of  slightly  magnifying 
spectacles  will  be  a  help.  The  needle  is  introduced  into  the  hair-follicle 
alongside  of  the  hair,  down  to  the  papilla;  if  the  follicle  is  entered,  the 
needle  slips  in  very  readily  without  puncturing  the  skin  or  bringing 
blood.  The  depth  to  which  the  needle  is  introduced  depends  upon  the 
individual  case  and  the  individual  hair,  varying  from  yV  to  \  of  an  inch; 
the  sense  of  resistance  met  with  will  usually  indicate  the  proper  depth. 
The  circuit  is  then  made  by  the  patient  touching  the  positive  electrode, 
which  is  covered  with  wet  sponge  or  wet  cotton,  with  the  ringers  or  palm, 
the  other  hand  holding  this  electrode  by  an  insulated  needle;  the  current 
is  allowed  to  act  for  from  ten  to  thirty  seconds,  during  which  time  the 
needle  is  to  be  moved  a  trifle,  so  as  to  bring  it  in  contact  with  the  sides 
of  the  lower  part  of  the  follicle.  Slight  blanching  and  frothing  or  bub- 
bling at  the  point  of  entrance  are  noticed  while  the  current  is  passing. 
When  sufficient  action  is  thought  to  have  taken  place,  usually  in  from 
ten  to  thirty  seconds,  the  patient  removes  the  hand  from  the  positive 
pole  and  the  needle  is  withdrawn.  If  the  papilla  has  been  destroyed, 
the  hair  will  readily  come  out  with  but  little,  if  any,  traction.  In  many 
instances  a  small,  hive-like  spot  marks  the  site  of  each  operation,  sub- 
siding in  the  course  of  some  minutes  or  hours;  in  other  instances  the 
reaction  is  extremely  slight.  If  the  action  has  been  too  severe  or  the  cur- 
rent too  long  continued,  and  even  under  the  most  favorable  conditions 
in  some  skins,  there  is  considerable  reaction  at  each  of  the  points  of 
operation,  and  pustulation  and  crusting  result  in  one  or  two  days,  with 
sometimes  slight  or  insignificant  scarring.  As  a  rule,  however,  if  the 
operator  is  practised,  careful,  and  skilful,  scarring,  in  the  popular  sense 
of  the  word,  should  not  take  place.  There  will  be  less  danger  of  this  if 
the  hairs  operated  upon  at  the  one  sitting  are  not  too  close  together — 
picking  them  out  here  and  there,  and  avoiding  closely  contiguous  hairs. 
In  fact,  operating  at  the  one  sitting  on  adjoining  follicles  is  almost  sure 
to  produce  fusing  zones  of  redness  or  inflammation,  and  sometimes  posi- 
tive tissue  destruction  and  scarring.  Another  precaution  is  not  to  re- 
enter  the  same  follicle  at  the  same  sitting — a  temptation  when  the  first 
introduction  has  not  been  successful.  On  the  upper  lip  the  weakest 
possible  current  should  ordinarily  be  used,  both  on  account  of  the  ex- 
treme sensitiveness  of  the  part  and  the  greater  tendency  to  tissue  de- 
struction. In  2  instances  freckle-like  pigment  spots  marked  the  sites 
of  operation  on  the  upper  lip — i  case  of  my  own  and  in  i  operated 
on  by  another  physician.  Jackson  also  refers  to  this  possibility — an 
extremely  rare  one,  however;  several  weeks  or  months  elapsed  before 
their  entire  disappearance.  The  weaker  the  current,  the  less  chance  of  too 
much  action,  although  the  needle  must  be  kept  in  the  follicle  somewhat 
longer.  After  the  sitting  the  part  should  again  be  wiped  off  with  alcohol. 
Two  or  three  times  during  the  next  ten  or  twelve  hours  the  patient  is  to 
apply  hot  water  for  several  minutes;  this  will  reduce  any  reddening  or 
inflammatory  tendency.  If  there  is  much  reaction,  an  occasional  anoint- 
ing with  cold  cream  containing  2  or  3  per  cent,  of  boric  acid  will  be  of 


970  DISEASES   OF  THE  APPENDAGES 

service.  The  frequency  of  the  sittings  will  depend  upon  the  amount  of 
surface  involved — if  limited,  a  week  is  allowed  to  go  by  before  operating 
again;  this  will  have  given  ample  tune  for  all  irritation  to  subside;  if  the 
region  is  large,  sittings  can  follow  closely  one  after  another,  a  new  part  or 
scattered  hairs  being  operated  on  each  time. 

Another  method  which  has  recently  been  experimentally  tried  is 
that  by  the  x-tay.  It  has  been  known  for  some  time  that  its  use  was 
occasionally  followed  by  falling  of  the  hair.  Schiff  and  Freund,1  Wood,2 
Pusey,3  and  a  few  others  have  utilized  this  fact  in  treating  hypertrichosis, 
and  with  alleged  favorable  effects,  but  numerous  exposures  are  required, 
and  the  results  can  scarcely  be  said  to  have  been  permanent,  and  it  is 
not  without  some  risk  of  troublesome  dermatitis  and  of  subsequent 
atrophic  changes  in  the  skin.  Even  its  former  warmest  supporters  now 
recognize  its  shortcomings.  It  should  be  limited,  if  used  at  all,  to  cases 
not  otherwise  manageable,  and  the  exposure  be  at  first  cautiously  given; 
a  number  of  exposures  are  required.  After  some  months  the  hair  usu- 
ally regrows,  but,  as  a  rule,  in  less  number.  It  is  to  be  considered  an 
uncertain  and  dangerous  method. 

Although  electrolysis  constitutes  the  only  method  of  treatment 
that  will  yield  permanent  results,  there  are  several  other  expedients 
adopted  in  such  cases  which,  although  only  temporary  in  their  effect, 
can,  by  repetition,  keep  the  face  free  from  this  blemish.  These  are  ex- 
traction of  the  hairs  with  the  tweezers,  cutting  or  shaving,  and  the 
use  of  depilatories.  Another  method  not  so  commonly  used,  but  which 
I  have  found  occasionally  employed,  is  that  by  a  smooth  piece  of  pumice- 
stone;  by  gently  rubbing  this  over  the  part  every  few  days  the  hairs  are 
kept  ground  off  even  with  the  skin.  It  is  popularly  believed,  and  it  is 
probably  true,  that  all  these  methods  tend  to  make  the  hair  stronger 
and  to  promote  the  growth  of  the  downy  hairs.  It  is  even  possible  that 
the  operation  of  electrolysis  may  have  this  influence  on  the  remaining 
lanugo  hairs.  Still,  when  the  latter  operation  is  not  available,  owing  to 
the  necessary  expense,  time  outlay,  or  other  reason,  some  other  expedient 
is  resorted  to.  For  this  purpose  depilatories  are  most  frequently  em- 
ployed, and,  judging  by  the  extensive  advertisement  of  secret  prepara- 
tions of  this  character,  their  use  must  be  quite  general.  One  of  the  best 
depilatories  (Duhring)  consists  of  from  2  to  4  drams  (8.-i6.)  of  barium 
sulphid,  with  enough  zinc  oxid  and  starch  to  make  an  ounce  (32.). 
The  sulphid  should  be  well  and  usually  freshly  made,  and  kept  tightly 
corked,  otherwise  its  action  is  unsatisfactory.  At  the  time  of  applica- 
tion sufficient  water  is  added  to  make  a  paste,  which  is  thickly  spread 
over  the  part,  and  allowed  to  remain  for  a  short  time,  rarely  more  than 
a  minute  or  two,  and  then  scraped  or  washed  off,  and  a  little  soothing 
ointment  or  a  dusting-powder  applied.  A  variable  amount  of  redness 
follows;  the  object  is  to  allow  the  paste  to  remain  on  only  a  sufficient 
length  of  time  to  destroy  the  hair,  so  as  to  limit  the  resulting  irritation. 

1  Schiff  and  Freund,  Wiener  med.  Wochenschr.,  1898,  pp.  1058,  1118,  and  1178;  and 
(Freund)  Weiner  klin.  Wochenschr.,  1899,  p.  966. 

2  Wood,  Lancet,  1900,  i,  p.  231. 

3  Pusey,  Trans.  Amer.  Derm.  Assoc.for  igoi. 


HYPERTRICHOSIS  971 

Ordinarily  a  feeling  of  warmth  or  slight  burning  is  an  indication  that  the 
paste  has  been  on  long  enough.  The  application  is  repeated  as  soon  as 
the  hair  has  reappeared — about  every  one  or  two  weeks.  Bottger's 
paste,  as  advocated  by  Kaposi  and  Brayton,1  made  by  passing  hydrogen 
sulphid  into  hydrated  lime,  is  also,  when  well  made,  a  good  preparation; 
it  is  to  be  made  into  a  paste  at  the  time  of  application  by  the  addition  of 
water.  Brayton2  also  commends  highly  a  similar  one  (dry  calcium 
sulphohydrate),  made  by  heating  together  at  a  high  temperature  plaster 
of  Paris  and  granulated  wood-charcoal,  although  the  product,  like  most 
others  in  my  own  experience,  seems  to  vary  in  efficiency.  It  is  also  to  be 
made  into  a  paste  at  time  of  application. 

In  cases  in  which  these  various  expedients  do  not  seem  advisable 
or  eligible,  the  bleaching  properties  of  hydrogen  peroxid,  especially 
in  patients  with  a  dark  growth,  can  be  made  use  of,  as  suggested  by 
Bulkley3  at  first,  in  order  to  avoid  the  possibility  of  irritation,  diluting 
with  an  equal  part  of  water,  and  gradually  increasing.  It  is  to  be  thor- 
oughly and  frequently  applied.  Bulkley  states  that  it  also  has  the  ad- 
vantage, if  constantly  employed,  of  retarding  the  growth.  I  can  testify 
as  to  its  value  as  a  bleacher,  and  thus  occasionally  serviceable  as  a  pal- 
liative, but  I  have  seen  no  evidence  of  its  retarding  influence  on  the 
hair  growth. 

Plica  polonica  is  a  term  formerly  much  in  use,  applied  to  a  condition 
of  the  scalp  hair,  especially  observed  in  Poles,  in  which  entangling  and 
matting  were  the  conspicuous  characters.  Much  was  formerly  written 
upon  the  subject,  several  varieties  and  stages  were  described,  and  it 
was  even  deemed  worthy  of  atlas  illustration,  but  all  its  interest  faded 
away  when  it  was  demonstrated  (Hebra),  and  finally  accepted  after 
much  controversial  discussions,  that  it  was  not  in  itself  a  disease,  but 
simply  the  result  of  lack  of  cleanliness  and  care,  associated  with  pediculi, 
eczematous  oozing,  and  extraneous  dirt.  Under  such  circumstances  it 
can  be  understood  how  inextricable  matting  could  readily  ensue. 

Plica  neuropathica  is  an  idiopathic  matted  or  felted  condition  of  the 
scalp  hair  of  which  but  several  cases  have  been  recorded — i  by  Le  Page,4 
by  Pestonji,5  De  Amicis,6  i  by  myself,7  and  possibly  a  few  others.  In 
the  first  2 — young  women — the  matting  developed  shortly  after  washing 
the  hair  in  warm  water,  and  in  i  (Le  Page's)  was  confined  to  the  hair  of 
the  right  side,  and  in  the  other  to  the  sides  of  the  occipital  region.  These 
cases  were,  therefore,  of  sudden  development,  and  though  suspicious  as 
to  possibility  of  artificial  production,  this  element  seems  to  have  been 
carefully  eliminated.  In  De  Amicis'  case,  the  patient  having  lost  the  hair 
of  the  scalp  in  consequence  of  typhoid  fever,  the  regrowth  on  the  ante- 
rior portion  was  of  a  bushy,  tangled  nature,  wholly  different  from  the 

1  Brayton.  Indiana  Med.  Jour.,  June  and  Aug.,  1896. 

2  Brayton,  Jour.  Amer.  Med.  Assoc.,  April  16,  1898. 

3  Bulkley,  Jour.  Amer.  Med.  Assoc.,  1890,  ii,  p.  1598. 

4  Le  Page,  Brit.  Med.  Jour.,  1884,  i,  p.  160. 

5  Pestonji,  Lancet,  1885,  ii,  p.  431. 

8  De  Amicis,  Trans.  Internal.  Derm.  Cong.,  Vienna,  1892,  p.  422;  abs.  in  Annales, 
1892,  p.  1182. 

7  Stelwagon,  Amer.  Jour.  Med.  Sci.,  Dec.,  1892. 


972 


DISEASES   OF   THE   APPENDAGES 


other  hair  posteriorly.  This  patient  had  distinct  nervous  symptoms  as 
well,  leading  De  Amicis  to  believe  that  the  condition  was  a  trophoneurotic 
one.  In  my  own  case  the  felting  was  limited  to  a  dollar-sized  area  poste- 
riorly just  below  the  occipital  protuberance,  and  had  been  a  growth 
of  years,  forming  a  rounded,  matted,  felted  lock  4  feet  long.  The 
patient  was  perfectly  cleanly,  and  the  scalp  free  from  dirt  or  vermin. 
The  other  hair  exhibited  no  tendency  to  similar  felting.  It  is  difficult 
to  find  an  explanation  of  these  cases.  In  the  discussion  on  my  own  case 
White1  suggested  that  it  might  be  due  to  some  peculiar  arrangement  of 


Fig.  243. — Plica  neuropathica  (case  referred  to  in  the  text). 

the  cortical  cells,  similar  to  those  of  the  hair  of  animals  in  which  natural 
felting  occurs.  Unfortunately,  my  patient  was  thoroughly  imbued  with 
the  superstitious  sentiment  always  associated  with  these  formations,  and 
I  was  therefore  not  able  to  cut  off  any  for  investigation.  That  excep- 
tionally a  curly  or  other  property  can  be  given  to  one  or  two  locks  or  a 
part  of  the  scalp  hair  without  necessarily  to  the  whole  region  uniformly 
is  also  shown  by  Flesch's  case,2  a  boy  of  six  years,  in  whom  were  two 
locks,  of  about  i  inch  diameter,  distinctly  curly  and  light  yellow  in 
color,  the  other  hair  being  smooth,  straight,  and  brown.  No  other 
member  of  the  family  presented  this  peculiarity,  nor  was  there  any 
hereditary  history  of  such. 

1  J.  C.  White,  Trans.  Amer.  Derm.  Assoc.  for  1892. 

2  Flesch,   Verhandl.  Berlin.  Anthropolog.  Gesellsch.,  April,  1886;  abs.  in  Monats- 
hefte,  1886,  p.  522. 


FRAGILITAS   CRINIUM  973 

ATROPHIA  PILORUM  PROPRIA1 

Synonym. — Atrophy  of  the  hair. 

Atrophy  of  the  hair  is  a  general  term  employed  to  cover  various 
varieties  of  hair  changes,  of  an  atrophic  or  destructive  character,  which 
may  be  due  to  the  invasion  of  parasites  in  the  hair  or  about  the  hair- 
roots,  or  which  may  result  from  some  known  or  unknown  general  sys- 
temic conditions  from  which  the  hair,  as  well  as  other  tissues  or  organs, 
may  suffer  partial  nutritive  starvation,  and  thus  become  weakened  and 
fragile.  It  is  not  improbable,  however,  that  even  those  considered  tropho- 
neurotic  in  origin  may  be  so  only  so  far  as  it  weakens  the  hair  and  makes 
it  an  easy  prey  and  lodging-place  for  microbic  elements.  It  is  usual  to 
divide  the  cases  into  those  idiopathic  in  origin  and  those  symptomatic, 
but  it  is  purely  an  arbitrary  division,  and  practically  signifies  that 
those  belonging  to  the  former  class  are  without  recognizable  cause,  while 
the  latter  class  includes  those  apparently  due  to  constitutional  disease, 
such  as  phthisis,  fevers,  syphilis,  diabetes,  and  the  like,  and  to  such  local 
affections  as  favus,  ringworm,  seborrhea,  etc.  The  various  conditions 
found  are  commonly  known  as  fragilitas  crinium,  trichorrhexis  nodosa, 
monilethrix,  piedra,  tinea  nodosa,  Beigel's  disease  (chignon  fungus), 
and  lepothrix.  It  is  the  first  three,  however,  which  are  usually  included 
under  the  above  heading,  the  others  being  characterized  by  concretions 
upon  the  hair-shafts,  although  some  resulting  atrophy  is  generally 
noticeable. 

FRAGILITAS  CRINIUM 

As  the  name  signifies,  this  is  a  condition  of  the  hair  characterized  by 
extreme  fragility,  which  may  manifest  itself  in  several  ways:  the  hair 
may  split  up  into  a  few  or  many  filaments,  either  at  or  toward  their  free 
end,  or  near  and  sometimes  extending  into  the  root,  or  it  may  be  simply 
brittle  and  break  off  from  brushing,  combing,  or  handling.  It  may  be 
extremely  slight  or  quite  pronounced.  The  scalp  hair  of  women  and 
long  beard  in  men  are  its  usual  sites.  Duhring2  described  a  peculiar  case 
involving  the  beard,  characterized  by  marked  atrophy  of  the  hair-bulb 
and  splitting  of  the  hair  substance,  the  fission  taking  place  within  the 
follicle  and  producing  irritation  of  the  skin  and  follicular  papules.  Parker3 
and  Hyde4  each  refer  to  a  somewhat  similar  instance.  The  most  common 
part,  however,  for  the  fission  to  take  place  is  at  the  hair-ends,  and  it  may 
extend  some  distance  up  the  shaft.  In  other  cases,  exceptionally,  how- 
ever, it  occurs  near  the  middle  of  the  shaft.  The  condition  may  confine 
itself  to  scattered  hairs,  or  chiefly  to  the  hairs  of  a  limited  region;  on  the 

1 1  am  indebted  to  Jackson's  book  on  Diseases  of  the  Hair  and  Scalp,  1890, 
for  suggestions,  etc.,  in  the  preparation  of  the  articles  on  the  various  atrophic 
diseases  of  the  hair;  and  also  to  his  (Jackson  and  McMurtry)  later  work,  Dis- 
eases of  the  Hair,  1912.  The  small  book  by  Beigel,  The  Human  Hair,  also  contains 
much  interesting  matter;  also  G.  Behrend's  paper  ("Ueber  Knotenbildung  am  Haar- 
schaft,"  Virchoiv's  Archiv,  1885,  vol.  ciii,  p.  437,  reviews  several  atrophic  affections 
and  gives  numerous  references  and  some  illustrations). 

2  Duhring,  "Undescribed  Form  of  Atrophy  of  the  Hair  of  the  Beard,"  Amer. 
Jour.  Med.  Sci.,  July,  1878  (with  illustration). 

3  Rush  ton  Parker,  Brit.  Med.  Jour.,  1888,  ii,  p.  1335  (with  illustration). 

4  Hyde  and  Montgomery,  Diseases  of  the  Skin. 


974  DISEASES   OF   THE  APPENDAGES 

other  hand,  almost  all  the  hairs  may  show  more  or  less  involvement. 
The  hair  is  usually  noted  to  be  dry  and  sometimes  is  of  slightly  irregular 
contour. 

Exclusive  of  the  cases  (symptomatic  fragilitas  crinium)  due  to  ring- 
worm and  favus,  in  which  the  short  and  broken-off  hairs  are  affected, 
nothing  is  really  known  as  to  the  cause  of  the  affection.  The  patients 
seem  in  good  health.  Kaposi's  idea  that  it  is  owing  to  the  distance  the 
end  is  from  the  source  of  nutrition  scarcely  holds  when  we  know  that 
sometimes  the  process  is  not  limited  to  the  longer  hairs,  and,  moreover, 
occasionally  the  same  condition  takes  place  in  the  middle  of  the  shaft, 
and  indeed  at  the  root-end — at  the  very  point  of  nutritive  supply. 
Gamberini  thinks  it  due  to  lack  of  care  and  excessive  length,  but  these  are 
not  always  factors.  Examinations  of  the  bulb  show  some  to  be  normal 
and  some  atrophied — the  latter  was  especially  noted  in  Duhring's  case, 
and  the  medulla  was  nowhere  normal,  and  the  cortical  substance  in  the 
narrowed  portion  brittle  and  dry. 

Treatment. — As  in  all  diseases  of  the  skin,  the  general  health  should 
receive  attention  if  there  are  any  indications  pointing  toward  the  neces- 
sity for  such.  When  involving  the  shaft  or  ends  the  hairs  should  be 
clipped  off  just  below  the  cleft  part.  Singeing,  so  often  resorted  to,  is 
damaging.  The  scalp  and  hair  should  be  kept  clean;  if  shampooing  is 
frequently  necessary,  a  little  vaselin  should  be  rubbed  into  the  scalp 
afterward.  If  there  is  a  marked  disposition  to  dryness  and  splitting 
up,  a  little  oiliness,  imparted  by  a  trifling  amount  of  liquid  vaselin  to 
the  hair,  by  oiling  the  comb,  and  then  wiping  off  the  excess,  will  some- 
times lessen  the  tendency.  If  occurring  on  the  bearded  part  at  the  hair- 
ends,  these  should  be  kept  well  clipped;  and  if  on  the  root-ends,  con- 
stant shaving  should  be  practised  for  a  time. 

TRICHORRHEXIS  NODOSA 

This  name,  proposed  by  Kaposi  (1881),  is  employed  for  a  peculiar 
nodose  condition  of  the  hair,  previously  described1  by  Wilson  (tricho- 
clasia,  clastothrix),  and  more  fully  by  Beigel  (1855)  and  Wilks  (1857), 
Beigel2  usually  receiving  the  credit  for  the  first  description.  Devergie3 
(tricoptilose)  published  the  first  French  case.  A  number  of  cases  have 
been  since  reported — in  this  country  by  Sherwell,  Bulkley,  and  others. 
Its  chief  characteristic  is  that  breakage  or  fracture  of  the  hair,  more  or 
less  common  to  all  atrophic  hair  diseases,  always  takes  place  through 
the  nodes.  The  region  commonly  the  site  of  the  affection  is  the  mus- 
tache, although  the  bearded  parts,  scalp,  and  exceptionally  other  regions 
may  show  it.  A  single  hair-shaft  may  be  the  seat  of  several  nodes. 
There  are  no  symptoms  except  the  disfigurement,  and  this  is  perceptible 
only  upon  close  examination.  The  patient  usually  becomes  aware  of 
it  first  by  feeling,  in  handling  the  part,  knotty  swellings  along  the  hair; 

1  Colcott  Fox,  Lancet,  1878,  vol.  ii,  p.  803,  gives  a  review  of  the  earlier  literature; 
Heidingsfeld,  Jour.  Cutan.  Dis.,  June,  1905,  p.  246,  gives  a  resume  of  the  literature, 
with  bibliography. 

-  Beigel,  "Ueber  Auftreibung  und  Bersten  der  Haare,"  Sitzungsbericht  der  Mathem. 
Natunu.  Klasse  der  Wien,  1855,  vol.  xvii,  p.  612. 

3  Devergie,  Annales,  1870-71,  p.  5  (cases  communicated  to  him  by  Lagneau). 


TRICHORRHEXIS  NOD  OS  A  975 

in  other  cases  the  first  discovery  is  that  the  hairs  break  readily  and  that 
there  are  nodular  formations  on  the  shafts  which  suggest  nits.  On 
inspection  it  is  then  noticed  that  the  hair  has  apparently  burst  at  the 
nodular  swelling,  the  fibrillae  being  seemingly  pushed  asunder;  it  has  an 
appearance  as  if  two  small  brushes  had  been  jammed  together  end  to  end. 
If  the  hair  has  completely  broken  off,  which,  when  it  occurs,  is  through 
the  middle  part  of  the  swelling,  there  is  left  a  free  end  of  a  brush-  or 
broom-like  character.  While  the  fracture  is  usually  transverse  through 
the  node,  Jackson  states  that  sometimes,  if  there  is  an  excessive  amount 
of  medulla  present,  it  is  longitudinal.  The  swellings  are  whitish  or  gray- 
ish, and,  when  broken  and  numerous,  the  hair  at  a  little  distance  looks 
as  if  it  had  been  incompletely  singed.  The  shafts  being  markedly  brittle, 
are  readily  broken  by  combing  or  handling.  In  some  hairs  the  splinter- 
ing may  extend  considerably  along  the  length.  The  nodes  are  usually 
most  pronounced  near  the  distal  end,  and  although  several  may  be 
seated  along  the  shaft,  the  hair  remains  in  its  proximal  and  root  portion 
apparently  normal  and  firmly  fixed  in  the  follicle.  Loss  of  hair,  there- 
fore, does  not  ensue,  although  the  condition  is  persistent  and  chronic.1 

Etiology  and  Pathology.— The  disease  is  rare,  and  seen  usually 
in  males.  Raymond,  however,  states  that  he  has  found  it  quite  common 
on  the  genital  hairs  in  women.  As  a  rule,  the  subjects  are  in  good  health. 
I  have  met  with  3  cases — all  physicians.  Various  causes — atrophic  and 
mechanical — have  been  assigned,  but  the  affection,  nevertheless,  remains 
yet  a  mystery,  although  the  belief  is  growing  that  the  nodular  swelling, 
bursting,  and  consequent  fracture  are  due  to  parasitic  invasion.  In 
support  of  this  various  observers — Raymond,2  Hodara,3  Spiegler,4 

r  Jackson,  "Two  Peculiar  Cases  of  Fragilitas  Crinium,"  Jour.  Cutan.  Dis.,  1903,  p. 
473,  records  2  cases,  in  men,  upon  the  scalp,  characterized  by  several  sharply  denned 
patches,  in  which  the  hair  was  short,  broken  off,  and  the  remaining  portion  curled  up 
close  to  the  scalp,  presenting  an  appearance  similar  to  the  curly  hair  of  a  negro.  The 
malady  came  on  suddenly,  each  case  having  been  first  noticed  about  four  or  five  weeks 
before  seeking  advice.  Microscopic  examination  (G.  W.  Wende,  Mewborn)  of  the 
affected  hairs  in  one  of  the  cases  disclosed  many  with  evidences  of  trichorrhexis  nodosa. 
Recovery  ensued,  in  the  course  of  a  few  months,  from  application  of  an  ointment  con- 
sisting of  salicylic  acid  and  tincture  of  benzoin,  each  i  part,  and  neat's-foot  oil,  50  parts, 
together  with  shampooings  with  tar  soap. 

Recently  a  rare  condition  of  pseudoknotting  and  fraying  of  the  hair  has  been  described 
by  Galewsky  (Archiv,  1906,  vol.  Ixxxi,  p.  195;  2  cases),  associated  with  thinning  and 
breaking  of  the  hair-shaft;  the  hair  tending  to  break  off  at  a  knot,  leaving  a  trichorrhexis- 
like  stump;  to  this  he  gave  the  name  triclwnodosis;  i  case  was  a  man,  the  malady  affect- 
ing scalp,  beard  and  pubes,  and  lanugo  hairs  on  trunk;  the  other  case  a  woman,  with 
scalp  hair  only  affected;  Saalfeld  (ibid.,  1906,  vol.  Ixxxii,  p.  245)  records  2  similar  cases, 
the  pubic  hair  being  affected,  and  later  Macleod  (Brit.  Jour.  Derm.,  1907,  p.  40)  has 
described  and  pictured  an  instance  (girl,  scalp  hair)  of  true  "knotting  of  the  hair";  the 
hairs  were  dry  and  lusterless,  their  ends  either  split  up  or  pointed  and  trophic,  occasion- 
ally bent  up  like  a  hook;  the  majority  curled  up  at  the  ends,  forming  one  or  more  loops, 
but  the  most  marked  peculiarity  were  the  small  nodes,  on  considerable  proportion  of  the 
hair,  easily  detected  by  the  naked  eye;  these  were  found  to  be  true  knots,  mostly  single 
knots  and  slip  knots;  Kren  ("Trichonodosis,"  Wien.  klin.  Wochenschr.,  1907,  p.  916; 
abs.  Jour.  Cutan.  Dis.,  1908,  p.  438)  states  that  out  of  54  women,  who  had  skin  diseases, 
whose  scalp  hair  was  carefully  examined,  in  35  nodes  (hair-knotting)  were  found  on  the 
hair,  usually  on  the  scalp  hair  and  about  the  middle  or  terminal  portion  of  the  hair,  some 
times  on  the  body  hair;  several  varieties  of  knots  are  pictured  in  his  paper. 

2  Raymond,  Annales,  1891,  p.  508  (diplococcus). 

3  Hodara,  Monatshefte,  1894,  vol.  xix,  p.  173  (bacillus). 

4  Spiegler,  Wiener  med.  Blatter,  1895,  p.  599  (bacillus — different  from  Hodara's). 


DISEASES   OF   THE  APPENDAGES 


Essen,1  and  Markusfeld2 — claimed  to  have  found  organisms,  and,  with 
the  exception  of  Raymond,  state  that  they  succeeded,  by  experimental 
attempts,  in  producing  the  disease.  Unfortunately,  their  findings  do  not 
all  agree,  and  others  (Neisser,  Jadassohn,  Unna,  Bruhns,  Pringle,  myself, 
and  others)  have  failed  to  discover  bacteriologic  evidence,  although 
personally  I  am  disposed  to  believe  that  it  is  of  microbic  origin. 

Hodara's  investigations  are  based  upon  a  rather  unusual  form  of 
the  disease,  or  possibly  a  distinct,  though  allied,  affection,  which  he  found 
quite  frequent  in  the  scalp  hair  of  women  in  Constantinople.3  The 
nodules  are  extremely  small  and  recognizable  only  upon  close  examina- 
tion. It  is  associated  usually  with  a  splitting-up  of  the  hair,  which  is  the 
first  symptom  noticed,  and  which  is  generally  observed  at  the  ends, 
although  it  may  also  occur  along  the  shaft.  The  hair  frequently  partly 
breaks  at  a  nodule,  on  one  side  of  it,  and  may  thus  form  an  angle,  some- 
times quite  acute,  with  the  main  part  of  the  shaft.  Either  as  the  result 
of  combing  or  brushing  or  spontaneously  the 
hairs  readily  break  off  at  the  joint  thus  made. 
Another  fact  which  seemed  to  support  the 
parasitic  view  also  was  the  observation  by 
Ravenel4  and  myself  that  the  tooth-  and  shav- 
ing-brushes of  one  affected  (Ravenel  himself) 
displayed  the  same  nodosities.  This  was  found 
to  be  so  in  another  instance,  referred  to  in 
Ravenel's  paper.  Since  then  the  same  obser- 
vation has  been  made  by  others  (Blaschko, 
Jadassohn,  Bruhns,  Saalfeld,  and  Barlow).  In 
the  brushes  used  by  Ravenel  and  the  other 
patient  referred  to  bristles  were  found  to  be 
severally  made  up  of  different  hair,  one  of  the 
shaving-brushes  being  what  is  called  in  the 
shops  "badger"  hair,  and  the  other  a  coarser  hair, 
resembling  hog-bristles;  while  the  tooth-brushes 
were  composed  of  still  another  kind.  This 
eliminated  the  suspicion  that  possibly  one  variety 
of  brush  hair  was  subject  to  these  changes.  The  supposition  was  that 
the  brushes  were  infected  by  the  patients,  inasmuch  as  numerous  other 
unused  brushes  examined  did  not  show  this  condition,  nor  did  it  occur 
in  brushes  used  by  our  acquaintances.  A  barber's  brush,  hair  or  mus- 
tache brush,  becoming  thus  affected,  could  readily  be  the  means  of 
conveying  the  disease  to  others.  Unfortunately,  however,  Barlow's5 

1  Essen,  Archive,  1895,  v°l-  xxxiii,  p.  415  (bacillus — different  from  Hodara's). 

2  Markusfeld,  Centralbl.f.  Bacterial,  u.  Parasitenkunde,  1897,  abt.  i,  vol.  xxi,  p.  230 
(bacillus — seemed  similar  to  Spiegler's);  de  Keyser,    Verhandl.    V.  Internal.  Derm. 
Congress,  Berlin,  1904,  vol.  i,  part  3,  p.  437  (micrococcus;  this  paper  gives  bibliography 
to  date). 

3  Hiibner  and  Walter,  "Ueber  Trichorrhexis  nodosa,"  Munchen  Med.  Wochenschr., 
Jan.,  1912,  lix,  p.  140,  have,  however,  reported  an  epidemic  of  the  malady  in  a  school 
for  girls  affecting  scalp  hairs,  of  apparently  the  usual  characters. 

4  M.  P.  Ravenel,  "Trichorrhexis  nodosa — a  Preliminary  Note,"  Medical  News,  Oct. 
29,  1892. 

5_  Barlow,  Munch,  med.  Wochenschr.,  1896,  p.  651  (references,  especially  to  papers 
bearing  upon  bacteriologic  findings,  and  cites  the  various  culture  methods  employed). 


Fig. 


244. — Trichorrhexis 
nodosa. 


TRICHORRHEXIS  NO  DOS  A  977 

investigations  do  not  accord  with  those  by  Ravenel  and  myself,  as  he 
states  that  he  found  the  same  condition  of  the  hairs  in  brushes  used  by 
unaffected  individuals.  This  seems  to  give  some  weight  to  the  belief 
that  these  formations  may  be  produced  mechanically — by  external 
injuries,  as  Wolfberg's,1  Sabouraud's,  Lasseur's,2  and  Adamson's3 
observations  also  indicate. 

On  the  other  hand,  it  is  possible,  as  Beigel  suggested,  that  the  swell- 
ings may  be  due  to  gaseous  disintegration  of  the  medullary  portion 
pushing  out  the  cortical  substance,  which  finally  gives  way.  He  found, 
as  have  also  Unna  and  others,  that  the  first  stage  of  the  formation  con- 
sisted in  spindle-like  swelling  of  the  medulla.  A  microscopic  examination 
discloses  that  the  cortex  is  split  up  into  filaments,  with,  in  some  instances, 
changes  in  the  medullary  portion;  in  others  the  latter  is  practically  un- 
disturbed, or  at  least  remains  unbroken  and  continuous,  although  some- 
what swollen.  Pigment  granules  and  other  granular  debris  are  usually 
to  be  seen  between  the  fibers. 

Prognosis  and  Treatment.— The  disease  is  persistent  and  rebel- 
lious to  treatment,  and  therefore  the  chances  of  permanent  relief  are 
problematic,  although  cases  do  get  well,  but  whether  from  treatment 
or  spontaneously  cannot  be  definitely  stated.  If  the  parasitic  view, 
however,  is  the  correct  one,  persistent  measures  should  finally  be  suc- 
cessful. Almost  all  plans  advised — and  they  are  numerous — are  prac- 
tically in  line  with  this  theory.  If  many  hairs  are  involved,  and  the 
disease  is  of  the  mustache  or  beard,  as  commonly  observed,  frequent 
shaving  and  the  application  daily  of  a  saturated  solution  of  boric  acid, 
with  |  to  i  or  2  grains  (0.035-0.135)  of  corrosive  sublimate  to  the  ounce 
(32.),  can  be  advised.  Weak  corrosive  sublimate  lotions  have,  in  fact, 
been  advocated  by  several,  strongly  by  Sabouraud,  who,  however,  pre- 
scribes it  in  equal  parts  of  ether  and  alcohol  (i:  500),  and  with  5  to  10 
grains  (0.35-0.65)  of  resorcin,  and  2  or  3  grains  (0.135-0.2)  of  tartaric 
acid  to  each  ounce  (32.).  Besnier  and  Roeser  and  Brocq  speak  favorably 
of  extraction  of  the  affected  hairs,  and  touching  the  part  daily  with 
tincture  of  cantharides,  pure  or  diluted,  according  to  the  sensitiveness  of 
the  skin,  and  continuing  the  application  until  the  hair  has  well  appeared. 
A  i  per  cent,  pyrogallol  salve  has  been  commended  by  Jadassohn,  and  a 
2  per  cent,  aqueous  solution  of  the  same  drug  by  Veiel.  Schwimmer 
used  an  ointment  composed  of  15  grains  (i.)  of  sulphur,  y|  grains  (0.5) 
of  zinc  oxid,  and  i\  drams  (10.)  of  unguentum  simplex. 

Crocker  states  that  change  of  climate  has  been  successful.  If  there  is 
anything  in  the  trophoneurotic  theory  of  its  production,  such  remedies 
as  arsenic,  strychnin,  phosphorus,  cod-liver  oil,  etc.,  should  be  pre- 
scribed if  at  all  indicated,  and  ought  theoretically  to  have  some  influence, 
but  experience  does  not  seem  to  afford  substantial  proof  of  their  value. 

1  Wolfberg,  Dentsch.  med.  Wochenschr.,  No.  31,  1884  (himself  the  patient). 

2  Lassueur,  Annales,  1906,  p.  911.     Both  Sabouraud  and  Lassueur  say  that  these 
formations  can  be  produced  on  the  moustache  of  any  one  with  not  too  coarse  hair  by 
frequent  (three  times  daily)  washing  with  soap  and  water  and  the  associated  traumat'sm 
of  this  operation. 

3  Adamson,  Brit.  Jour.  Derm.,  1907,  p.  99  (probably  only,  as  Adamson  indicates, 
when  the  nutrition  of  the  hairs  is  impaired). 

62 


DISEASES   OF   THE  APPENDAGES 

MONILETHRIX 

Synonyms. — Moniliform  or  beaded  hair;  Nodose  hair  (Smith);  Aplasia  pilorum 
intermittens  (Virchow);  Aplasia  pilorum  moniliformis  (Behrend);  Fr.,  Aplasie  monili- 
forme  des  cheveux  et  des  poils  (Hallopeau  and  Leredde) ;  Nodosite  des  poils  (Brocq) ; 
Ger.,  Spindelhaare. 

This  rare  affection  of  the  hair  was  first  described  by  Walter  Smith, 
and  later  by  Bulkley,  McCall  Anderson,  Payne,  Thin,  Lesser,  Hallo- 
peau, Beatty,1  Gilchrist,2  Morrow,3  Ruggles,4  and  others.  The  affection 
is  usually  confined  to  the  scalp,  and  sometimes  to  a  limited  portion  of 
it;  but  exceptionally  it  has  been  noted  on  other  regions  as  well;  in  the 
cases  described  by  Gilchrist,  Morrow,  and  Ruggles  it  was  limited  to  the 
legs.  The  hairs  are  made  up  of  elongated,  fusiform-looking  nodes  and 
connecting,  narrowed  atrophic  portions,  so  that  the  hair  has  a  beaded 
appearance.  In  fact,  it  may  appear  as  if  made  up  of  a  series  of  thin, 
connected  spindles.  The  nodular  parts  are  much  darker  than  the  nar- 
rowed portions,  the  latter  being  almost  colorless,  so  that  the  hair  has  a 
ringed  aspect.  The  whole  shaft  is  involved  from  root  to  the  free  ex- 
tremity. The  hairs  readily  break,  not  at  the  nodes,  as  in  trichorrhexis 
nodosa,  but  at  the  thin  portion,  between  the  nodes,  and  the  broken  end 
of  which  is  frayed  or  brush-like.  So  fragile  are  they  that  most  of  the  hair 
of  the  scalp  or  affected  part  of  it  is  broken  off  near  or  at  the  surface, 


Fig.  245. — Monilethrix — hair  showing  the  breaks  at  the  internodes. 

and  a  variable  degree  of  alopecia  is  noticeable,  slightly  similar  to  the  con- 
ditions observed  in  some  patches  of  ringworm.  This  resemblance  is 
somewhat  added  to  by  a  keratosis  pilaris  of  the  parts,  which  gives  an 
exaggerated  appearance  of  the  stuffed  follicular  openings  or  goose-flesh 
surface  sometimes  observed  in  recent  cases  of  this  latter  disease.  The 
baldness  may  be  finally  quite  extensive.  Cases  vary  somewhat  in  degree, 
some  being  slight,  and  recognizable  only  on  close  inspection,  others  being 
quite  conspicuous.  In  some  of  the  hairs  there  may  be  continuous  thin- 
ning, the  whole  hair  appearing  simply  atrophic. 

Etiology  and  Pathology — The  affection  occurs  in  both  sexes. 
It  begins  in  early  infancy, — in  the  first  year  or  two, — and  is  looked  upon 
as  congenital.  There  are  some  exceptions  to  this  on  record:  among  which 
one  of  Smith's  cases  and  Unna's  case,  and  those  of  Gilchrist,  Morrow, 

1  Beatty  and  Scott,  "Moniliform  Hairs  (Monilethrix),"  Brit.  Jour.  Derm.,  1892, 
p.  171 — an  excellent  review  and  resume  of  all  recorded  cases  to  date,  24  in  number 
(Walter  Smith  (2),  Liveing  (i),  Thin  (i),  Kaposi  (2),  Vidal  (3),  Unna  (i),  Bulkley  (i), 
Bury  (i),  McCall  Anderson  (5),  Luce  (i),  Lesser  (i),  Payne  (2),  Hallopeau  and  Lefevre 
(i),  Arnozan  (i),  Abraham  (i));  and  description  of  an  additional  new  case  by  Beatty. 
Literature  references  are  given. 

2  Gilchrist,  "A  Case  of  Monilethrix,  with  an  Unusual  Distribution,"  Jour.  Cutan. 
Dis.,  1898,  p.  157  (with  illustrations  and  an  analytic  table  of  all  previously  published 
cases  (60),  with  bibliography,  which  includes  cases  recently  exhibited  before  Dermato- 
logical  Society  of  London  by  Colcott  Fox  (1896),  Galloway  (1896),  and  Anderson  (1897). 

3  Morrow,  ibid.,  1899,  p.  41  (case  demonstration). 

4  Ruggles,  ibid.,  1900,  p.  500  (with  illustrations). 


MONILETHRJX  979 

and  Ruggles,  in  which  the  disease  appeared  much  later — in  the  last 
3  cases — all  physicians — in  adolescent  or  adult  life.  McCall  Anderson's 
patients  were  of  a  family  in  which,  in  six  generations,  there  were  14  cases 
among  27  persons;  and  Sabouraud1  records,  in  five  generations  of  a  family, 
17  cases.  Payne's  2  cases  were  brothers,  and  Hallopeau  saw  3  cases  in 
the  same  family,  3  of  whose  relatives  also  were  affected.  Beatty's  case 
was  a  brother  of  one  of  Smith's  patients;  and  2  other  children,  deceased, 
were  affected  similarly,  and  there  was  a  suspicious  history  of  baldness  in 
the  maternal  uncle  and  maternal  grandmother2  While  these  family 
tendencies  point  to  a  hereditary  affection,  the  possibility  of  contagion 
is  one  that  cannot  be  arbitrarily  set  aside,  although  it  is  true  that  a  con- 
tagious disease  would  ordinarily  not  be  such  a  rare  one.  The  common 
view,  however,  is  that  the  disease  is  congenital,  and  that  the  thinned 
portions  of  the  hair-shaft  result  from  some  defective  development,  the 
thicker  or  node-like  portion  being  scarcely,  if  at  all,  beyond  the  normal 
thickness.  There  is  much  less  pigment  in  the  thinner  portion — almost 
nil,  in  fact;  the  cases  of  Lesser,  Gilchrist,  and  Ruggles  were  exceptional 
in  this  respect,  the  thinner  part  being  the  darker  portion.  From  Scott's 
microscopic  investigations  it  would  appear  that  at  one  time  the  papillae 
over  the  entire  affected  region  are  forming  nodes,  at  another  time  inter- 
nodes.  There  is  usually  an  associated  follicular  hyperkeratosis — 
keratosis  pilaris.  In  fact,  Brocq,  Ledermann,3  and  others  think  that  the 
malady  is  closely  related  to  keratosis  pilaris.  Both  Gilchrist  and  Scott 
examined  for  organisms,  but  without  result.  Bonnet  believes  the  nar- 
rowing due  to  an  intermittent  muscular  contraction  around  the  follicle 
just  below  the  point  where  the  sebaceous  gland  empties  into  it,  and 
where  the  young  hair-cells  are  still  soft  and  readily  compressed.  Vir- 
chow,  Kaposi,  and  a  few  others  believe  it  due  to  periodic  aplasia  of  the 
hair.  Nervous  shock  is  said  to  have  given  the  start  to  the  disease  in 
Sabouraud's  series  and  also  in  Unna's  patient. 

Treatment. — Very  little,  if  anything,  is  to  be  hoped  from  treat- 
ment. In  one  area  in  Gilchrist's  case  the  disease,  after  existing  for  a 
number  of  years,  disappeared  spontaneously.  Possibly  in  the  later  ac- 
quired cases,  remedies,  both  constitutional  and  local,  the  former  of  an 
invigorating  and  the  latter  of  a  stimulating  character,  such  as  prescribed 
in  alopecia  areata,  might  be  of  service.  In  all  instances  in  which  the 
hyperkeratosis  element  is  marked,  weak  sulphur  and  salicylic  acid  oint- 
ments should  be  used  to  lessen  or  remove  this. 

1  Sabouraud,  Annales,  1892,  pp.  781  and  830  (good  review  of  the  subject). 

2  At  a  meeting  several  years  ago  of  the  Philadelphia  Dermatological  Society,  I.  M. 
Koeh  exhibited  2  cases — brothers;  and  Dore,  Brit.  Jour.  Derm.,  1911,  p.  in,  presented 
before  the  Dermatological  Section  of  Royal  Soc'y  of  Medicine,  London,  2  cases,  brothers. 
In  the  discussion  Galloway  referred  to  2  cases,  (2  brothers);  as  the  boys  grew  older  the 
affection  became  less  obvious,  being  covered  up  by  the  healthy  hairs.    McMurray  and 
L.  Johnston,  Australasian  Med.  Gaz.,  Jan.  25,  1913,  p.  74,  also  report  a  series — mother 
and  2  children;  observed  in  all  in  the  first  month  of  life. 

3  Ledermann  (3  cases),  Berlin,  klin.  Wochenschr.,  1903,  p.  332. 


980  DISEASES   OF   THE  APPENDAGES 

PIEDRA1 

Synonyms. — Fr.,  Trichomycose  nodulaire  (Juhel-Renoy);  Trichosporosis  nodosa 
(Macleod). 

This  is  a  condition  of  the  hair,  studied  by  Osorio,  Malcolm  Morris, 
Desenne,  Juhel-Renoy,  Lion,  Behrend,  Unna,  and  others,  characterized 
by  minute,  pin-head-sized,  hard  nodules  on  the  hair-shaft — in  appearance 
somewhat  suggestive  of  nits,  but  much  smaller.  It  is  rarely  seen  outside 
of  Cauca,  of  the  United  States  of  Colombia,  South  America,  although  a 
few  instances  (Unna,  Behrend)  have  been  observed  in  Europe.  It  is 
not  improbable  that  the  "chignon  disease"  (chignon  fungus),  essentially 
similar  in  its  symptomatology,  described  by  Beigel2  and  T.  Fox,3  which 
apparently  was  at  one  time  not  infrequent  in  Europe,  is,  as  Behrend  sug- 
gests, identical  with  piedra.  The  affection  is,  with  some  exceptions, 
limited  to  the  scalp  hairs  of  the  native  women;  occasionally,  however,  it 
is  also  noted  in  men,  and  either  on  the  scalp  or  bearded  parts.  Hyde 
and  Montgomery4  briefly  refer  to  a  case  of  a  young  girl  in  whom  the 
nodules  were  seated  on  the  eyelashes  of  both  eyes.  The  nodules  are 
dark-colored,  gritty,  and  almost  stony  hard,  and,  if  numerous,  give  out, 
when  the  hair  is  combed  or  shaken,  a  crepitant  or  rattling  noise.  One 
to  ten  or  more,  irregularly  placed,  may  be  attached  to  a  single  hair-shaft, 
but,  as  a  rule,  the  nearest  to  the  scalp  is  not  less  than  \  inch  dis- 
tant. The  view  held  by  Desenne  and  Morris  that  the  concretions  are 
due  to  fungus  growths  has  been  confirmed  by  Juhel-Renoy,  Behrend, 
Unna,  and  others,  although  some  slight  differences  have  been  observed. 
Unna  and  Trachsler  believe  that  the  formations  may  be  due  to  several 
forms  of  fungus,  the  spores  being  of  various  size.  The  women  of  Cauca 
are  in  the  habit  of  using  a  mucilaginous  oil  for  a  hair-dressing,  and 
Morris  considers  that  this  is  probably  an  important  factor.  The  con- 
cretions may  be  either  on  the  side  of  a  hair  or  may  completely  encompass 
it.  The  structure  of  the  hair  does  not  suffer,  as  in  trichorrhexis  nodosa 
and  monilethrix,  and  this  serves  well  as  a  differential  factor  in  the  diag- 
nosis. Lepothrix  occurs  only  on  the  axillary  and  scrotal  hairs,  nor  is 
it  due  to  a  mycelium-forming  fungus. 

The  treatment  suggested  by  Juhel-Renoy  and  Lion,  based  upon 
their  culture  experiments,  consists  in  frequent  washings  with  hot  corrosive 
sublimate  solution,  i :  1000,  the  hot  water  softening  the  nodules  and  per- 
mitting thorough  penetration.  The  same  plans  used  for  softening  and 
detaching  nits  can  also  be  employed. 

1  Literature:  Malcolm  Morris,  London  Pathol.  Soc'y's  Trans.,  1879,  v°l-  x***  P- 
441;  Med.  Times  and  Gaz.,  1879,  i,  p.  409  (with  discussion);  Desenne,  Compt.  rend, 
de  I'Acad.  des  Sci.,  1878,  vol.  Ixxxvii,  p.  34 — editorial  abs.  in  Lancet,  1878,  vol.  ii, 
p.  165;  Juhel-Renoy,  Annales,  1888,  p.  777  (illustrations  of  hair  and  fungus);  Juhel- 
Renoy  and  Lion,  ibid.,  1890,  p.  765  (with  culture-tube  illustrations);  G.  Behrend, 
Berlin,  klin.  Wochenschr.,  May  26,  1890,  p.  464;  Unna,  Leunn's  Festschrift,  Berlin, 
1896;  abs.  in  Brit.  Jour.  Derm.,  1876,  p.  in;  Trachsler,  Monatshefle,  1896,  vol.  xxii, 
p.  i  (with  illustrations  of  hair  and  cultures);  Fernet,  Brit.  Jour.  Derm.,  1900,  p.  141 
(fungus  demonstration);  Macleod,  ibid..  1912,  p.  132  (review,  hair  and  fungus  illustra- 
tions, cultures,  and  references);  Dubois.  "Etude  d'  un  Case  de  Trichosporie,  Annales, 
1910,  p.  447  (with  review  and  illustrations). 

2  Beigel,  The  Human  Hair,  p.  in. 

3  T.  Fox,  Jour.  Cutan.  Med.,  1868,  vol.  i,  p.  175  (with  illustrations). 

4  Hyde  and  Montgomery,  Diseases  of  the  Skin. 


TINEA   NODOSA  981 

TINEA  NODOSA 

Under  this  term  Cheadle  and  Morris1  described  an  affection  of  the 
hairs  of  the  bearded  parts  observed  in  a  young  man,  characterized  by 
irregular  nodular  incrustations  along  or  around  the  hair-shaft,  of  a  dull 
brown  or  dark-brown  color.  Crocker2  also  met  with  a  similar  case,  in 
which  it  was  limited  to  one  side  of  the  mustache ;  and  that  described  by 
Thin,3  involving  the  mustache  hairs,  was  possibly  a  similar  or  allied  affec- 
tion, although  the  coating  was  somewhat  continuous  and  free  from  nodose 
elevations.  The  lower  part  of  the  hair  is  usually  free,  the  root  remaining 
healthy  and  unaffected.  The  incrustation  is  found  due  to  a  fungus  made 
up  of  spores  somewhat  smaller  than  those  observed  in  ringworm.  The 
affected  hairs  are  rendered  somewhat  brittle  and  inelastic,  and  tend  to 
break  off  or  split  up,  although,  as  a  rule,  the  fungus  growth  does  not  in- 
vade the  hair  substance. 

In  this  connection,  as  bearing  trifling  resemblance  to  slight  conditions 
of  tinea  nodosa,  the  small,  narrow,  ring-like  sheath  of  sebaceous  and 
epithelial  matter  sometimes  carried  up  from  the  follicle  outlet  by  the 
growth  of  the  hair  can  be  referred  to.  It  is  only  occasionally  observed 
and  usually  in  association  with  moderate  seborrhea.  Examined  hastily 
and  carelessly,  these  formations  might  also  be  mistaken  for  nits.  Allied 
to  this,  too,  is  doubtless  the  case  described  by  Grindon,4  in  which  in  a 
few  limited  regions  of  the  scalp,  in  which  the  skin  was  slightly  red  and 
scaly,  many  of  the  hairs  presented  "along  their  length  peculiar  beaded 
concretions,  grayish  white  in  color,  and  to  the  casual  glance  closely  simu- 
lating the  ova  of  pediculi,  under  low  power  looking  like  casts  of  inspissated 
sebum  three  to  five  times  the  diameter  of  the  shaft,  which  they  com- 
pletely inclosed  like  a  sleeve."  A  careful  investigation  showed  the  affec- 
tion "to  consist  of  an  inflammation  of  the  hair-follicle  characterized 
by  extrusion  of  the  cells  of  a  portion  of  the  root-sheath  proper  en  masse, 
carried  up  with  the  growth  of  the  hair."  It  was  accompanied  by  a  slight 
redness  about  the  follicular  orifice,  and  was  chronic  in  character.  Bei- 
gel5  had  previously  referred  to  this  condition.  This  latter  observer 
considered  that  a  hyperplastic  action,  consequent  on  irritation  or  in- 
flammation, exists  in  the  sheaths  of  the  hair-roots,  producing  an  abnormal 
number  of  cells  which  are  glued  together  and  adhere  to  the  cuticle  of  the 
hair  while  passing  through  the  hair-sac. 

Treatment  of  tinea  nodosa  consists  in  frequent  shaving  or  clipping 
and  the  application  of  a  mild  parasiticide. 

1  Cheadle  and  Morris,  Lancet,  1879,  i,  p.  190  (with  illustration);  Giovannini's  dis- 
ease (Archiv,  1887,  vol.  xiv,  p.  1049 — with  illustrations  and  some  references),  was 
apparently  a  similar  or  allied  condition. 

2  Crocker,  Diseases  of  the  Skin. 

3  Thin,  Lancet,  1882,  ii,  p.  742  (with  illustration);  abs.  in  Jour.  Cutan.  Dis.,  1883, 
p.  188. 

4  Grindon,  "A  Peculiar  Affection  of  the  Hair-follicles,"  Jour.  Cutan.  Dis.,  1897, 
p.  256  (with  illustration). 

5  Beigel,  The  Human  Hair,  1869,  p.  125  (with  illustration  almost  exactly  like  the 
condition  pictured  by  Grindon). 


982  DISEASES   OF   THE   APPENDAGES 

LEPOTHRIX 

Synonym. — Trichomycosis  palmellina  (Pick). 

Lepothrix  is  the  name  given  by  Wilson  to  a  peculiar,  roughly  nodular 
affection  of  the  hairs  of  the  axilla  or  genital  region,  which  had  been  first 
described  by  Paxton.  The  axilla  is  its  usual  site.  The  hairs,  examined 
by  the  naked  eye,  are  found  lusterless,  somewhat  uneven,  and  jagged. 
They  usually  break  readily,  especially  when  dry.  Examined  more  closely, 
with  some  magnification,  they  appear  irregularly  nodular,  the  nodular 
masses  being  arranged  continuously  along  the  whole  length  of  the  shaft, 
or  in  clumps  here  and  there,  but  not  encompassing  the  whole  surface  of  the 
hair.  The  accumulation  increases  the  thickness  of  the  hair  considerably. 
They  are  small,  grayish-yellow  to  yellowish-red,  rough  concretions, 
their  outer  edge  directed  upward  toward  the  end  of  the  hair-shaft.  This 
seems  to  be  due  to  the  fact  that  the  cells  of  the  cuticle,  which,  shingle-like, 
overlap  in  this  direction,  are  probably  loosened  or  softened  by  the  heat, 
moisture,  and  sebaceous  and  sweat  secretions  of  the  part,  and  the  bacteria 
of  which  the  concretions  are  composed  find  a  convenient  place  to  lodge 
and  multiply.  They  are  firmly  attached  to  the  hair,  a  bacterial  secretion 
probably  forming  a  hard,  gluey  mass  of  which  the  concretions  are  partly 
made  up.  An  added  micrococcus  in  the  axilla  is  occasionally  observed, 
which  gives  the  concretions  the  red  color,  and  by  which  also  the  sweat  is 
rendered  of  the  same  tinge  (Pick,  Balzer,  Barthelemy,  and  others); 
the  same  concretions  are  seen  on  the  scrotal  hairs  without  the  red  color 
(Crocker).  It  is  a  rare  affection  according  to  ordinary  observations  or 
statistics,  but  both  Behrend  and  Crocker  consider  it  quite  common,  but 
as  it  seldom  gives  rise  to  trouble,  advice  is  not  sought,  or  affected  individ- 
uals may  remain  unconscious  of  its  existence.  Behrend  states  that  it 
exists  to  some  degree  in  20  per  cent,  of  all  people  The  disease  has  been 
investigated  by  Behrend,  Payne,  Patterson,  Eisner,  Sonnenberg,1  Cas- 
tellani,  and  others,  and  the  concretions  found  to  be  due  to  parasitic 
growths;  the  last-named  observer  has  noted  several  varieties.2  Appar- 
ently, however,  there  is  some  difference  in  the  findings. 

The  condition  is  persistent  and  it  is  rebellious  to  treatment.  Fre- 
quent washings  with  soap  and  water  and  the  application  of  antiseptic 
lotions,  such  as  one  of  corrosive  sublimate,  i :  2000  up  to  i :  500,  are 
employed.  Castellani  advises  dabbing  the  hair  two  or  three  times  daily, 
with  a  2  per  cent,  solution  of  formalin  in  spirit;  and  applying  at  night  a 
2  per  cent,  sulphur  ointment.  A  preliminary  shaving  of  the  parts  has 
also  been  advised. 

1  Sonnenburg,  Monatshefle,  1898,  vol.  xxvii,  p.  538  (with  review  of  the  subject  and 
literature  references) ;  see  also  literature  references  under  red  sweat. 

2  Castellani,  Brit.  Jour.  Derm.,  1911,  p.  341  and  1913,  p.  14,  describes  three  varieties 
in  the  axillary  regions,  found  in  the  hot  damp  district  of  Ceylon — trichomycosis  flava, 
trichomycosis  nigra,  and  trichomycosis  rubra — but  the  formations  are  of  rather  soft 
consistency,  and  easily  removed  from  the  hairs  by  scraping.     It  is  quite  common  in 
Ceylon.     He  ascribes  the  yellow  variety  to  a  bacillary-like  fungus,  probably  a  strepto- 
thrix  or  a  microsporoides;  the  pigmentation  in  the  black  and  red  varieties  is  caused  by 
coccus-like  organisms,  which  grow  on  the  hair  in  symbiosis  with  the  fungus.     He 
considered  these  several  varieties  as  closely  allied  to  lepothrix,  as  above  described. 
The  papers  are  illustrated. 


CANITIES  983 


Synonyms. — Grayness  of  the  hair;  Gray  hair;  Whiteness  of  the  hair;  Atrophy 
of  the  hair  pigment;  Trichonosis  discolor;  Poliosis;  Poliothrix;  Hoariness. 

Symptoms. — Canities,  or  graying  of  the  hair,  may  be  congen- 
ital or  acquired,  usually  the  latter.  Congenital  grayness  is  somewhat 
rare,  and  almost  invariably  is  observed  limited  to  one  or  several  tufts  or 
patches  on  the  scalp;  exceptionally  general  grayness  or  whiteness  is  met 
with,  but  is  then  merely  a  part  of  that  condition  known  as  albinism,  and 
which  is  described  elsewhere.  In  congenital  patchy  canities  there  is 
often  a  striking  hereditary  history,  the  affection  (so-called  poliosis  cir- 
cumscripta  hereditaria)  extending  through  several  generations,  as  in  the 
examples  recorded  by  Godlee,1  Morgan,2  Strieker,3  and  others. 

Acquired  canities,  or  graying  of  the  hair,  is  most  commonly  a  con- 
sequence of  advancing  years  (canities  senilis),  although  it  is  also  ob- 
served in  young  and  middle-aged  adults  (canities  praematura).  In 
most  instances  the  development  is  a  gradual  one.  It  may  either  involve 
all  the  hairs,  or  practically  so,  a  slow  and  scarcely  perceptible  progress 
toward  general  grayness  taking  place;  or,  what  is  probably  more  usual, 
scattered  hairs  first  showing  the  change,  new  ones  being  added  to  these, 
and  so  until  all  are  involved  in  the  process.  In  other  instances  certain 
parts  of  the  scalp  show  the  depigmentation  first,  especially  toward  the 
temporal  region,  and,  indeed,  several  parts  may  gradually  grow  gray, 
while  others  remain  but  little  changed  from  the  original  color.  Various 
conditions  are,  therefore,  observed,  from  those  of  localized  areas  to  more 
or  less  general,  and  from  slight  blanching  to  complete  grayness  or  white- 
ness. As  described  in  alopecia  areata,  the  new-growing  hairs  in  that 
disease  are  light  colored,  and  sometimes  remain  as  whitish  locks  for  some 
time  or  almost  indefinitely.  Blanching  also  not  infrequently  ensues  in 
the  hairs  of  vitiligo  patches.  In  ordinary  graying  of  the  hair  the  loss 
of  pigment  takes  place,  as  a  rule,  slowly,  and  the  hairs  are  often  noted, 
on  close  examination,  to  be  speckled  with  gray  and  various  shades  from 
this  to  the  original  color.  The  blanching  is  probably  most  commonly 
noted,  in  the  beginning,  at  the  new-growing  portion,  although  excep- 
tionally the  distal  ends  exhibit  the  graying  changes  first.  In  some 
instances,  too,  after  a  certain  degree  of  grayness  or  gray  sprinkling  has 
ensued,  it  is  apparently  stationary  for  a  time,  at  least;  as  a  rule,  however, 
the  blanching  is  progressive,  though  it  may  be  scarcely  perceptible  from 
month  to  month.  The  scalp  hairs  are  usually  the  first  to  show  the  gray- 
ing tendency;  later  the  bearded  parts  share  in  the  blanching,  although 
considerable  "time  often  elapses  after  the  beginning  scalp  grayness  before 
the  beard  change  is  especially  observable.  On  the  other  hand,  in  some 
instances  the  bearded  parts  suffer  first.  Still  later  the  eyebrows,  and 
finally  the  other  general  surface  hairs,  may  undergo  depigmentation  also, 
but  it  is  ordinarily  slight  and  often  long  deferred. 

The  question  of  the  possibility  of  sudden  graying  of  the  hair  is  one 
that  has  been  considerably  discussed,  and  still  has  many  doubters, 

1  Godlee,  Med.  Times  and  Gas.,  1884,  i,  p.  180  (four  generations). 

2  Morgan,  Brit.  Med.  Jour.,  1890,  ii,  p.  85  (four  generations). 

3  Strieker,  Virchow's  Archiv,  1878,  vol.  Ixxiii,  p.  623  (six  generations). 


984  DISEASES   OF  THE  APPENDAGES 

but  the  various  instances  reported  by  competent  observers  indicate 
that  such  can  take  place.  Apart  from  historic  cases,  such  as  Henry  IV,  of 
France,  Marie  Antoinette^  and  a  few  others,  which,  however,  must,  I 
believe,  be  accepted  with  considerable  reservation  as  to  striking  sudden- 
ness, there  are  now  to  be  found  in  medical  literature  a  number  of  examples 
in  which  the  change  to  grayness  was  noted  to  occur  within  the  space  of  a 
few  hours  or  days  (Landois,  Raymond,  Laycock,  Brown-Sequard,  and 
others).1 

Ringed  Hair  (Synonyms:  Pili  annulati  (Karsch) ;  Leukotrichia  annu- 
laris;  Trichonosis  versicolor;  Fr.,  Canitie  annellee;  Ger.,  Ringelhaare) .— 
Ringed  hair,  or  ring-like  grayness,  is  an  extremely  rare  condition,  first 
described  by  Karsch,2  and  subsequently  by  E.  Wilson,3  characterized 
by  alternate  narrow,  ring-like,  white  and  pigmented  bands,  the  lat- 
ter usually  being  the  normal  color  of  the  hair,  whereas  the  gray  or 
white  segments  result  from  some  obscure  pathologic  changes  or  from 
intermittent  arrest  of  the  pigment-producing  process.  The  bands  are 
usually  extremely  narrow — in  Wilson's  case  the  white  segment  being 
about  TW  of  an  inch  in  width,  and  the  dark  or  normal  segment  about 
twice  as  broad.  In  Karsch's  patient,  and  also  in  the  2  observed  by 
Crocker4  and  the  i  by  Unna,5  the  pigmented  and  decolorized  parts  were 
somewhat  irregular.  Bray  ton6  recently  reported  i,  and  Galloway7  2 
instances,  similar  to  the  uniform  ring  type  described  by  Wilson.  McCall 
Anderson's8  case  was  also  regular  in  the  band-like  formation,  about  one 
line  in  width,  and  was  observed  in  a  girl  aged  nine  and  a  half,  apparently 
of  short  duration,  and  disappearing  after  cutting  of  the  hair  and  the  use 
of  a  stimulating  pomade.  Excepting  the  ring-like  aspect  detected  on 
close  examination,  the  hairs  show  no  other  changes,  their  shaft  being 
usually  of  normal  and  uniform  thickness;  in  this  respect  it  differs  from 
monilethrix  with  which  it  might  otherwise  be  confounded,  and  further 
also  by  the  fact  that  heredity  seems  to  play  no  part;  in  Galloway's  cases, 
however, — two  brothers  aged  eight  and  ten, — it  appeared  to  have  been 
congenital.  Various  explanations  have  been  given  for  this  peculiar 
condition,  but  beyond  that  it  seems  attributable  to  the  presence  of  gas- 
eous material  or  air-bubbles  nothing  definite  is  known.  In  the  reported 
instances — but  several  in  number — the  affection  involved  the  scalp  hair, 
with  the  exception  of  one  of  Crocker's  cases,  in  which  the  mustache  was 
the  part  affected  and  existed  conjointly  with  trichorrhexis  nodosa. 

Landois,  "Das  plotzlich  ergrauende  Haupthaar,"  Virchow's  Archiv,  1866,  vol. 
xxxv>  P-  575  (patient  with  delirium  tremens — hair  changed  in  one  night);  Raymond, 
Revue  de  Med.,  1882,  ii,  p.  770  (woman — as  a  result  of  sudden  financial  disaster — 
changed  in  one  night,  and  subsequently  fell  out) ;  Laycock,  Brit,  and  For.  Med.-Chir. 
Review,  1861,  vol.  i,  p.  458  (a  Sepoy,  turned  gray  in  one-half  hour);  Brown-Sequard, 
Archives  de  Physiol.,  1869,  p.  442  (noticed  that  several  of  his  own  beard  hairs  daily 
changed  to  white). 

2  Karsch,  quoted  by  Landois,  loc.  cit. 

3  E.  Wilson,  Trans.  Royal  Soc'y  London,  1867,  vol.  xv,  p.  406. 

4  Crocker,  Diseases  of  the  Skin  (i  case);  Brit.  Jour.  Derm.,  1893,  p.  175  (second 
case). 

5  Unna,  Histo  pathology,  p.  1046. 

8  Brayton,  Indiana  Med.  Jour.,  1897-98,  vol.  xvi,  p.  10. 

7  Galloway,  Brit.  Jour.  Derm.,  1896,  p.  437  (case  demonstrations). 

8  McCall  Anderson,  Diseases  of  the  Skin. 


CANHIES  985 

Other  Color  Changes. — In  connection  with  canities  the  other  color 
changes,  in  some  instances  spontaneously,  in  others  as  the  result  of  the 
ingestion  or  local  action  of  a  few  drugs,  which  have  been  exceptionally 
observed,  may  be  referred  to.  In  a  case  described  by  Smythe,1  in  a 
man  aged  forty-seven,  the  hair,  which  was  of  light  color  up  to  the  age  of 
thirty-five,  began  to  gray,  but  not  uniformly,  over  the  scalp;  those  hairs 
which  did  not  undergo  this  change  turned  to  almost  a  jet-black  color; 
at  the  same  time  his  skin  assumed  a  pigmented  hue.  Reinhard2  observed 
periodic  change  of  color  from  a  reddish  blonde  to  a  light  yellow  in  an 
epileptic  idiot  boy  following  violent  outbursts  of  temper,  the  change 
occurring  in  about  two  days,  apparently  beginning  at  the  distal  ends  and 
affecting  almost  all  the  hair,  and  again  returning  to  the  normal  color 
in  the  course  of  a  week  or  so.  A  striking  example  of  change  of  color  re- 
sulting from  drug  ingestion  is  that  reported  by  Prentiss,3  occurring  in  a 
young,  blonde-haired  woman,  with  pyelonephritis  with  anuria,  after  the 
administration  of  pilocarpin  hypodermically,  the  color  change  being  first 
observed  after  the  twelfth  day;  under  the  continued  administration  of 
the  drug  the  hair  gradually  became  almost  a  pure  black,  the  later  pig- 
mentation increasing  even  after  the  pilocarpin  was  stopped.  It  is  not 
impossible  that  the  disease  itself  had  some  influence,  inasmuch  as  no  other 
instance  of  hair  coloration  from  this  drug  has  been  since  reported. 

It  is  well  known  that  severe  illness  or  strong  emotion  is  exceptionally 
responsible  for  color  change  other  than  blanching,  as  in  Reinhard 's 
case,  already  cited,  and  also  in  those  reported  by  Rayer,  Beigel,  and 
Smyly,  quoted  by  Jackson.4  In  2  cases  of  Alibert's  of  hair  fall  after 
fever,  cited  by  Rayer,  in  one  blonde  hair  was  replaced  by  black,  and 
in  the  other  brown  hair  was  replaced  by  red.  Beigel's  case  was  similar 
to  the  former;  and  in  Smyly 's  patient  suppurative  disease  of  the  left 
temporal  bone  was  followed  by  change  of  color  from  a  brownish  to  a 
reddish  yellow  in  the  hair  of  the  opposite  side.  Such  instances  are, 
it  is  true,  exceptional,  but  similar  examples,  though  few  in  number,  are 
to  be  found  in  literature. 

Those  rare  anomalous  cases  of  green  hair,  blue  hair,  and  other  unusual 
colors  encountered  are  due  to  the  local  action  of  chemicals  or  drugs 
coming  in  contact  with  the  hair  either  through  occupations,  as  in  workers 
in  copper,  cobalt,  indigo,  etc.,  or  as  a  result  of  some  medical  or  tonsorial 
application.  Of  the  latter  may  be  mentioned  the  yellowish-red  or  brown 
produced  by  chrysarobin,  the  yellowish  or  yellowish-red  tinge  in  light- 
haired  individuals  following  careless  or  prolonged  use  of  resorcin  hair 
tonics — in  fact,  these  are  in  the  same  class  with  the  ordinary  hair-dyes 
occasionally  resorted  to.  Closely  allied  to  these  is  the  yellowish  tinge 
sometimes  seen  in  jaundice  patients. 

Ktiology. — The  causes  of  canities  have  in  a  measure  already 
been  touched  upon.  Almost  all  cases  are  the  result  of  age,  some  pre- 
maturely. In  the  latter  a  strong  hereditary  tendency  is  usually  noted. 

1  Smythe,  Arch.  Derm.,  1880,  p.  246. 

2  Reinhard,  Virchow's  Archiv,  1884,  vol.  xcv,  p.  337. 

3  Prentiss,  Philada.  Med.  Times,  July  2,  1881,  p.  609. 

4  Jackson,  Diseases  of  the  Hair  and  Scalp,  p.  74. 


986 


DISEASES   OF   THE  APPENDAGES 


Fevers  or  other  serious  illnesses  frequently  are  the  turning-point  toward 
beginning  grayness.  There  is  no  question  but  that  excessive  mental 
work,  prolonged  anxiety,  worry,  nervous  shock,  and  other  nervous  dis- 
turbances have  an  influence  in  some  cases.  Reference  has  already  been 
made  to  instances  of  sudden  blanching  so  produced.  Other  examples 
following  neuralgia,  operations,  etc.,  in  which  the  graying  has  been 
more  or  less  localized,  have  also  been  noted  by  various  observers.  The 
most  important  factors  in  the  general  run  of  cases,  however,  are  heredity 
and  advancing  years.  In  rare  instances,  it  is  true,  an  explanation  of 
the  graying  is  entirely  lacking,  as  in  an  instance  reported  by  Ledermann1 
in  a~man  aged  twenty-four,  in  whom  in  a  space  of  six  weeks  the  hair  of 
the  scalp,  beard,  thorax,  left  axilla,  and  pubis  turned  gray,  the  patient's 
health  being  good  and  no  hereditary  tendency. 

Pathology. — Grayness  is  the  result  of  some  lack  of  pigment 
production  in  the  hair-papilla,  or  due  to  the  presence  of  air  in  the  cortical 
portion;  in  many  cases  both  factors  are  probably  operative.  Pincus2 
states  that  in  the  earliest  stage  of  canities  the  pigment  gradually  leaves 
the  under  layers  of  the  papilla,  and  is  to  be  found  only  in  the  outer 
layers,  and  later  is  produced  only  by  a  portion  of  the  latter,  which  finally, 
in  complete  blanching,  fails  entirely.  Ehrmann,3  who  has  contributed 
valuable  papers  on  the  pigment-producing  process  of  the  skin,  believes, 
on  the  contrary,  that  the  pigment  is  formed,  but  that  there  is  defective 
transmission,  owing  to  the  absence  of  transferring  cells.  Michelson4 
suggests  that  it  might  also  be  assumed  that  it  is  not  the  papilla  which 
has  lost  the  power  of  producing  pigments,  but  the  hair-cells  which  have 
lost  the  capacity  of  imbibing  it,  and  this  pigment,  he  further  adds, 
intended  for  the  hair,  may  be  taken  up  again  and  deposited  elsewhere, 
thus  possibly  accounting  for  the  abundance  of  pigment  in  the  senile  skin. 
It  is  known,  however,  whatever  the  amount  of  pigment  contained  in  the 
iiair,  that  the  color  is  materially  influenced  by  the  quantity  of  air  or  air- 
bubbles  inclosed  in  the  substance  and  cortical  portions.  It  has  been  found 
that  some  gray  hairs  often  contain  considerable  pigment,  but  that  it  is 
obscured  by  air,  especially  in  the  cortical  layers.  Indeed,  Wilson  and 
Landois  have  indicated  that  in  this  fact  is  to  be  found  the  explanation 
of  sudden  blanching — for  some  reason  there  is  a  rapid  formation  or  col- 
lection of  air-bubbles,  especially  between  the  cells  of  the  cortical  layers, 
which  renders  the  hair  opaque  and  white,  the  contained  pigment  being 
obscured. 

Prognosis. — Canities  is  usually  progressive  and  permanent,  al- 
though there  are  exceptional  instances  on  record  where  there  has  been  a 
return  of  color.  For  example,  the  case  quoted  by  Jackson,  of  a  man 
whose  scalp  hair  and  beard  changed  from  black  to  white  and  the  reverse 

1  Ledermann  (case  demonstration  before  Berlin  Derm.  Soc'y),  ref.  in  Annales,  1895, 
p.  697. 

2  Pincus,  Virchow's  Archiv,  1869,  vol.  xlv,  p.  129;  see  also  Archiv,  1872,  vol.  ii, 
p.  i. 

Ehrmann,  Allg.  Wien.  med.  Zeit.,  1884,  p.  331;  Archiv,  1885,  vol.  xii,  p.  507, 
and  1886,  vol.  xiii,  p.  57. 

4  Michelson,  "Anomalies  in  the  Coloration  of  the  Hair,"  Ziemssen's  Handbook  of 
Skin  Diseases,  p.  433. 


ALOPECIA  987 

three  times  in  thirty  years,  the  change  to  gray  being  rapid,  while  that  to 
black  again  requiring  four  or  five  years.  Wilson,1  Leonard,2  and  others 
also  cite  cases  where  there  has  been  a  return  to  the  original  color.  In 
some  instances  of  graying  after  an  acute  disease  and  neuralgia  in  persons 
still  young  the  hair  has  been  noted  to  become  again  pigmented.  These 
all  are,  however,  to  be  considered  as  curiosities  of  dermatology,  the  rule 
of  permanency  in  graying  of  the  hair  being  practically  absolute. 

Treatment. — There  is  really  no  treatment  for  canities,  unless  the 
use  of  hair-dyes  for  its  concealment  can  be  so  called.  In  former  years 
these  were  quite  generally  resorted  to,  but  at  the  present  time  are  entirely 
out  of  fashion.  I  have  never  advised  them,  although  others  have. 
McCall  Anderson3  states  that  a  good  black  can  be  produced  by  the  con- 
joint use  of  a  corrosive  sublimate  solution,  2  grains  (0.135)  to  the  ounce 
(32.),  and  one  of  sodium  hyposulphite,  i  dram  (4.)  to  the  ounce  (32.), 
the  former  being  applied  and  followed  by  the  latter.  The  nitrate  of 
silver  dye  is  perhaps  that  most  commonly  employed;  a  plain  solution, 
i  to  3  per  cent,  strength,  will  produce  a  black  color,  the  hair  being  thor- 
oughly moistened  with  it  and  dried  in  the  sunlight.  Kaposi4  gives  the 
following  formulae:  For  a  black  dye:  fy  Argenti  nitratis,  gr.  Ixxv  (5.); 
plumbi  acetatis,  gr.  xv  (i.);  aquae  cologniensis,  Tltxv  (i.);  aquae  rosae, 
rosae,  q.  s.  ad  f5iij  (96.).  For  a  brown  color:  1$.  Pyrogallol,  gr.  xl  (2.65) ; 
aquae  cologniensis,  TTUxxv  (5.);  aquae  rosae,  5iij  (96.).  Leonard  gives 
the  conjoint  use  of  these  two  solutions — No.  i:  fy  Bismuth,  citrat., 
5j  (32.);  aquae  rosae,  aquae  destillat.,  aa  f5ij  (64.);  alcoholis,  f3v  (20.); 
ammoniae,  q.  s.  No.  2:  fy  Sodii  hyposulphit,  5xij  (48.);  aquae  dest., 
5iv  (128.).  No.  i  is  to  be  applied  in  the  morning  and  No.  2  the  same 
evening. 

ALOPECIA 

Synonyms. — Baldness;  Calvities;  Fr.,  Alopecie;  Ger.,  Alopecie;  Kahlheit;  Haar- 
schwund. 

Definition. — Alopecia  is  a  general  term  applied  to  loss  of  hair, 
which  may  vary  in  extent  from  slight  thinning  to  complete  baldness. 

The  so-called  varieties  are  essentially  based  upon  etiology,  and  are 
known  as  alopecia  congenita,  alopecia  senilis,  alopecia  praematura, 
and  alopecia  areata.  This  last  is  an  entirely  distinct  affection,  presenting 
a  special  symptomatology  of  its  own,  and  differs  in  many  particulars,  and 
is,  therefore,  considered  elsewhere  under  a  separate  heading. 

Alopecia  Congenita  (Alopecia  Adnata).5 — Congenital  alopecia  is  a  rare 
condition  in  which  the  hair  loss  may  be  patchy,  or  the  general  hair  growth 
may  simply  be  scanty,  incompletely  grown,  or  downy  in  character.  In 
exceptional  instances  the  hair  has  been  entirely  wanting,  and  in  such  cases 
it  is  usual  to  find  also  defective  development  of  other  structures,  such 

1  E.  Wilson,  Lectures  on  Dermatology,  London,  1878. 
z  Leonard,  The  Hair,  etc.,  Detroit,  1880. 

3  McCall  Anderson,  Diseases  of  the  Skin,  p.  77. 

4  Kaposi,  Diseases  of  the  Skin,  p.  487. 

5  A  recent  paper  by  Kingsbury,  "Alopecia  Congenita,"  Jour.  Cutan.  Dis.,  1906,  p. 
418,  reporting  3  cases  in  a  family  with  hereditary  tendency  gives  a  resum6  of  many  of  the 
recorded  cases,  with  bibliography. 


DISEASES   OF  THE  APPENDAGES 

as  the  teeth  and  nails,  the  latter  more  rarely.1  Schede2  recorded  2  cases, 
brother  and  sister,  in  whom  the  hair  was  completely  lacking  on  scalp  and 
elsewhere,  and  remained  permanently  so;  they  were  otherwise  healthy, 
as  were  likewise  the  parents  and  their  other  two  children,  and  with  normal 
hair  growth.  As  Michelson3  states,  however,  in  some  of  the  congenital 
cases  there  is  not  a  permanent  arrest  of  hair  growth,  but  merely  delayed, 
the  scalp  after  a  year  or  so  often  becoming  covered  with  downy  growth, 
which  sooner  or  later  may  develop  into  hair  of  normal  thickness;  he  refers 
briefly  to  an  instance  under  his  own  observation,  and  also  one  observed 
by  Luce.  More  frequent,  probably,  are  those  examples  in  which  the 
alopecia  is  only  partial,  and,  according  to  Michelson,  who  briefly  describes 
2  cases,  in  such  instances  growth  is  never  to  be  anticipated.  Audry4 
had  under  observation  a  case  in  which  the  alopecia  followed  the  cranial 
sutures. 

The  fact  that  not  infrequently  the  condition  is  observed  in  brothers 
and  sisters,  an  example  of  which  has  already  been  referred  to,  furnishes 
the  only  known  etiologic  cause — heredity.  Hutchinson's5  observation 
of  congenital  alopecia  of  the  scalp  in  a  boy  aged  three  and  one-half 
years,  whose  mother  had  been  bald  since  the  age  of  six,  primarily  be- 
ginning as  patchy  areas,  is  also  a  suggestive  instance.  As  illustrating 
this  fact  and  other  features  of  this  malady,  the  cases — mother  and  two 
daughters — observed  by  Abraham6  may  be  referred  to:  the  mother  had 
complete  absence  of  hair  from  eyebrows,  eyelids,  arms,  legs,  and  body, 
but  had  a  scanty  supply  on  the  scalp,  pubes,  and  in  the  axillae;  at  birth 
she  had  a  little  down  on  the  head,  but  this  soon  disappeared,  and  she 
remained  absolutely  hairless  until  the  age  of  eighteen  was  reached,  at 
which  time  it  began  to  appear  gradually  on  the  scalp,  axillae,  and  pubes. 
Her  two  children — girls — aged  respectively  five  years  and  fifteen  months, 
were  both  practically  hairless;  the  older  child  was  born  with  a  little  down 
on  scalp,  which  fell  out  when  she  was  about  three  months  old,  and  since 
then  the  alopecia  had  remained  nearly  complete;  the  younger  child  was 
born  with  but  little  real  black  hair,  which  fell  off  at  about  the  same  age, 
and  she  had  remained  completely  without  hair. 

The  pathologic  anatomy  has  been  studied  by  Schede,  Jones,  and 
Aitkens,  but  inasmuch  as  the  cases  vary  considerably,  little  has  been 
learned.  Schede  found,  in  his  older  patient,  that  the  sebaceous  glands 
opened  directly  on  the  skin,  and  that  there  were  no  hair-follicles,  but 
in  the  deeper  layers  of  the  corium  he  found  rudiments  of  such  appear- 

1  Thurnam  reported  (London  Med.  Chir.  Soc'y  Trans.,  1848,  p.  71)  2  cases — cousins 
— who  had  but  little  lanugo  hair  on  scalp  or  general  surface,  and  who  had  but  four  teeth; 
he  also  quotes  additional  cases;  Danz,  quoted  by  Michelson  (Ziemssen's  Handbook), 
saw  2  adults  who  had  never  had  either  hair  or  teeth.     See  also  literature  references  un- 
der Diseases  of  the  Nails. 

2  Schede,  Arckiv  fur  klin.  Chirurg.,  1872,  vol.  xiv,  p.  158  (with  histologic  illustra- 
tions); Kingsbury,  "Alopecia  Congenita,"  Jour.  Cutan.  Dis.,  1906.  p.  419  (3  cases  in  a 
family,  with  illustration  of  cases  and  histologic  cut;  review  and  bibliography);  Hyde, 
"Congenital  Alopecia  as  an  Expression  of  Atavism,"  Jour.  Cutan.  Dis.,  1909,  p.  i 
(several  illustrations,  review,  and  bibliography). 

3  Michelson,  loc.  cit.,  p.  409. 

4  Audry,  Annales,  1893,  p.  899  (with  cuts). 

5  Hutchinson,  London  Med.-Chir.  Soc'y  Trans.,  1886,  p.  473  (case  demonstration). 
•Abraham,  Brit.  Jour.  Derm.,  1895,  p.  162  (case  demonstrations). 


ALOPECIA  989 

ing  as  short,  straight,  or  slightly  convoluted  tubules,  without  percept- 
ible internal  cavity,  their  whole  structure  corresponding  to  the  external 
root-sheath.  Jones  and  Aitkens,  quoted  by  Michelson,  found  the  epi- 
derm  atrophic,  the  cutis  replaced  by  "cord-like  areolar  tissue,  with  inter- 
spersed fat-cells  and  accumulations,  between  which  were  altered  follicles, 
and  here  and  there  indications  of  papillae." 

Alopecia  Senilis. — Senile  alopecia,  as  its  name  implies,  is  that  so  fre- 
quently seen  in  men  developing  in  advancing  years,  being  rather  uncom- 
mon in  women.  It  is  usually  preceded  by  graying  of  the  hair.  It  may 
consist  of  a  general  thinning,  or  more  cpmmonly  of  a  general  thinning 
with  complete  baldness  of  the  vertex.  Pincus  states  that  if  the  latter  its 
starting-point  is  almost  always  at  the  very  summit  or  central  point  of  the 
vertex,  and  then  advances  anteriorly,  and  later  also  laterally  and  pos- 
teriorly. From  this  it  gradually,  and,  as  a  rule,  slowly,  extends,  and  in 
some  instances  involves  a  large  part  of  the  entire  region,  generally  leaving 
a  fringe  of  variable  width,  except  anteriorly,  where  the  baldness  is,  as  a 
rule,  complete.  The  loss  of  the  stiff  hair  is  usually  followed  by  the  ap- 
pearance of  down,  but  this,  for  the  most  part  at  least,  soon  disappears,  and 
with  the  atrophic  thinning  and  partial  or  complete  disappearance  of  vis- 
ible follicular  openings  the  shiny,  billiard-ball  smoothness  more  or  less 
characteristic  of  the  condition  results.  It  is  commonly  believed,  or 
often  alleged,  that  a  certain  amount  of  thinning  of  the  hair  also  is  to  be 
noted  on  other  parts  of  the  body,  and  this  would  seem  to  find  support 
in  the  investigations  by  Pincus  and  Neumann,  which  indicate  that  the 
hair-loss  is  simply  the  result  of  cutaneous  atrophic  changes  concomitant 
with  old  age;  but  this  is  by  no  means  always  the  fact,  for  while  some- 
times observed,  in  most  instances,  on  the  contrary,  advancing  years,  ac- 
cording to  my  own  observations,  which  agree  with  the  views  of  Michelson 
and  Unna,1  show  a  tendency  to  increased  hairiness  on  other  parts — at 
least  on  the  general  body  surface.  As  Unna  rightly  states,  this  tendency 
to  increased  general  hairy  growth  is  observed  in  women  as  well  as  in  men. 
The  anatomic  structure  of  the  skin  in  senile  alopecia  has  been  studied 
chiefly  by  Pincus,  Neumann,  Michelson,  and  Unna.  As  to  be  expected, 
atrophic  changes  are  found,  and  considerable  thinning  of  the  cutis  proper, 
and  also  of  the  hypoderm;  in  fact,  in  its  essential  features  Pincus  found  the 
changes  more  rapid,  but  similar  to  those  observed  in  alopecia  seborrhoica 
(alopecia  pityrodes),  an  opinion  which  Unna  shares,  the  latter  diverging 
somewhat  from  Pincus,  believing  that  there  are  no  differences  further 
than  the  simple  difference  of  age,  and  inclining  to  the  opinion  that  in 
reality  the  condition  is  only  a  relatively  delayed  alopecia  due  to  long- 
standing seborrheic  catarrh.  According  to  Michelson,  the  atrophic 
changes  are  preceded  by  alterations  in  the  blood-vessels,  the  cutaneous 
arteries  being  narrowed  by  a  fibrous  endarteritis,  and  with  a  resulting 
destructive  atrophy  or  destruction  of  the  capillary  network.  Not  much 
change  is  noted  in  the  glandular  structures;  and  Unna  found  a  thick- 
ening of  the  panniculus,  at  the  expense  of  the  thinned  cutis. 

Alopecia  Praematura. — Premature  alopecia  is  conveniently  divided 
etiologically  into  two  varieties — idiopathic  and  symptomatic.  Idio- 
1  Unna,  Histopathology,  p.  1062. 


990  DISEASES   OF   THE  APPENDAGES 

pathic  premature  alopecia  may  be  briefly  described  as  an  alopecia,  for 
the  most  part  similar  to  senile  alopecia,  and  occurring  without  recogniz- 
able cause  beyond  hereditary  influence.  At  first  it  is  noted  that  there 
is  a  good  deal  of  daily  loss,  and  as  this  continues  thinning  is  noticed,  and 
also  that  the  new-growing  hairs  are  less  vigorous.  While,  like  alopecia 
senilis,  it  often  begins  at  the  vertex,  it  frequently  takes  its  start  anteriorly, 
usually  at  the  temple,  and  gradually  extending  backward  in  elliptic  shape, 
encroaching  on  sides  and  the  middle  of  the  scalp,  so  that,  when  well 
advanced,  the  whole  anterior  portion  excepting  a  small  ridge  toward 
the  ears  and  a  tongue-like  projection  in  the  middle  is  completely  bald. 
Not  infrequently  it  thins  both  centrally  and  in  the  forehead  region,  and 
in  occasional  instances  almost  the  entire  scalp  may  be  denuded  of  hair. 
As  in  other  forms  or  varieties,  slight  or  moderate  downy  growth  takes 
the  place  of  the  normal  hair,  but  this,  with  the  exception  of  a  scarcely 
perceptible  tuft  here  and  there,  also  often  disappears.  In  some  instances 
a  seborrhea  is  added,  or  goes  hand  in  hand  with  the  hair  fall,  although  such 
cases  usually  belong  to  the  symptomatic  type,  the  alopecia  being  due  to 
the  seborrhea.  Alopecia  praematura  idiopathica  presents  itself,  as  a  rule, 
between  the  ages  of  twenty  and  thirty-five,  and  chiefly  in  men,  occa- 
sional cases  only  being  observed  in  women.  It  is,  as  already  stated, 
without  recognizable  cause  except  heredity.  Family  influence  is  almost 
always  noted,  and  this  is  observed,  too,  in  the  very  form  the  baldness 
takes,  its  starting-point,  extent,  etc.,  being  often  a  counterpart  of  a  father, 
grandfather,  or  near  male  relative.  Various  causes  have  been  assigned, 
such  as  wearing  hats,  especially  a  stiff  hat,  which  binds  the  temporal 
arteries,  and,  I  believe,  with  Jamieson  and  others,  that  this  must  be  con- 
sidered one  of  the  contributing  factors.  In  consequence  also  of  keeping 
the  scalp  sealed  against  the  light  and  air,  contrary  to  nature's  intentions, 
growth  is  impaired,  the  vascular  supply  in  the  skin  about  the  roots  is 
thus  indirectly  lessened,  and  the  hair  suffers  from  want  of  nutritive  ma- 
terial.1 It  is  known,  too,  that  premature  idiopathic  baldness  is  much 
more  common  among  mental  workers,  especially  of  the  professional  class, 
who  are  a  great  part  of  the  time  indoors.  As  corroborative  of  its  greater 
prevalence  among  the  intellectual  and  educated  classes,  Eaton2  found 
in  Boston,  in  church  and  opera-goers,  that  from  40  to  50  per  cent,  of  the 
men  were  bald,  whereas  in  the  audiences  of  cheap  museums  and  prize- 
fights the  average  was  less  than  half  this  percentage.  It  is  in  the  intel- 
lectual and  brain-working  class,  too,  according  to  my  experience,  that  the 
occasional  cases  of  this  variety  of  hair  loss  or  moderate  alopecia  is  noted 
in  women.  Ellinger3  is  inclined  to  the  view,  in  which  opinion  Jackson4 
apparently  concurs,  that  the  habit  of  daily  sousing  the  scalp  with  water 
is  a  possible  contributing  factor,  inasmuch  as  he  found  this  to  be  the  cus- 

1  Harding,  "Exposure  to  the  Sun  as  an  Etiological  Factor  in  Alopecia,"  Jour. 
Cutan.  Dis.,  March,  1911,  p.  167,  is  of  the  opinion,  from  repeated  observations,  that 
the  mode  in  vogue  with  youth  of  the  present  day  of  going  hatless  is  becoming  a  factor 
in  hair  loss. 

-  Eaton,  The  Popular  Science  Monthly,  Oct.,  1886. 

3  Ellinger,  Virchow's  Archiv,  1879,  vol.  Ixxvii,  p.  549. 

4  Jackson,  "Baldness:  What  Can  We  Do  For  It?"  New  York  Med.  Record,  April  7, 
1887. 


ALOPECIA  991 

torn  of  85  per  cent,  of  his  patients.  Various  other  causes  are  often  named, 
but,  after  all,  in  these  cases  the  strongest  factor  is  heredity.  Pincus1 
ascribes  this  variety  of  baldness  to  the  fact  that  in  certain  families  there 
is  a  distinct  tendency  to  sclerosis  of  the  connective  tissue  underlying  the 
aponeurosis  of  the  occipitofrontalis  muscle,  in  this  way  gradually  atrophic 
changes  in  the  hair-papillae  ensue,  and  probably  also  compression  and 
restriction  of  the  vascular  supply  as  well;  in  fact  in  occasional  instances 
of  decided  general  scalp  hair  thinning  or  more  or  less  baldness  the  skin  is 
somewhat  hide-bound,  moderately  sclerodermic  with  variable  atrophy.2 
Symptomatic  premature  alopecia,  in  contradistinction  to  the  idio- 
pathic  variety,  has  a  recognizable  cause,  and  this  may  be  widely  dif- 
ferent in  the  various  cases.  The  hair  loss  takes  place  either  gradually 
or  rapidly,  and  may  be  temporary  or  permanent.  The  final  condition 
may  be  such  as  already  described,  or  it  simply  consists  of  more  or  less 
general  thinning.  After  fevers  or  other  severe  acute  systemic  diseases, 
rapid  hair-shedding  (defluvium  capillorum)  is,  as  well  known,  not  in- 
frequently observed,  but  rarely  progresses  to  baldness.  In  the  active 
stage  of  syphilis,  several  months  or  so  following  the  contraction  of 
the  disease,  there  is  usually  hair  loss  of  the  character  of  thinning  out, 
rather  than  the  production  of  distinct  alopecia;  it  is  commonly  limited 
to  the  scalp,  but  it  is  also  sometimes  observed  on  other  parts  as  well. 
The  hair  loss  occurring  after  these  various  systemic  conditions  is  rarely 
permanent,  both  after  fevers  and  other  acute  constitutional  diseases, 
as  well  as  after  syphilis,  a  regrowth,  with  some  exceptions,  generally 
taking  place  unless  there  is  a  family  tendency  to  baldness,  in  which  event 
it  is  more  likely  to  be  permanent.  The  most  common  cause  of  symp- 
tomatic premature  alopecia,  however,  is  seborrhea  or  the  allied  condition, 
dermatitis  seborrhoica  (alopecia  pityrodes,  alopecia  furfuracea).  Elliot's3 
analysis  of  344  cases  gave  316  in  which  he  attributed  the  hair  fall  to  sebor- 
rheic  disease.  Jackson4  found  this  the  exciting  cause  in  about  75  per  cent, 
of  his  patients,  and  C.  J.  White5  in  79  per  cent.  No  one  can  question 
the  important  etiologic  bearing  of  this  seborrheic  affection,  but  in  many 
instances  doubtless  it  has  the  aid  of  a  hereditary  predisposition.  There 
is  usually  a  general  thinning  of  the  scalp  hair,  usually  more  marked  over 
the  vertex  and  at  the  temporal  regions;  this  may  continue  slowly,  with- 
out producing  perceptible  baldness  for  some  time,  but  sooner  or  later, 
in  most  cases,  the  usual  goal  is  reached.  If  seborrheic  affections  are  to  be 
considered  communicable,  then,  as  the  factor  in  most  cases  of  baldness, 
this  latter  practically  becomes  so  likewise.  In  fact,  in  recent  years,  the 
hint  has  been  made  now  and  then  that  baldness,  irrespective  of  the  sebor- 
rheic factor,  is  possibly  contagious — a  conclusion  that  needs  much  to 
support  it  before  it  can  gain  full  acceptance.  Sabouraud  maintains  that 

1  Pincus,  Berlin,  klin.  Wochenschr.,  1883,  p.  645. 

2  Sutton,  Jour.  Cutan.  Dis.,  1912,  p.  471,  describes  3  cases  o.  this  character  in  women 
and  suggests  the  name  "alopecia  indurata  atrophica." 

3  Elliot,  "A  Further  Study  of  Alopecia  Prematura,  and  its  Most  Frequent  Cause, 
Eczema  Seborrhoicum,"  New  York  Med.  Jour.,  1895,  vol.  Ixii,  p.  525. 

4  Jackson,  'Loss  of  Hair:  A  Clinical  Study  Founded  on  Three  Hundred  Private 
Cases,"  Trans.  Amer.  Derm.  Assoc.for  ipoo,  p.  50. 

6  C.  J.  White,  "Alopecia  and  Seborrhcea,"  Jour.  Amer.  Med.  Assoc.,  Sept.  24,  1910, 
p.  1074. 


992 


DISEASES   OF   THE  APPENDAGES 


the  essential  factor  in  practically  all  cases  of  baldness  is  his  microbacillus 
of  seborrhea.  Other  diseases  of  the  scalp  which  are  followed  by  loss  of 
hair,  usually  circumscribed  or  partial  in  character,  are  chronic  and  per- 
sistent eczema,  psoriasis,  erysipelas,  folliculitis  decalvans,  lupus  eryth- 
ematosus,  ringworm,  favus,  and  late  atrophic  or  ulcerative  syphilo- 
dermata.  Eczema  and  psoriasis  are  rarely  attended  by  any  pronounced 
hair  loss,  and  only,  as  a  rule,  after  long  continuance;  and  after  their  cure 
the  hair  usually  regrows;  that  following  erysipelas  is  seldom  permanent. 
In  ringworm  the  hair  loss  is  temporary;  in  favus,  in  which  destruction 
and  atrophy  of  the  follicles  frequently  result,  the  loss  is  never  entirely 
made  up.  The  destructive  syphilodermata,  lupus  erythematosus,  and 
folliculitis  decalvans  bring  about  follicular  destruction,  and  naturally  the 
effect  is  lasting.  Other  diseases,  usually  of  rare  occurrence,  such  as 
morphea,  leprosy,  etc.,  may  also  be  -followed  by  permanent  hair  loss  in 
the  areas  involved. 

Prognosis. — The  prognosis  has  been  touched  upon  in  speaking 
of  the  individual  varieties.  Exceptional  cases  of  congenital  alopecia 
finally  present  permanent  growth,  although  most  are  hopeless.  There 
is,  moreover,  no  hope  in  senile  alopecia,  and  but  little  in  pure  uncompli- 
cated and  apparently  causeless  cases  of  idiopathic  premature  alopecia, 
especially  if  the  hereditary  tendency  is  pronounced.  Much  can  be  done 
in  the  symptomatic  forms,  and  if  the  element  of  heredity  is  lacking,  a 
regrowth  is  not  unusual,  certainly  worth  trying  for;  indeed,  all  cases  of 
hair  falling  or  lost  hair,  except  those  in  which  distinct  atrophic  changes 
are  evident,  as  shown  by  a  thinning  and  stretched-looking  and  bound- 
down  condition  of  the  skin  and  a  partial  or  complete  obliteration  of  the 
follicular  openings,  are  worth  an  effort,  if  not  to  cure,  certainly  toward 
the  prevention  of  further  loss.  An  opinion  as  to  regrowth  should,  how- 
ever, in  all  cases  be  given  with  a  good  deal  of  reserve.  The  hair  thinning 
following  the  acute  systemic  diseases  and  active  syphilis  will  usually 
look  after  itself,  although  much  more  rapidly  and  more  certainly  under 
treatment.  The  custom  of  shaving  the  scalp  after  fevers  is  absolutely 
unnecessary,  barbarous,  and  without  common  sense  to  support  it.  Re- 
peated shaving,  at  intervals  of  a  few  days,  and  for  one  or  two  months, 
might  possibly  stimulate  growth,  but  a  single  operation  does  nothing 
except  to  disfigure  and  grieve  the  victim  and  enrich  the  wig-makers. 
Another  custom  may  also  be  mentioned  here,  and  that  is  the  practice 
of  singeing,  alleged  "to  seal  up  the  hair  and  prevent  the  outflow  of  the 
hair  strength  or  nutrition";  this  is  not  only  a  wholly  useless  measure, 
solely  benefiting  the  tonsorial  establishments,  but  it  has  no  scientific 
basis,  and  is  damaging  to  the  hair  for  an  inch  or  more  up  beyond  the  ends 
to  which  the  heat  is  applied.  It  needs  only  to  be  mentioned,  therefore, 
to  be  condemned. 

Treatment. — In  the  treatment  of  hair  loss,  both  the  state  of  the 
patient's  general  health  and  the  scalp  must  be  considered.  There  are 
really  no  specifics  as  to  constitutional  remedies,  although  it  has  seemed 
to  me  that  in  some  instances  arsenic,  fluidextract  of  jaborandi,  or  pilo- 
carpin,  and  sulphur  in  small  doses— 2  or  3  grains  (0.135-0.2)  three  times 
daily — have  an  influence.  Of  the  general  tonics,  when  indicated,  arsenic, 


ALOPECIA  993 

strychnin,  iron,  and  cod-liver  oil  and  the  hypophosphites  need  only  be 
mentioned.  The  external  treatment  is  the  essential  part  of  the  manage- 
ment. In  cases  in  which  seborrhea  or  dermatitis  seborrhoica  is  the  cause 
or  is  present,  treatment  (q.  z>.)  is  to  be  directed  against  that  alone,  and 
when  this  is  removed,  the  usual  applications  for  uncomplicated  cases  of 
hair  loss  can  be  resorted  to  to  stimulate  new  growth.  Various  applica- 
tions are  in  favor  for  this  purpose,  often  failing,  however,  in  accomplish- 
ing the  end.  Most  of  the  remedies  used  in  seborrhea  and  seborrheic 
dermatitis  are  also  often  valuable,  as  hair  tonics,  especially  the  resorcin 
lotions,  one  containing  15  to  30  grains  (i.-2.)  to  the  ounce  (32.)  of  water, 
of  i  part  of  alcohol  and  3  of  water,  or  alcohol  alone;  if  the  former,  then 
with  2  or  3  minims  (0.135-0.2)  of  glycerin;  if  alcohol,  the  same  quantity 
of  castor  oil  to  the  ounce  (32.).  Carbolic  acid  can  also  be  often  added 
to  advantage,  in  the  proportion  of  5  to  10  grains  (0.33-0.65)  to  the  ounce 
32.).  A  caution  is  necessary  as  to.  resorcin;  it  should  not  be  used  ex- 
cept cautiously,  scantily,  and  for  a  short  time,  in  those  of  white  or  gray 
hair,  as  this  drug  undergoes  change  of  color,  and  often  gives  the  hair  in 
such  cases  a  dingy  or  dirty  yellowish  tinge.  If  used  carefully  and  to  the 
scalp  only,  keeping  it  off  of  the  hair,  this  does  not  result  so  readily. 
Indeed,  in  all  instances  remedies  are  to  be  employed  sparingly,  as  most 
of  them  are  dark  colored  and  stain.  Both  Elliot  and  C.  J.  White  speak 
well  of: 

fy     Hydrarg.  chlorid.  corros.,  gr.  i-ij  (0.066-0.12); 

Euresol,  3H4-); 

Spts.  formicarum,  f3ij-iv  (8.-i6.) 

Ol.  ricini,"  ITJJXXX-XC  (2.-6.); 

Spts.  vini  rect.,  q.s.  ad  f5iv  (120.). 

Another  compound  lotion  often  valuable  is:  !$.  Resorcin.,  5j  (4.); 
quininae  (alkaloid),  gr.  xv  (i.);  ol.  ricini,  TTLx-xxx  (0.65-2.);  alcohol,  ad 
fSiv  (128.).  In  those  of  very  light  or  gray  hair  the  resorcin  can  be 
omitted.  An  excellent  stimulating  tonic,  long  in  general  use,  is  one  con- 
taining 2  to  4  drams  (8.-i6.)  of  tincture  of  cantharides,  4  to  8  drams 
(i6.-32.)  of  tincture  of  capsicum,  20  to  60  minims  (1.35-4.)  of  castor 
oil,  and  alcohol  to  make  4  ounces;  or  the  oil  and  alcohol  can  be  replaced 
by  bay-rum. 

Ointments  frequently  do  better  than  lotions,  and  one  that  seems 
to  be  of  aid  is  that  composed  of:  T$.  Ac.  salicylici,  gr.  x-xxx  (0.65-2.); 
/5-naphthol,  gr.  xx-lx  (1.35-4.);  sulphur,  praecip.,  3j-ij  (4.-8.);  vaselin, 
q.  s.  ad  3j  (32.).  Another  containing  coal-tar,  a  tarry  preparation  which 
is  free  from  penetrating  and  tenacious  odor,  is:  1$.  Liq.  carbonis  deterg., 
3j-ij  (4--8.);  lanolin,  3iij  (12.);  vaselin,  ad  5j  (32.).  The  ordinary  tars 
are  more  valuable,  but  their  odor  limits  their  use:  Oil  of  cade,  i  or  2 
drams  (4--8.),  2  drams  (8.)  of  lanolin,  and  vaselin  to  make  an  ounce  (32.), 
is  one  of  the  best;  occasionally,  in  warm  weather,  a  small  proportion  of 
paraffin,  to  stiffen  it,  may  be  needed.  Or  this  oil  can  be  used  with  2  or 
3  parts  of  olive  oil,  liquid  vaselin,  or  alcohol,  and  in  this  form  is  sometimes 
preferred.  Heitzmann1  commended  the  crude  oleum  rusci,  made  up 
with  vaselin  and  paraffin,  or  vaselin  and  lanolin,  in  10  to  20  per  cent. 

1  Heitzmann,  Trans.  Amer.  Derm.  Assoc.,  1885,  p.  32. 
63 


OQ4  DISEASES   OF   THE  APPENDAGES 

strength;  this  is  valuable,  but  the  odor  finds  many  objectors.  An  oint- 
ment containing  pilocarpin,  5  to  10  grains  (0.35-0.65)  to  the  ounce  (32.) 
of  vaselin,  can  also  be  used.  Lassar,1  thoroughly  believing  in  the  para- 
sitic character  of  the  alopecias,  advises,  more  especially  for  alopecia 
furfuracea,  the  following:  first  washing  the  scalp  with  tar  soap,  rinsing, 
drying,  and  applying  a  lotion  consisting  of  3  grains  (0.2)  of  corrosive  sub- 
limate and  2  ounces  (64.)  of  alcohol,  and  5  drams  (20.)  each  of  glycerin 
and  cologne  spirits;  the  scalp  is  then  dried,  and  an  alcoholic  solution  of 
naphthol,  0.5  to  i  per  cent,  strength,  is  applied;  and,  finally,  a  1.5  per 
cent,  carbolized  oil.  This  is  to  be  done  at  first  daily.  It  is  a  method 
to  which,  however  efficacious,  the  average  hurried  American  would 
object.  Cottle2  advises:  1$.  Ac.  acetici,  5ij  (8.);  pulv.  boracis,  gr.  xxx 
(2.);  glycerin.,  3iss  (6.);  spts.  vini,  3ij  (8.);  aq.  rosse,  5iv  (128.);  and  also 
fy  Liq.  ammon.  acetat.,  5j  (32.) ;  ammon.  carbonat.,  gr.  xv  (i.) ;  glycerin., 
3iss  (6.);  aq.  sambuci,  ad  3iv  (128.)  Jackson,  while  not  placing  much 
weight  upon  medicinal  applications,  speaks  well  of  an  ointment  of  cold 
cream  as  the  base,  with  10  per  cent,  of  precipitated  sulphur,  and  3  to  5 
per  cent,  of  salicylic  acid;  also  of  one  containing  i  dram  (4.)  of  extract 
of  jaborandi  to  the  ounce  (32.);  and  one  suggested  by  Bronson,  of  20 
grains  (1.35)  of  ammoniated  mercury  and  40  grains  (2.65)  of  calomel  to 
the  ounce  (32.)  of  vaselin.  Davis  has  used  freely  in  alopecias  and  sebor- 
rheic  conditions  and  extols  highly  a  "stearoglycerid  ointment"  as  an 
ointment  base — made  up  of  2  ounces  (64.)  of  stearic  acid,  18  drams  of 
glycerin  (72.),  30  grains  (2.)  of  potassium  carbonate,  12  grains  (0.7) 
of  sodium  borate,  and  34  drams  (136.)  of  water;  incorporating  most 
frequently  sulphur  and  beta-naphthol.  Boric  acid  and  salicylic  acid  are 
incompatible  with  it,  but  the  effect  of  the  latter,  if  desired,  can  be 
obtained  by  incorporating  sodium  salicylate,  20  to  40  grains  (1.3-2.6) 
to  the  ounce  (32.)  The  advantages  over  the  ordinary  bases  are  that 
"it  is  not  greasy,  is  soluble  in  water  and  therefore  easily  washed  off" 
(Davis). 

The  application  selected  should  be  made  for  the  first  few  weeks 
once  daily,  later  three  or  four  times  weekly.  Shampooing  is  necessary 
from  time  to  time,  once  every  one  to  two  or  three  weeks,  depending  in 
great  part  upon  the  care  with  which  the  applications  have  been  made — if 
used  freely  and  carelessly,  a  certain  amount  of  soiling  of  the  hair  the 
sooner  results.  For  shampooing  the  most  satisfactory  soap  is  one  of  boric 
acid  or  the  tincture  of  green  soap,  with  10  to  20  grains  (0.65-1.35)  of 
resorcin  to  the  ounce  (32.). 

There  are  certain  other  measures  to  be  advised  in  these  cases  which 
are  really  often  more  beneficial  than  the  remedial  applications.  The 
scalp  should  be  kept  well  aired,  exposed  to  light  and  air  as  much  as  pos- 
sible. Massage  should  be  practised  once  or  twice  daily,  'and  this  is  best 
done  by  grasping  the  scalp  with  one  or  both  hands  laterally  as  well 
as  anteroposteriorly,  and  with  some  pressure  loosening  the  tissues  from 
the  underlying  parts  and  trying  to  raise  it  into  folds.  It  can  also  be  gone 
over  with  one  hand,  pinching  it  up  with  the  extended  finger-ends,  and  pro- 

1  Lassar,  Monatshefle,  1882,  p.  iri. 

2  Cottle,  The  Hair  in  Health  and  Disease,  London. 


ALOPECIA   ARE  ATA 


995 


ducing  some  vascular  flux  and  a  sense  of  warmth.  Simply  rubbing  the 
scalp  is  of  very  little  use,  and  as  done  with  the  amount  of  friction  put  on 
by  the  average  barber  even  the  good  hair  can  be  rubbed  out.  This 
procedure — massage — which  Jackson  considers  the  only  one  remedy 
worth  the  name  for  stimulating  the  growth  of  hair,  is  one  that  should 
not  be  neglected,  and  should  be  an  essential  part  of  the  treatment 
except  in  cases  where  there  is  seborrhea  or  irritation;  if  the  latter  are 
present,  they  should  at  first  receive  attention,  after  which  massage  can 
be  instituted.  Another  measure  of  therapeutic  importance  is  the  use  of 
electricity.  Two  or  three  times  weekly  or  more  frequently  the  scalp 
can  be  gone  over  for  five  to  ten  minutes  with  a  metallic  brush  or  comb 
attached  to  a  faradic  battery,  using  as  strong  a  current  as  can  be  com- 
fortably borne;  this  often  produces  considerable  temporary  hyperemia 
and  stimulation.  In  addition  to  this  the  static  current  is  also  of  value, 
and,  employed  with  the  crown  a  few  inches  above  the  scalp  for  five 
minutes,  several  times  weekly,  it  has  seemed  to  me  to  be  of  value  in  some 
cases. 

ALOPECIA  AREATA 

Synonyms. — Area  Celsi;  Alopecia  circumscripta;  Porrigo  decalvans;  Tinea  decal- 
vans;  Fr.,  Pelade. 

Definition. — Alopecia  areata  is  an  affection  of  the  hairy  system, 
most  commonly  of  the  scalp,  characterized  by  one  or  more  usually  cir- 
cumscribed, rounded  or  oval  patches  of  complete  baldness,  unattended 
by  any  apparent  alteration  in  the  skin. 

Symptoms. — In  the  large  majority  of  cases  the  malady  is  limited 
to  the  scalp,  but  it  may  invade  other  parts,  as  the  bearded  region,  eye- 
brows, eyelashes,  and,  in 
rare  instances,  the  entire 
surface.  The  disease  be- 
gins either  insidiously  or 
suddenly,  and  usually 
without  any  premonitory 
symptoms.  Occasionally 
patients  note  a  precursory 
feeling  of  slight  irritation 
or  insignificant  itchiness 
at  the  point  at  which 
the  area  is  to  develop, 
and  in  some  instances  the 
appearance  of  the  patches 
is  preceded  for  several 
days  or  a  few  weeks  by 
slight  or  severe  headache, 
itching,  burning,  or  other 
manifestation  of  disturbed  innervation.  As  a  rule,  however,  and 
writh  but  few  exceptions,  the  first  evidence  of  disease  is  the  bald 
patch.  If  developing  suddenly,  the  hair  falls  out  with  great  rapidity, 


Fig.  246. — Alopecia  areata  of  a  common  type,  In 
a  man  of  forty-five,  of  several  months'  duration;  his 
son,  aged  twenty,  had  a  short  time  previously,  accord- 
ing to  the  statement  of  the  patient,  the  same  malady. 


99<5 


DISEASES   OF   THE  APPENDAGES 


in  fact,  almost  as  a  mass  or  lock,  one  or  several  typical  areas 
being  formed  within  a  few  hours.  If  occurring  at  night,  the  patient 
awakes  to  find  a  lock  of  hair  on  the  pillow,  slight  or  consider- 
able in  amount.  Generally,  however,  and  according  to  my  observa- 
tions in  most  instances,  several  days  or  a  few  weeks  elapse  before 
the  bald  spots  are  sufficiently  large  to  become  noticeable.  The  patches 
continue  to  extend  peripherally  for  a  variable  period,  and  then  often 
remain  stationary  for  some  days  or  weeks  or  indefinitely;  if  there  are 
several,  and  in  close  proximity,  from  gradual  extension  they  may  fuse 
together,  and  there  results  a  large,  irregular,  bald  area,  involving  a  con- 
siderable portion  of  the  scalp.  If  the  patches  are  numerous,  or  sometimes 
when  in  small  number  and  spreading  rapidly,  the  whole  scalp  may  be- 
come involved,  and  completely  or  almost  wholly  devoid  of  hair.  In 

average  cases,  however,  there  are 
usually  two  or  three  areas,  and 
these  are  commonly,  when  fully 
developed,  about  i  to  2  inches  in 
diameter. 

The  skin  of  the  affected  areas 
is  apparently  unaltered,  showing 
no  departure  from  the  normal, 
presenting  merely  the  hair  loss, 
usually  with  slight  depression;  it 
is  smooth,  milky  white,  or  some- 
times, in  the  early  period  of  forma- 
tion, faintly  pink;  at  the  peripheral 
part  quite  frequently  some  pro- 
jecting stumps  are  to  be  seen, 
which  may  be  readily  extracted, 
and  which  are  noted  to  be  club- 
shaped,  or,  as  Crocker  says,  bear 
some  resemblance  to  an  exclama- 
tion point,  with  the  broad  .  end 
externally  and  the  small  end  with 
the  constricted  neck  within  the 
follicle.  These  stumps  are  rarely 


Fig.  247. — Alopecia  areata,  showing  a 
large,  elongated  area,  resulting  from  the 
coalescence  of  several  rounded  patches. 
The  patient  was  a  woman  aged  thirty-two, 
in  whom  the  disease  had  lasted  ten  years, 
areas  filling  up  with  regrowth  of  hair,  but 
with  the  recurrence  of  new  patches  at  the 
same  and  other  parts  of  the  scalp  at  irreg- 
ular intervals. 


seen  in  the  clearly  neurotic  cases, 
such  as  follow  fright,  nervous 
shock,  accidents,  etc.  The  bordering  hairs,  if  the  patch  is  still  in 
process  of  advancing,  are  found  to  be  loose  or  relatively  so.  There 
is  no  inflammation  and,  except  as  an  accidental  coincidence,  no  scali- 
ness.  Not  infrequently,  however,  an  oily  seborrhea,  usually  of  trifling 
character,  is  present.  If  the  disease  is  of  considerable  duration,  and  also 
in  some  of  the  recent  cases,  the  follicles  are  observed  to  be  less  prominent 
than  normally,  and  slight  atrophy  or  thinning  sometimes  occurs;  the 
plaques  are  noted  to  be  slightly  depressed,  this  being  more  noticeably 
so  at  the  central  part.  The  malady,  which  is  almost  invariably  chronic, 
may  continue  after  well  developed,  without  exhibiting  progressive  or 
retrogressive  tendency.  As  a  rule,  however,  after  the  lapse  of  a  variable 


ALOPECIA   ARE  ATA 


997 


period  the  patches  cease  to  extend,  the  hairs  at  the  margins  no  longer 
exhibit  any  loosening  tendency,  and  remain  firmly  fixed  in  the  follicles; 
sooner  or  later  a  fine  white  lanugo  or  down  shows  itself,  which  is  generally 
of  extremely  slow  growth,  and  which  may  continue  to  develop  until  it  is 
about  \  inch  or  so  in  length,  and  then  disappoint  expectations  by 
dropping  out  again ;  or  it  may  remain  and  become  stronger,  coarser,  and 
pigmented,  and  the  malady  thus  come  gradually  to  an  end.  Not  in- 
frequently after  growing  for  a  time  the  new  hairs  fall  out,  and  this  may 
happen  once  or  twice  before  finally  recovery  is  permanently  established. 
In  other  patients  weeks  or  months  elapse  before  a  disposition  to  renewal 
of  the  hair  sets  in;  and  occasionally  the  new-grown  hair  remains  unpig- 
mented  for  a  long  while,  and  exceptionally  indefinitely. 

Thus  run  the  majority 
of  cases  encountered.  Occa- 
sionally conjointly  with  or 
independently  of  scalp  in- 
volvement the  male  bearded 
region  is  the  seat  of  one  or 
more  variously  sized  plaques, 
which  follow  about  the  same 
course  as  observed  in  the 
scalp  patches.  In  ^the  less 
favorable  instances,  in  addi- 
tion to  several  or  more 
spreading  scalp  plaques,  the 
eyebrows  are  invaded,  to- 
ward the  outer  side  most 
frequently,  and  a  portion  of 
the  hair  falls  out;  or  the 
greater  part  or  all  may  go. 
In  others,  instead  of  dis- 
tinct bald  spot  the  eye- 
brow is  noted  to  undergo 
general  thinning.  In  more 


Fig.  248. — Alopecia  areata  in  a  young  man 
aged  twenty;  a  wide  band-like  area  involving  the 
outer  portion  of  the  entire  scalp,  beginning  as 
typical  plaques  similar  to  that  now  seen  higher 
up. 


severe  cases  the  lashes  also  fall  out,  in  part  or  completely.  Even 
without  involving  these  regions,  however,  the  scalp  disease  may  be 
of  a  severe  type,  may  extend,  gradually  or  rapidly,  and  sweep  off 
every  hair.  In  other  cases,  still  more  extreme  in  degree,  not  only 
do  the  scalp,  brow,  and  eyelid  regions  become  devoid  of  hair,  but 
the  malady  may  finally  invade  other  parts,  as  the  axilla,  pubic  region, 
and,  in  rare  instances,  the  hairy  growth  of  the  entire  surface,  whether 
lanugo  or  coarse  hair,  disappears  (alopecia  universalis) .  In  such 
instances  there  is  usually  a  cropping-up  here  and  there,  but  most 
frequently  on  the  scalp,  of  sparse,  weak,  downy  hair,  scattered  or 
in  ill-defined  tufts;  these,  however,  often  drop  out,  and  thus  the  case 
continues,  with,  in  such  instances,  very  little,  if  any,  tendency  to 
recovery. 

As  a  less  frequent  clinical  variety  is  that  in  which,  instead  of  well- 
defined  areas,  the  hair  loss  is  in  the  form  of  a  band,  most  commonly 


998 


DISEASES   OF   THE  APPENDAGES 


occurring  about  the  border1  of  the  scalp,  although  the  scalp  region  in 
extreme  instances  of  this  kind  may  be  completely  grooved  with  these 
band-  or  ribbon-like  bald  patches  or  streaks.  Another  variety  is  that 
in  which  there  are  observed  numerous  small  rounded  or  irregularly 
outlined  spots  scattered  over  the  entire  scalp.  In  a  few  instances  there 
may  be  small  irregularly  shaped,  sometimes  ill-defined,  spots  (scarcely 
patches)  scattered  thinly,  occasionally  in  number,  as  to  be  here  and  there 
almost  coalescent,  over  the  scalp,  especially  the  posterior  half;  this 

type,  giving  the  scalp  "a  moth- 
eaten  and  mangy  appearance,"  is 
considered  by  some  observers  as 
always  syphilitic,  but  it  may  occur 
also  independently  of  that  disease. 
In  other  cases — the  universal  form 
—instead  of  distinct  patch-forma- 
tion there  may  be  a  rapid  thinning 
of  the  hair  on  all  parts  and  its 
final  disappearance.  In  my  ex- 
perience, however,  in  these  latter, 
there  are  at  first  one  or  two  well- 
defined  spots,  not  necessarily  large, 
and  these  are  soon  followed,  and 
rapidly,  with  general  thinning  and 
involvement  of  the  hairs  of  the 
entire  surface.  In  another  class 
of  cases,  instead  of  irregular  distri- 
bution of  the  patches,  they  occur 
at  or  near  the  site  of  an  injury  or  in 
the  course  of  a  nerve.  In  still  an- 
other group  are  those  first  described 
by  Neumann  as  alopecia  circum- 
scripta  seu  orbicularis,  in  which 
the  areas  are  small,  quite  distinctly 
depressed,  and  atrophic,  and  usually  anesthetic,  and  run  a  persistent 
and  unfavorable  course. 

In  some  instances  associated  conditions,  neurotic  in  character,  other 
than  those  described  are  noted.  Thus  occasionally  vitiligo  has  been 
observed  (Besnier,  Feulard,  Duhring,  Senator,  Dubreuilh,  Thibierge, 
and  others),2  and  the  vitiligo  areas  themselves  may  be  the  seat  of  the 
alopecia,  as  in  a  case  recorded  by  Eddowes.3  In  several  instances  the 
coexistence  of  these  two  diseases  has  come  under  my  observation,  all 
patients  of  a  nervous  type.  Nail  changes  have  also  been  noted,  the 
nails,  sometimes  of  both  fingers  and  toes,  becoming  white,  spotty,  gran- 

1  Heidingsfeld's  case,  Cincinnati  Lancet-Clinic,  March  3,  1900  (with  illustration),  is 
a  good  example,  associated  with  rounded  areas. 

2  Feulard,  Annales,  1892,  p.  842,  and  1893,  pp.  31  and  1311;  Besnier,  ibid.,  1892, 
p.  845  (discussion  also  refers  to  two  brothers,  one  of  whom  had  vitiligo,  the  other  alo- 
pecia areata);  Dubreuilh,  ibid.,  1893,  p.  375;  Morel  Lavallee,  ibid.,  p.  376;  Thibierge, 
quoted  by  Crocker. 

3  Eddowes,  Bril.  Jour.  Derm.,  1898,  p.  465  (case  demonstration). 


Fig.  249. — Alopecia  areata  in  a  female 
child  aged  four  and  one-half  years,  begin- 
ning when  two  and  one-half  years  old  as 
several  typical  rounded  patches,  which  ex- 
tended, and,  with  new  areas,  swept  off  the 
entire  scalp  hair;  the  hair  of  the  right  eye- 
brow has  also  almost  completely  gone,  and 
that  of  the  left  is  already  thinned;  the  eye- 
lashes are  also  partly  involved. 


ALOPECIA   ARE  ATA 


999 


ular,  several  examples  of  which  have  been  described  by  Darier  and  Le 
Sourd,1  Audry,2  Abraham,3  Crocker,  and  others.4  Morphea,  another 
neurotic  disease,  has  also  been  observed  in  a  few  instances  to  coexist.5 
Quite  recently  a  case  came  under  Eddowes's6  notice  in  which  alopecia, 
general  in  character,  was  later  associated  with  scleroderma  and  vitiligo. 
Its  coexistence  with  disease  of  the  thyroid  has  also  been  exceptionally 
recorded  (Bazin,  Kaposi,  Berliner).7 

Etiology. — The  disease  occurs  in  both  sexes,  and  at  almost  all 
ages.  It  is,  however,  rare  before  the  age  of  five,  and  uncommon  after 
forty,  being  most  frequent  be- 
tween ten  and  twenty-five. 
While  met  with  in  all  stations 
of  life,  there  is  a  preponderance, 
according  to  my  observations, 
among  the  poorer  classes. 
Bulkley  has  found  it  more  com- 
mon in  private  practice.  The 
malady  is  not  so  frequent  in 
our  country — being  somewhat 
less  than  i  case  in  100 — as 
abroad,  more  especially  in 
France  and  England. 

There  are  two  prevailing 
theories  as  to  the  cause  of  the 
disease:  one  of  these  regards  it 
as  parasitic  and  the  other  as 
neurotic.  I  feel  confident  that 


Fig.  250. — Alopecia  areata  in  a  man  of 
thirty,  of  about  one  year's  duration,  showing 
in  some  parts  a  regrowth  of  hair  which  still 
remains  uncolored. 


both  are  right,  as  a  study  of 
the  literature,  taken  with  per- 
sonal observation,  would  indi- 
cate that  there  are,  as  regards 

etiology,    two  varieties — the  contagious  or  parasitic  and  the  non-con- 
tagious or  the  trophoneurotic. 

There  are  numerous  cases  on  record  in  which  the  malady  followed 
nervous  shock,  fright,  accidents,  etc.  Several  years  ago  such  an  example 
came  under  my  observation:  A  man,  while  driving  at  night  in  an  open 
wagon  along  a  country  road,  was  thrown  from  the  vehicle  by  an  over- 
hanging branch,  striking  upon  his  head;  he  was  unconscious  for  some 
hours;  within  a  week  or  ten  days  a  rapidly  spreading  alopecia  areata 
had  denuded  almost  the  entire  scalp,  and  later  involved  the  eyebrows 
and  eyelashes.  A  somewhat  similar  case,  in  which,  however,  the  hair 
loss  occurred  later  after  the  accident,  is  referred  to  by  Stowers.8  In- 

1  Darier  and  Le  Sourd,  Annales,  1898,  p.  1009  (i  case  fully  reported,  and  Darier 
refers  to  6  others). 

2  Audry,  Jour,  des  mal.  cutan.,  1900,  p.  161  (2  cases). 

3  Abraham,  Brit.  Jour.  Derm.,  1900,  p.  100  (case  demonstration). 

4  G.  W.  Wende,  Jour.  Cutan.  Dis.,  1905,  p.  517  (with  illustration  and  review  of  some 
other  cases  reported).  B  Jamieson,  Arch.  Derm.,  1881,  p.  141. 

6  Eddowes,  Brit.  Jour.  Derm.,  1899,  p.  325,  and  1900,  p.  137  (case  demonstrations). 

7  Berliner,  Monatshefte,  1896,  vol.  xxiii,  p.  361. 

8  Stowers,  Brit.  Jour.  Derm.,  1897,  p.  44  (case  demonstration). 


IOOO 


DISEASES   OF   THE  APPENDAGES 


stances  following  injuries  to  the  scalp  are  also  reported  by  Schiitz,1  and 
extensive  development — universal  alopecia — has  been  recently  observed 
after  severe  fright  by  Boisser2  and  Bidon.3  Malcolm  Morris4  mentions 
a  case  in  which  total  alopecia  occurred  in  a  woman  within  forty-eight 
hours  of  receiving  news  of  the  death  of  her  son.  Other  examples  have 
been  referred  to  by  Duhring,  Crocker,  Duckworth,  Steppe,  and  many 

others.  Indeed,  the  clinical 
proof  that  fright,  shock,  acci- 
dents, great  anxiety,  and  men- 
tal worry,  etc.,  are  the  causa- 
tive factors  in  many  cases 
is  overwhelming.5  Jacquet's6 
belief,  that  it  may  be  due  to 
peripheral  irritation  from  de- 
fective teeth  has  not  received 
much  support,  nevertheless  it 
is  not  impossible  that  such 
reflex  irritation  as  from  this 
source  as  well  as  from  defect- 
ive vision,  nasopharyngeal 
disorders,  etc.,  may  be  in- 
fluential in  some  cases.  In 
occasional  instances  of  direct 
scalp  injury  alopecia  does  not 
appear  to  result  so  much  from 
the  effect,  which  may  be  slight, 
upon  the  general  nervous  sys- 
tem, but  occurs  apparently  in 
consequence  of  induced  local  neuritic  changes.  In  2  of  Schiitz's  cases  fol- 
lowing scalp  wounds  the  ensuing  hair  loss  was  in  streaks  diverging  from 

1  Schiitz,  Miinchener  med.  Wochenschr.,  1889,  No.  8,  p.  124. 

2  Boisser,  La  progres  med.,  June  17,  1899,  p.  380. 

3  Bidon,  La  France  med.,  1899,  p.  269. 

4  Malcolm  Morris,  Diseases  of  the  Skin. 

5  Meachen  and  Provis,  Brit.  Jour.  Derm.,  1912,  p.  272  (case  demonstration,  woman 
aged  thirty-one),  record  an  instance  of  alopecia  areata  involving  the  whole  scalp,  in 
which  a  complete  or  almost  complete  regrowth  took  place  during  pregnancy,  and 
relapsing  with  the  establishment  of  the  menses;  this  had  occurred  upon  several  occa- 
sions; her  finger-nails  shared  the  atrophic  changes;  later,  hairs  of  some  other  parts  of 
the  body  were  also  involved;  the  first  signs  of  falling  out  usually  were  noticed  toward  the 
end  of  the  pregnancy.     In  the  discussion  of  this  case  Sequeira  referred  to  an  instance 
in  which  the  loss  was  complete  after  each  of  three  pregnancies,  twice  the  hair  growing  in 
again,  but  after  the  third  the  loss  was  permanent;  and  Leslie  Roberts,  cited  the  case 
of  a  patient  under  his  care  with  total  alopjecia  areata  of  the  scalp,  who  subsequently  mar- 
ried, and  while  pregnant  all  the  hairs  came  rapidly  back. 

6  Jacquet,  "La  pelade  d'origine  dentaire,"  Annales,  1902,  p.  362;  Jones,  "On  Reflex 
Irritation  as  a  Cause  of  Alopecia  Areata,"  Brit.  Jour.  Derm.,  1912,  p.  362.  found  in  his 
examination  of  50  consecutive  cases  of  alopecia  areata  that  carious  teeth  were  quite 
common,  but  not  more  common  than  in  fifty  consecutive  full-haired  individuals,  and 
that,  moreover,  he  found  in  his  analysis  of  cases  in  which  the  bald  areas  were  considered 
in  relation  to  their  nerve-supply  that  there  was  a  great  preponderance  of  areas  in  the 
regions  which  are  not  supplied  by  the  trigeminal  nerve.     On  the  other  hand,  Jourdenet, 
Bull.  Soc.  franc,  de  derm,  et  de  syph.,  April,  1910,  p.  77,  cites  his  own  case  (one  patch)  of 
dental  origin,  and,  Rousseau-Decelle,  ibid.,  Jan.  21,  1909,  gives  resume  and  8  detailed 
cases  of  alleged  dental  origin. 


Fig.  251. — Alopecia  areata,  in  a  man  of 
twenty-eight,  showing  a  rather  common  site  at 
the  nape,  with  small  ill-defined  areas  above 
which  have  partly  filled  in  with  new  hair;  dura- 
tion, some  months. 


ALOPECIA   A  RE  ATA  IOOI 

the  seat  of  injury.  Schiitz  states  that  hair  loss  noted  in  German  students 
from  wounds  received  in  the  sword  duels  doubtless  belongs  fn  the  same 
class.  The  question  of  heredity  in  the  extensive  or  generalized  examples 
has  received  no  attention,  and  yet,  personally,  I  have  observed  2  in- 
stances in  which  the  family  history  disclosed  a  similar  condition  in  a 
member  of  a  preceding  generation.  In  these  2  were  involved  3  cases, 
all  males,  2  of  whom  were  brothers.  The  alopecia,  beginning  as  an  ordi- 
nary case  of  alopecia  areata,  in  all  about  the  age  of  three  or  four  years, 
rapidly  spread,  and  involved  the  entire  scalp,  eyebrows,  and  eyelashes, 
and  the  down  on  some  other  parts.  Inquiry  elicited  the  fact  that  in  both 
instances  a  grand-uncle  had  had  the  same  misfortune,  likewise  develop- 
ing it  early  in  life. 

On  the  other  hand,  one  cannot  deny  that  there  is  also  a  contagious 
or  parasitic  class,  and  this  cause  probably  accounts  for  the  majority  of 
cases,  although  the  contagiousness,  except  under  some  unknown  favoring 
circumstances,  is  usually  extremely  slight.  These  cases  are,  I  believe, 
commonly  represented  by  the  type  with  the  peripheral  stumpy  hair  often 
noticeable  in  the  early  stages,  and  are  generally  characterized  by  one  to 
several  small  or  moderately  sized  areas,  or  by  numerous  scattered  pea- 
to  dime-sized  rounded  or  irregularly  outlined  spots,  as  in  many  of  the 
patients  in  the  epidemics  reported  by  Putnam1  and  Bowen.2  The  spread 
of  the  disease,  starting  from  i  case  in  one  of  these  epidemics,  was  re- 
markable, finally  63  out  of  the  69  girls  in  the  institution  presenting  areas. 
These  are  the  first  and,  so  far  as  my  knowledge  goes,  the  sole  epidemics 
ever  recorded  in  this  country.  In  France  epidemics  have  been  observed 
in  schools  among  children,  and  in  barracks  among  soldiers.  Besnier,3 
Merklen,4  Brocq,5  and  other  French  observers  have  collected  a  number 
of  instances  in  illustration  of  its  contagious  character.  The  towels, 
brushes,  barber-shops,  and  hair-clipping  instruments  were  variously 
thought  to  be  the  means  of  communication.  English  observers  do  not 
share  the  extreme  views  of  the  French  as  to  its  contagiousness,  but 
Crocker6  is  a  strenuous  advocate  of  the  parasitic  and  contagious  character 
of  most  cases;  and  recently  Colcott  Fox,7  although  disclaiming  any  belief 
in  the  contagiousness  of  ordinary  alopecia  areata,  has  reported  a  small 
epidemic  in  a  school.  This  observer  and  also  Pye-Smith  refer  to  several 
instances  of  its  appearance  in  two  or  more  members  of  the  same  family. 
The  Germans  have  been  reluctant  to  accept  this  view,  but  in  late  years 

1  Putnam,  Archives  of  Pediatrics,  August,  1892. 

2  Bowen,  "Two  Epidemics  of  Alopecia  Areata  in  an  Asylum  for  Girls,"  Jour.  Culan. 
Dis.,  1899,  p.  399;  and  also  concerning  first  (Putnam's)  epidemic,  Brit.  Jour.  Derm., 
1894,  p.  80;  and  3  cases  in  same  family  (father  and  2  children),  Jour.  Cutan.  Dis.,  1904, 
p.  37;  and  Boston  Med.  and  Surg.  Jour.,  1912,  vol.  clxv,  p.  937  (citation  of  some  instances 
suggesting  communicability). 

3  Besnier,  "Sur  la  pelade,".  Bull.  Acad.  de  Med.,  1888,  p.  182. 

4  Merklen,  "Etiologie  et  prophylaxis  de  la  Pelade,"  Annales,  1888,  p.  813. 

8  Brocq,  "Clinical  Facts  Bearing  on  the  Contagious  Nature  of  Alopecia  Areata," 
Paris  letter  in  Brit.  Jour.  Derm.,  1889,  p.  479;  Moty  describes,  Annales,  May,  1902,  epi- 
demics occurring  among  troops. 

6  Crocker,  "Alopecia  Areata,  its  Pathology  and  Treatment,"  Lancet,  Feb.  28,  1891, 
Brit.  Jour.  Derm.,  1891,  p.  197:  also  in  treatise  on  Diseases  of  the  Skin. 

1  Colcott  Fox.  "On  a  Small  Epidemic  of  an  Areate  Alopecia,"  Brit.  Jour.  Derm., 
1913,  p.  51  (in  a  school  for  girls — 21  cases  in  all,  ages  from  nine  to  fourteen). 


1002  DISEASES   OF  THE  APPENDAGES 

suggestive  cases  have  been  reported,  and  recently  an  epidemic  of  the 
disease  in  an  asylum  has  been  recorded  by  Ehrenhaft.1  Plonski2  and 
others  have  observed  its  transmission  from  one  member  of  a  family  to 
another.  American  dermatologists3  have,  upon  the  whole,  accepted 
the  view  of  two  classes  of  the  disease,  the  trophoneurotic  and  the  para- 
sitic or  contagious,  but  have  very  little  clinical  evidence  of  the  latter  to 
offer.  Duhring,  Bulkley,  and  a  few  others  hold  strictly  to  its  nervous 
origin.  Crocker  believes  the  disease,  as  exemplified  in  the  majority  of 
cases,  related  to  ringworm,  and  Hutchinson's  theory  as  to  its  occurring 
in  those  who  had  previously  had  ringworm  is  well  known.  Syphilis  has 
been  suggested  as  etiologic  in  some  instances,  but  cannot,  I  believe,  be 
considered  more  than  a  predisposing  or  contributing  factor,  although  there 
is  a  pervading,  but  ill-defined,  acceptance  of  such  cause  in  some  cases 
by  the  general  profession,  notwithstanding  that  there  is  a  remarkable 
dearth  of  reliable  literature  observation  to  support  it.4 

Pathology. — Clinical  observations,  together  with  experimental 
investigation,  leave  but  little  if  any  doubt  that  the  malady  or,  more 
properly  speaking,  the  bald  areas  which  we  are  accustomed  to  place 
under  the  one  class  name  alopecia  areata,  is  the  result  of  at  least  two 
pathologic  processes — trophoneurotic  and  parasitic — and  this  is  the 
opinion  held  by  the  large  majority  of  dermatologists.  In  addition  to  the 
evidence  already  quoted  in  etiology  as  indicating  local  or  general  nerve 
influence,  and  the  occasional  association  of  other  nervous  diseases,  such 
as  vitiligo,  nail  changes,  Graves'  disease,  etc.,  must  be  mentioned  the 
animal  experiments  made  by  Joseph5  and  Moskalenko  and  Ter-Gregory- 
anetz,6  in  which,  in  a  large  proportion,  excision  of  the  second  cervical 
ganglion  was  followed  by  bald  areas  in  the  region  covered  by  the  dis- 
tribution of  the  second  cervical,  the  great  auricular,  and  the  occipital 
nerves.  While  these  experiments  were  also  partly  confirmed  by  Mibelli, 
others — Behrend7  and  Samuel8 — were  not  successful.  The  observations 

1  Ehrenhaft,  Klin.-therap.  Wochenschr.,  1899,  p.  358;  abs.  in  Monatshefte,  1899, 
vol.  xxix,  p.  340. 

2  Plonski,  Dermatolog.  Zeitschrift,  1898,  p.  371. 

3  See  discussion  on  "Alopecia  Areata,"  Trans.  Amer.  Derm.  Assoc.  for  1892.     In  a 
recent  paper,  Jour.  mal.  cutan.,  May,  1906,  Hallopeau  goes  over  the  contagious  grounds 
pretty  thoroughly. 

4  Sabouraud  ("Nouvelles  recherches  sur  1'etiologie  de  le  pelade,"  Annales,  1910,  p. 
545)  and  DuBois  ("Reaction  de  Wassermann  chez  peladiques,"  ibid.,  1910,  p.  555)  are 
both  inclined  to  view  extensive  cases  of  alopecia  areata  as  of  syphilitic  origin,  acquired 
or  hereditary;    the  former  claims  sufficient  success  with  antisj^philitic  remedies  to 
warrant  such  belief,  and  the  latter  in  an  examination  of  14  cases  found  a  positive 
Wassermann  in  n,  although  there  were  no  symptoms  of  either  hereditary  or  acquired 
syphilis;  the  3  negative  cases  presented  only  single  patches.     Sampelayo  ("Actas  Der- 
mo-sinliograficas,"  Feb.  to  March,  1912,  No.  2,  abs.  in  Jour.  Cutan.  Dis.,  Feb.,  1913, 
p.  131)  reports  a  cured  universal  alopecia  areata  occurring  in  the  course  of  a  syphilitic 
infection  cured  after  two  injections  of  salvarsan. 

On  the  other  hand,  Sequeira  (Brit.  Jour.  Derm.,  191.1,  p.  265,  case  demonstration  of 
alopecia  areata  in  a  frank  syphilitic)  states  that  he  applied  the  Wassermann  test  in  a 
number  of  cases  and,  with  the  exception  of  the  case  shown,  always  with  negative 
reaction. 

5M.  Joseph,  Monalshefte,  1886,  p.  483,  and  Centralblatt  med.  Wissensch.,  1886, 
vol.  xxiv,  p.  178. 

6  Moskalenko  and  Ter-Gregoryanetz,  Vratch,  1899,  p.  541;  abs.  in  Jour.  Cutan. 
Dis.,  1899,  p.  432.  7  Behrend,  Virchow's  Archiv,  1889,  vol.  cxvi,  p.  173. 

8  Samuel,  ibid.,  1888,  vol.  cxiv,  p.  378. 


ALOPECIA  ARE  ATA  1 003 

of  Pontoppidan1  and  Bender,2  of  the  development  of  alopecia  patches 
after  operations  on  the  neck,  are  somewhat  confirmatory  of  the  experi- 
mental investigations.  Crocker  believes  the  neurotic  class  can  be  sub- 
divided into  three  divisions — alopecia  universalis,  in  which  general  nerv- 
ous shock  of  various  kinds  is  causative,  and  in  some  of  which  cases  the 
nails  also  suffer;  alopecia  localis  seu  neuritica,  consisting  of  but  few 
patches,  and  presenting  at  the  site  of  an  injury  or  in  the  course  of  a  nerve 
distribution;  alopecia  circumscripta  seu  orbicularis,  characterized  by  the 
marked  depression  of  the  bald  areas,  usually  with  nail  involvement,  and 
of  which  the  causes  are  unrecognized.  As  already  remarked,  his  other 
division  of  the  disease  is  the  largest,  and  which  he  designates  true  alopecia 
areata,  and  which  he  thinks  might  properly  be  called  alopecia  parasitica, 
or  by  the  old  name,  tinea  decalvans.  Leloir,3  in  an  analysis  of  142  cases, 
of  which  92  were  subjected  to  close  inquiry  and  study,  concluded  that 
some  cases  must  be  included  under  a  trophoneurotic  class,  some  under 
a  class  in  which  all  etiologic  factors  seemed  wanting,  and  a  third 
class  which  comprised  the  cases  which  were  contagious.  In  histologic 
examinations  of  a  case  of  the  trophoneurotic  class  the  nerves  pre- 
sented all  signs  of  a  degenerative  atrophic  neuritis  (parenchymatous 
neuritis) . 

While  doubtless  future  investigations  will  finally  disclose  the  true 
parasitic  element  in  the  contagious  class,  that  end  can  scarcely  be  said 
as  yet  to  have  been  reached.  From  time  to  time  a  specific  parasite 
has  been  heralded  by  different  observers,  but,  in  the  main,  that  found 
by  each  observer  was  unlike  that  discovered  by  the  other.  Thus  Gruby4 
has  been  credited  with  the  statement  that  he  had  discovered  it  in  the 
"microsporon  Audouini,"  and  this  may  be  responsible  for  some  cases 
of  bald  plaques,  properly  belonging,  however,  to  the  ringworm  group; 
ringworm  cases,  according  to  Sabouraud,  are  those  which  Gruby  had  in 
mind,  and  not  an  investigation  of  true  alopecia  areata.  Later  Bazin 
(1862)  attributed  the  disease  to  the  "microsporon  decalvans,"  and 
Thin5  still  later  described  another  fungus — minute  schizomycetes — 
which  he  denominated  the  "bacterium  decalvans."  Von  Sehlen6  added 
still  another,  which,  however,  seems  similar  to  that  found  by  Thin. 
Later  Robinson,7  in  an  elaborate  investigation,  found  cocci  in  masses  and 
rows,  and  chiefly  in  the  lymph-spaces  of  the  corium  and  subpapillary 
layer,  and  also  in  the  root-sheaths  of  the  hair  around  the  affected  areas.8 

1  Pontoppidan,  Monatshefte,  1889,  vol.  iii,  p.  51. 

2  Bender,  Dermatolog.  Centralbl.,  October,  1898. 

3  Leloir,  "Etudes  sur  la  pelade,"  Bull,  de  I' Acad.  de  Med.,  1888;  good  abs.  in  Brit. 
Jour.  Derm.,  1889,  p.  67,  and  Monatshefte  (with  some  case  details),  1888,  p.  857. 

4  Gruby,  Compt.  rend.  d.  I' Acad.  des  Sci.,  1843,  p.  301. 

5  Thin,  Trans.  Royal  Soc'y,  1881-82,  vol.  xxxiii,  p.  247. 

6  Von  Sehlen,  Virchow's  Archiv,  1885,  vol.  xcix,  p.  327. 

7  Robinson,  Monatshefte,  "Pathologic  und  Therapie  der  Alopecia  Areata,"  1888,  pp. 
409,  476,  525,  582,  735,  and  771  (an  exhaustive  study  of  the  disease,  with  a  review  of 
the  observations  and  work  of  others,  with  numerous  references).     See  also  his  article  on 
"Alopecia  Areata,"  Morrow's  System,  vol.  iii  (Dermatology),  p.  862. 

8  These  are  now  believed  to  be  an  ordinary  skin  coccus,  and  are  apparently  the  same 
as  found  by  Norman  Walker  and  Marshall-Rockwell  ("Alopecia  Areata;  A  Clinical  and 
Experimental  Study"  (63  cases),  Scot.  Med.  and  Surg.  Jour.,  July,  1901,  p.  12).     Their 
studies  led  them  to  believe  in  its  contagiousness,  and  that  the  nervous  element  in  the 
etiology  of  the  disease  is  greatly  overrated. 


IOO4  DISEASES   OF  THE  APPENDAGES 

More  recently  Sabouraud,1  after  a  careful  and  prolonged  investigation, 
states  the  disease  to  be  caused  by  a  microbacillus,  present  in  the  earliest 
and  progressive  stages  of  the  disease,  and  found  in  the  upper  part  of  the 
follicle,  massed  together  with  the  fatty  secretion  of  the  neighboring  glands 
and  the  vestiges  of  the  dead  hair.  The  bacillus  is  minute,  often  comma- 
shaped,  \-i  u  in  length,  and  \  (t  in  thickness,  lying  side  by  side,  or  occa- 
sionally two  or  three  attached  together.  It  is  the  same  microbacillus 
found  in  the  sebaceous  discharge  of  seborrhoea  oleosa  and  in  comedo, 
which  throws  doubt  upon  its  pathogenic  influence  in  alopecia  areata, 
although  it  is  possible  that  a  different  degree  of  virulence  might  exist, 
or,  in  other  words,  it  is  possible  that  though  morphologically  identical, 
the  toxic  nature  of  their  secretions  may  vary.  Sabouraud  regards  the 
disease  as  a  seborrhoea  oleosa  of  an  acute  type.  This  writer  states  that 
he  has  succeeded  in  experimental  animal  inoculations  with  pure  cultures 
in  producing  characteristic  areas.  Jacquet,2  on  the  contrary,  reports 
negative  results  in  direct  inoculation  experiments. 

Several  investigators  other  than  those  here  named  have  also  dis- 
covered organisms,  among  whom  may  be  mentioned  Bazin,  Eichhorst,3 
Malassez,4  Kazanli',5  Vaillard  and  Vincent,6  Bowen,  Crocker,  and  a 
few  others.7  Vaillard  and  Vincent's  investigations  of  cases  from  an  epi- 
demic affecting  44  soldiers  pointed  to  micrococci  as  the  pathogenic  factor; 
the  germ  was  cultivated  in  the  laboratory,  and  in  experimental  animal 
inoculation  it  was  shown  to  have  peladogenic  properties.  In  Roberts' 
review  he  suggests  the  possibility  that  we  have  to  do  with  three  organ- 
isms which  may  produce  the  disease:  (i)  Bacillary  alopecia  (Sabouraud) ; 

(2)  coccogenous  alopecia  (Vaillard  and  Vincent,  von  Sehlen,  Robinson) ; 

(3)  hyphogenous  alopecia — trichophytic  alopecia,  secondary  to  tricho- 
phytosis  capitis  (Crocker  and  others).     It  is  certainly  true  that  perfectly 
bald  plaques,  indistinguishable  from  ordinary  alopecia  areata,  are  occa- 
sionally seen  as  the  result  of  ringworm  fungi  invasion.     Such  was  Hil- 
lier's8  epidemic,  so  much  quoted  as  examples  of  epidemic  alopecia  areata. 
But  that  the  larger  proportion  of   cases  are  thus  to  be  explained,  as 
Crocker  intimates,  is  not,  I  believe,  sustained  by  the  experience  of  other 
observers. 

So  far  as  one  is  able  to  draw  inference  from  the  somewhat  conflicting 
evidence,  it  seems  probable  that  the  bald  areas,  which  may  be  more 
properly  considered  only  as  a  symptom,  result  from  whatever  influences 
the  hair-growing  process,  be  it  sudden  withdrawal  or  perversion  of  the 

1  Sabouraud,  Annales,  March,  April,  May,  and  June,  1896;  good  review  by  Leslie 
Roberts,  in  Brit.  Jour.  Derm.,  1896,  p.  444;  and  by  Brocq,  in  Paris  letter,  in  Jour. 
Cutan.  Dis.,  1896,  p.  366.     See  also  Sabouraud's  later  paper  (on  fatty  seborrhea  and 
alopecia  areata),  Annales,  de  Vlnstitut  Pasteur,  1897,  p.  134,  and  his  still  more  recent 
book  publication. 

2  Jacquet,  La  presse  med.,  Dec.  12,  1903  (100  attempts  in  6  individuals,  with  scrap- 
ings from  areas  in  several  cases). 

3  Eichhorst,  Virchow's  Archiv,  1879,  v°l-  Ixxviii,  p.  197. 

4  Malassez,  Arch,  de  phys.  norm,  et  path..  1874,  p.  203. 

5  Kazanli,  Vratch,  1888,  p.  763;  abs.  in  Brit.  Jour.  Derm.,  1889,  p.  132. 

6  Vaillard  and  Vincent,  Annales  de  I'Institut  Pasteur,  1890,  vol.  iv,  p.  446. 

7  See  Robinson's  paper,  loc.  cit. 

8  Hillier,  Handbook  of  Skin  Diseases,  p.  286;  also  Lancet,  1864,  ii,  p.  374. 


ALOPECIA   AREATA  IOO5 

innervation  of  the  part  due  to  shock,1  etc.,  to  injury  of  the  cutaneous 
nerves,  to  peripheral  irritation  by  parasites  or  their  toxins,  either  directly 
upon  the  trophic  nerves  or  primarily  upon  the  tissues.  It  was  formerly 
believed  that  no  textural  or  inflammatory  changes  occurred  except  slight 
atrophy  in  old  cases,  and  to  the  unaided  eye  this  seems  usually  true,  but 
histologic  investigations  (Giovannini,  Robinson,  Sabouraud,  Unna, 
Harris,  and  a  few  others)2  show  that  primarily  the  condition  is  an  inflam- 
matory one,  involving  the  corium.  In  7  cases  investigated  by  Robinson 
he  always  found  appearances  of  inflammation,  as  well  as  a  perivascular 
infiltration  with  round  cells;  in  recent  examples  lymph  had  coagulated 
in  the  dilated  lymphatics,  and  some  of  the  larger  and  small  arteries 
contained  thrombi.  In  those  of  longer  standing  thickening  of  the  blood- 
vessels was  always  noted.  Later  the  sebaceous  glands  undergo  atrophy, 
and  later  still  the  fatty  tissue.  Robinson  considers  the  primary  changes 
to  be  in  the  blood-  and  lymph-vessels;  the  subsequent  glandular  atrophy 
to  be  due  to  the  chronic  obliterative  disease  of  the  vessels.  The  fall  of 
hair  in  the  beginning  he  attributes  to  the  acute  thrombotic  closure  of  the 
vessels.  The  inflammatory  process  has  its  seat  in  the  corium,  especially 
in  the  subpapillary  layer.  The  slight  depression  noted  he  believes,  like 
Hutchinson,  to  be  due  to  the  absence  of  the  hair,  and  does  not  agree  with 
Michelson,  who  ascribes  it  to  the  loss  of  fat — this  latter  not  taking  place 
until  late  in  the  disease.  According  to  Giovannini,  an  infiltration  of 
white  blood-corpuscles  around  the  deep  part  of  the  hair-follicle  precedes 
and  accompanies  the  disease,  suggesting  to  him  a  deep-lying  folliculitis, 
the  other  phenomena  being  secondary  to  this  local  leukocytosis.  De- 
generative changes  ensue  in  the  hair-bulb,  and  also  in  the  suprabulbar 
part,  or  the  neck  of  the  hair.3  Similar  changes  are  also  noted  sometimes 
in  the  hair  just  beyond  the  neck  and  follicle,  somewhat  similar  to  the 
fibrillar  breaking-up  noted  in  trichorrhexis  nodosa. 

Diagnosis.— The  malady  with  which  alopecia  areata  is  most 
likely  to  be  confused  is  ringworm,  but  in  the  latter  the  scaliness,  though 
slight,  the  broken-off  or  nibbled-looking  hairs,  incomplete  baldness, 
rather  prominent  follicular  openings,  often  stuffed  with  projecting  debris, 
and  often  visible  inflammatory  signs  distinguish  it  from  alopecia  areata, 
which,  on  the  contrary,  presents  smooth,  scaleless  plaques,  generally 
completely  devoid  of  hair,  and  with  the  follicular  openings  frequently 
less  conspicuous  than  normally.  It  is  the  beginning  and  spreading 
circumscribed  patches  of  alopecia  areata,  with  some  stumps  peripherally, 
which  suggest  ringworm,  but  the  other  differential  features  named,  with 
the  history  of  the  case,  usually  indicating  rapid  development,  will,  as 
a  rule,  suffice  to  reach  a  correct  diagnosis.  The  bald  type  of  ringworm  is 
often  difficult  to  distinguish  from  the  patch  of  alopecia  areata,  but  the 

1  Among  these  can  be,  doubtless,  included  dental  irritation  and,  possibly,  visual 
defects,  but  scarcely  to  the  extent  believed  by  Jacquet  (Annales,  Feb.  and  March,  1902) 
and  Tremolieres  (La  presse  med.,  June  14,  1902,  and  Jan.  i,  1903). 

1  Giovannini,  Annales,  1891,  p.  921;  Robinson,  he.  tit.,  and  Morrow's  System,  vol. 
iii,  p.  865;  Sabouraud,  loc.  cit.;  Unna,  Histopathology ;  Harris,  quoted  by  Crocker, 
Diseases  of  the  Skin,  third  edit.,  p.  1226. 

3  In  addition  to  those  referred  to,  Behrend,  Virchow's  Archiv,  1887,  vol.  cix,  p.  493, 
has  also  investigated  the  hair  changes. 


1006  DISEASES   OF  THE  APPENDAGES 

beginning  features,  and  often  a  history  of  another  case  in  the  family  pre- 
senting the  usual  ringworm  features,  will  be  of  aid.  In  these  instances 
ordinarily  the  first  symptoms  are  distinctly  those  of  ringworm,  later  dis- 
appearing and  leaving  the  confusing  bald  plaque.  In  doubtful  cases 
examination  of  the  border  or  stump-like  hairs  can  be  resorted  to  (see 
Ringworm) .  Another  disease  in  which  plaque-like  hair  loss,  more  or  less 
pronounced,  is  noted,  is  favus,  but  this,  unlike  alopecia  areata,  presents 
crusts,  mild  inflammatory  symptoms,  and  usually  incomplete  baldness. 
If  the  crusts  are  temporarily  wanting,  owing  to  previous  removal  by 
washing,  the  atrophic  or  scar-like  character  of  the  patch,  together  with 
the  history,  will  be  sufficient  to  distinguish  it.  The  bald  areas  of  lupus 
erythematosus,  which  are  more  or  less  cicatricial,  with  follicular  destruc- 
tion and  a  mildly  or  moderately  inflammatory  border,  can  scarcely  be 
confounded  with  alopecia  areata,  in  which  these  features  are  absent. 
The  bald  spot  or  spots  left  on  the  scalp  of  children  of  the  poorer  classes 
from  a  preceding  cutaneous  abscess  or  blind  boil  might,  if  the  case  is 
carelessly  examined  and  considered,  be  mistaken  for  the  disease.  In 
folliculitis  decalvans  the  central  part  of  the  bald  plaque  is  distinctly 
atrophic  or  cicatricial,  and  the  border  shows  follicular  inflammation. 

Prognosis. — The  outlook  for  recovery  in  children  and  young 
adults  in  cases  in  which  but  several  patches  are  present  is  favorable. 
In  such  variety,  too,  in  older  patients,  those  not  over  forty,  the  result 
is  almost  always  a  regrowth.  In  more  extensive  involvement  of  the 
scalp  the  prognosis  in  those  under  twenty  or  thirty  is  usually  good,  but 
in  older  people  an  opinion  is  to  be  given  with  considerable  qualification. 
In  those  instances  involving  scalp,  eyebrows,  and  eyelashes,  if  only 
partial,  and  in  young  individuals,  recovery  may  take  place,  but  it  is 
best  not  to  be  too  positive ;  when  the  hair  fall  on  these  parts  is  complete, 
the  chances  are  much  less  favorable;  in  such  type  in  adults  past  thirty 
the  prognosis  becomes  even  less  hopeful.  In  the  more  or  less  generalized 
cases  of  the  malady  one  cannot  be  too  cautious  in  expressing  an  opinion, 
as  in  but  few  of  these  instances  does  a  regrowth  ever  take  place.  Alopecia 
areata  of  the  bearded  region  usually  runs  a  favorable  course.  A  hopeful 
feature  in  all  instances  of  the  disease  is  the  presence  of  a  downy  growth; 
if  no  tendency  to  such  appearance,  after  some  weeks  or  a  few  months,  is 
manifested,  the  outlook  is  not  so  promising;  and  it  is  still  less  so  if  atrophic 
changes  have  ensued,  and  the  follicular  openings  become  less  and  less 
visible.  In  all  cases  of  the  malady,  however,  the  uncertain  duration 
must  be  borne  in  mind;  several  months,  and  in  some  instances  one  or 
two  years,  may  elapse  before  complete  and  permanent  restoration  of 
hair  takes  place.  The  malady,  moreover,  is  one  in  which  relapses  are 
not  uncommon. 

Treatment. — The  necessity  of  systemic  measures  in  alopecia 
areata  is  somewhat  in  question  at  the  present  day,  owing  to  the  diverse 
views  held  regarding  the  nature  of  the  disease.  Those  who  consider  it  of 
neurotic  origin  place  great  stress  upon  the  value  of  constitutional  treat- 
ment, whereas  those  that  contend  that  the  malady  is  essentially  parasitic 
have  recourse  to  exclusively  local  measures.  Inasmuch  as  it  is  now  gen- 
erally admitted  that  we  have  cases  which  may  be  due  to  one  or  the  other 


ALOPECIA   A  RE  ATA  IOO/ 

of  these  causes,  and  as  in  many  instances  it  would  be  somewhat  difficult 
to  classify  them,  the  safer  course  to  pursue  is  to  prescribe  both  consti- 
tutional and  local  measures;  the  former  having  as  their  object  the  cor- 
rection of  any  defective  condition  of  the  general  health,  and  more  espe- 
cially the  invigoration  of  the  nervous  system,  and  the  local  treatment  hav- 
ing in  view  a  stimulation  of  and  parasiticide  action  upon  the  affected 
areas.  Fortunately  almost  all,  if  not  all,  the  external  remedies  employed 
are  active  parasiticides  as  well  as  stimulants,  and  their  use  meets,  in 
reality,  both  the  neurotic  and  parasitic  views.  While  the  possibility  of 
its  origin  from  peripheral  nerve  irritation  as  from  dental  caries,  defective 
sight,  nasopharyngeal  disorders,  etc.,  is  slight,  nevertheless  such  factors, 
if  present,  should  receive  attention. 

The  principal  remedies  prescribed  in  the  constitutional  treatment 
are  arsenic,  quinin,  mix  vomica,  phosphorus,  pilocarpin,  ferruginous 
tonics,  and  cod-liver  oil,  the  choice  depending  upon  a  study  of  the  in- 
dividual case.  Arsenic  has  been  highly  extolled  by  several  writers,  and 
Duhring1  especially  is  warm  in  praise  of  its  value  in  this  disease ;  it  appears 
to  be  of  distinct  benefit  in  some  cases,  and  more  especially  in  those  which 
are  apparently  truly  neurotic  in  origin.  It  should  be  given  in  moderate 
dosage,  from  3  to  5  drops  (0.2-0.33)  of  Fowler's  solution  or  the  solution 
of  sodium  arsenate  three  times  daily  or  its  equivalent  of  arsenious  acid, 
long  continued.  Nux  vomica  and  ferruginous  tonics  are  also  often  of 
service  either  directly  or  indirectly,  and  can  be  advised  conjointly  with 
the  arsenic.  Pilocarpin  or  the  fluidextract  of  jaborandi  has  had  some 
advocates.  The  former,  in  the  more  extensive  scalp  cases,  injected  sub- 
cutaneously  in  the  affected  part,  in  the  dose  of  -§V  to  iV  of  a  grain  (0.002- 
0.006)  of  the  hydrochlorate,  is,  I  believe,  occasionally  of  some  service; 
Pringle,2  Crocker,3  and  others  have  also  observed  a  beneficial  effect.  In 
debilitated  subjects  the  building-up  influence  of  cod-liver  oil  is  often  of 
marked  value.  The  benefit  from  outdoor  life,  relaxation  from  excessive 
mental  work  or  worry,  is  of  essential  importance  in  the  neurotic  cases. 
Morrow,4  who  is  probably  next  to  Robinson,  among  Americans,  firmest 
in  his  opinion  as  to  the  local  nature  of  the  malady,  believes,  however, 
especially  in  cases  where  the  disease  is  generalized  and  protracted,  the 
effect  of  local  treatment  to  be  materially  aided  and  energized  by  the  ex- 
hibition of  tonics  and  reconstituent  remedies;  and  in  all  cases  where 
there  is  evidence  of  a  loss  of  nerve  tone  he  is  accustomed  to  give  the 
phosphid  of  zinc  and  strychnin,  a  combination  of  phosphorus,  iron,  and 
strychnin,  or  phosphoric  acid  with  strychnin. 

While  constitutional  remedies  are,  therefore,  to  be  prescribed  accord- 
ing to  individual  indications,  with  a  possible  trial  of  arsenic  and  pilocar- 
pin, nevertheless  external  treatment  is  to  be  looked  upon  as  an  essential 
part  in  the  management  of  every  case.  As  some  of  the  cases  are  conta- 
gious, the  same  measures  to  prevent  its  spread  and  communications  as 
suggested  in  ringworm  are  to  be  advised:  the  patient  should  have  his 

1  Duhring,  discussion  in  Trans.  Amer.  Derm.  Assoc.for  1892,  p.  36. 

2  Pringle,  Brit.  Jour.  Derm.,  1898,  p.  198. 

3  Crocker,  Diseases  of  the  Skin. 

4  Morrow,  "The  Treatment  of  Alopecia  Areata — with  Cases,"  Jour.  Cutan.  Dis., 
1891,  p.  381. 


1008  DISEASES   OF   THE  APPENDAGES 

own  towel,  brush,  comb,  etc.,  and  a  weak  sulphur  or  sulphur  and  naphthol 
ointment  or  a  carbolic  acid  wash  applied  to  the  scalp  generally  every 
two  or  three  days ;  and  once  in  five  to  ten  days  the  parts  should  be  washed 
with  the  tincture  of  green  soap  or  with  a  sulphur-naphthol  soap.  The 
object  of  local  treatment  is  twofold — a  stimulation  of  the  part,  promoting 
a  flux  of  blood  and  aiding  the  nutrition  of  the  affected  area,  and  an  inhibi- 
tive  or  destructive  influence  upon  any  possible  pathogenic  parasite  which 
may  be  seated  there.  The  skin  of  the  affected  areas  will  usually  stand 
strong  remedies  and  show  no  irritation  compared  to  that  of  the  imme- 
diately adjacent  skin.  The  choice  and  strength  of  the  application  ad- 
vised will  depend  upon  the  extent  of  the  disease  and  the  frequency  of 
inspection.  The  strong  remedies  can  be  used  from  the  start  in  cases 
of  limited  extent,  and  to  small  parts  successively  in  the  more  extensive 
types,  along  with  the  general  application  of  the  milder  remedies.  The 
loose  hairs  of  the  outlying  border  should,  as  suggested  by  Besnier,  Mor- 
row, and  others  be  extracted,  which  can  be  done  by  grasping  the  hairs 
between  the  fingers  and  exerting  gentle  traction,  the  loose  hairs  alone 
coming  out,  while  those  that  are  firm  slip  through  the  fingers.  The 
remedial  application  should  always  be  carried  \  or  \  inch  beyond  the 
patch.  In  extensive  cases  or  with  patients  who  can  be  seen  only  at 
intervals  of  one  or  two  weeks,  the  most  efficient  local  remedies  are: 
ointments  of  tar  and  sulphur,  weakened  and  of  full  strength;  5  to 
15  per  cent,  ,3-naphthol  ointments;  the  tar  oils,  either  pure  or  with 
i  or  2  parts  of  alcohol,  or  in  ointment  form,  from  i  to  3  drams  (4.- 
12.)  to  the  ounce  (32.);  and  stimulating  lotions  containing  varying  pro- 
portions of  tincture  of  cantharides,  tincture  of  capsicum,  aqua  ammoniae, 
or  oil  of  turpentine,  such  as  prescribed  in  ordinary  alopecia.  Of  these 
I  have  most  frequently  prescribed  an  ointment  made  up  of  both  sulphur 
and  naphthol:  fy  Sulphur,  praecip.,  5j~ij  (4--8.);  ,9-naphthol,  gr.  xxx- 
3j  (2.~4.);  lanolin,  3ij  (8.);  vaselin,  q.  s.  ad  3j  (32.);  and  if  the  tar  odor 
is  unobjectionable,  an  oily  application,  composed  of  equal  parts  of  oil 
of  cade,  oil  of  turpentine,  and  olive  oil,  lessening  the  turpentine  if  the 
skin  is  sensitive.  In  addition,  at  each  inspection  of  the  patient  an  area 
of  i  or  2  square  inches  can  be  treated  by  a  strong  application  of  car- 
bolic acid,  chrysarobin,  or  tincture  of  iodin  containing  2  to  4  grains 
(0.135-0.25)  of  biniodid  of  mercury  to  the  ounce  (32.). 

If  there  are  but  two  or  three  areas,  the  stronger  remedies  can  be 
regularly  employed.  Of  these,  I  place  most  faith  in  an  ointment  of 
chrysarobin,  10  to  60  grains  (0.65-4.)  to  the  ounce  (32.)  of  lard 
as  recommended  by  Robinson ;  and  painting  over  the  areas  with  pure 
liquid  carbolic  acid,  as  suggested  by  Bulkley,1  or  a  similar  preparation, 
known  as  trikresol,  recommended  by  MacGowan,2  can  be  used.  If  in 
children  or  those  of  sensitive  skin,  the  carbolic  acid  is  weakened  with  i 
to  3  parts  alcohol.  It  is  to  be  painted  over,  and  then  gently  but  thor- 
oughly rubbed  in.  There  is,  in  some  cases,  considerable  pain,  which, 
however,  as  a  rule,  soon  subsides.  A  good  deal  of  irritation  results,  and 

1  Bulkley,  "A  Therapeutic  Note  on  Alopecia  Areata,"  Jour.  Cutan.  Dis.,  1892,  p.  47. 

2  MacGowan,  "A  New  Agent  for  the  Treatment  of  Alopecia  Areata,"  ibid.,  1899, 
p.  217. 


ALOPECIA   ARE  ATA 

the  skin  gradually  exfoliates.  An  excellent  method  of  applying  chrysaro- 
bin  is  as  a  saturated  solution  in  chloroform,  and  then  over  the  film  re- 
sulting 2  or  3  coatings  of  collodion.  If  the  chrysarobin  ointment  is  used 
only  occasionally,  the  strongest  is  to  be  employed — 60  grains  (4.)  to  the 
ounce  (32.) — and  well  and  energetically  rubbed  in.  It  is  a  remedy  which 
requires  some  caution  (see  Psoriasis).  Another  strong  application  which 
I  have  found  useful  is  one  consisting  of  equal  parts  of  oil  of  turpentine, 
tincture  of  capsicum,  and  tincture  of  cantharides;  it  is  to  be  employed 
with  care,  and  often  needs  weakening  with  almond  or  olive  oil. 

In  addition  to  these  measures  I  now  make  use  of  the  high-frequency 
current,  both  with  the  vacuum  electrode  and  carbon-point,  and  apply  it 
long  enough  to  produce  considerable  reaction.  The  galvanic  current  can 
also  be  applied,  with  an  electrode  pressed  upon  the  patch,  and  the  current 
gradually  increased  by  means  of  a  rheostat  up  to  several  milliamperes. 
Care  must  be  used,  however,  with  this  current  about  the  head,  and  the 
current  increased  cautiously  and  gradually  withdrawn — never  increasing 
or  decreasing  rapidly  or  breaking  it;  a  rheostat  and  a  milliamperemeter 
are  necessities  for  its  proper  application.  I  have  also  seen  good  effects 
in  extensive  cases  from  the  application  of  a  static  current  by  means  of 
the  crown  electrode. 

For  alopecia  areata  of  the  bearded  portions  and  the  eyebrows,  etc., 
the  same  applications  as  advised  for  the  scalp  can  be  employed,  but,  as 
a  rule,  not  more  than  one-half  to  two-thirds  as  strong.  Carbolic  acid,  if 
used,  must  be  diluted  with  several  parts  of  alcohol.  The  sulphur  and 
tar  applications  are  the  most  satisfactory,  all  things  considered.  One 
of  precipitated  sulphur,  3ij  (8.),  salicylic  acid,  gr.  x-xxx  (0.65-2.),  vase- 
lin,  sufficient  to  make  an  ounce  (32.),  is  also  serviceable. 

There  are  many  other  local  stimulating  and  parasiticide  applications 
which  would  probably  be  as  effectual  as  those  mentioned.  Morrow 
— adopting  the  plan  practised  by  French  observers,  Besnier,  Vidal, 
Brocq,  and  others — in  recent  cases,  is  accustomed  to  employ  chrysarobin, 
40  to  50  grains  (2.65-3.35),  with  or  without  10  to  25  grains  (0.65-1.65) 
of  salicylic  acid,  in  the  ounce  (32.)  of  liquor  gutta-perchae  or  lard;  to  be 
applied  every  three  or  four  days  in  sufficient  strength  to  excite  and  main- 
tain a  moderate  dermatitis. 

Hyde  and  Montgomery1  give  the  following  formula,  the  proportions 
of  the  various  ingredients  being  varied  according  to  the  case  and  in- 
dividual peculiarities:  1$.  Ol.  ricini,  f5ss  (16.);  acid,  carbolic.,  3j  (4.); 
tinct.  cantharid.,  f3ss  (16.);  ol.  rosmarin.,  gtt.  xv  (i.);  spts.  vin.  rectif., 
ad  f5iv  (128.).  Jackson2  speaks  well  of  a  pomade  of  jaborandi  made  by 
boiling  down  the  fluid  extract  to  one-half  its  volume,  and  adding  this  to 
4  parts  of  lard;  this  is  to  be  rubbed  in  twice  daily.  He  also  recommends 
a  lotion  of  corrosive  sublimate,  \\  grains  (o.i)  to  the  ounce  (32.)  of  water, 
not  on  account  of  its  parasiticide  qualities,  but  solely  for  its  stimulating 
effect.  Hardaway's3  usual  plan  is  to  blister  the  patches  every  two  weeks 

1  Hyde  and  Montgomery,  Diseases  of  the  Skin. 

2  G.  T.  Jackson,  "Alopecia  Areata:  Its  Etiology  and  Treatment,"  New  York  Med. 
Jour.,  Feb.  20,  1886. 

3  Hardaway,  Manual  of  Skin  Diseases. 

64 


1010  DISEASES   OF  THE  APPENDAGES 

with  acetic  cantharidal  collodion  after  thorough  washing  with  soap  and 
water,  and  in  the  intervals  to  rub  in  morning  and  evening  a  lotion  con- 
sisting of  equal  parts  of  tincture  of  cantharides  and  glycerin;  if  there  are 
several  areas,  and  of  large  extent,  the  vesicant  is  applied  to  one  or  two 
places  only  at  a  time.  Jamieson1  states  that  of  all  the  stimulants  he 
has  used,  the  one  which  has  given  him  the  most  satisfactory  results  has 
been  that  originally  suggested  by  Sir  Erasmus  Wilson:  fy  Liq.  ammon. 
fort.,  chloroformi,  ol.  sesami,  aa  5ss  (16.);  ol.  limonum,  oss  (2.);  spts. 
rosmarini,  ad  f5iv  (128.).  This  is  rubbed  gently  into  the  bald  part  at 
first  once,  and  then,  as  tolerance  becomes  established,  twice  daily,  and 
steadily  persevered  in.  Sabouraud's  plan  is  to  blister  the  patches  and 
then  to  paint  the  denuded  surface  with  5  to  6  per  cent,  solution  of  silver 
nitrate. 

It  will  be  noted  that  all  the  preparations  in  common  use  are  those 
which  possess  both  parasiticide  and  stimulating  properties,  and  to  these 
can  be  added  lactic  acid,  with  which  Rietema,2  Balzer  and  Stoianowitch3 
have  recently  had  good  results,  using  it  with  an  equal  part  of  water,  and 
increasing  the  strength  if  no  positive  irritation  is  produced.  Jersild,4 
of  Finsen's  institute,  Copenhagen,  has  lately  published  his  results  from 
treatment  by  the  concentrated  light  rays,  and  which  he  considered 
satisfactory;  a  daily  exposure  of  an  hour  each,  for  a  period  varying 
from  one  to  seven  or  eight  weeks,  being  required.  For  this  disease 
the  light  from  the  iron  electrode  lamp  would  be  sufficiently  pene- 
trating, and  would  require  but  several  minutes'  application  to  bring 
about  a  decided  reaction;  Jackson5  speaks  of  favorable  influence 
with  the  Piffard  lamp  for  this  purpose.  The  x-ra.y  also  has  advocates, 
with  short  exposure  and  with  intermittent  flashes,  but  has  possi- 
bilities of  making  matters  worse. 

FOLLICULITIS  DECALVANS 

In  recent  years  cases  have  been  reported,6  chiefly  by  French  writers, 
under  the  names  folliculite  epilante  (Quinquaud)  ,7  folliculites  et  peri- 
folliculites  decalvantes  agminees  (Brocq),8  alopecie  cicatricielle  innominee 
(Besnier),  acne  decalvante  (Lailler9  and  Roberts),10  lupoid  sycosis  (Mil- 
ton, Brocq),  ulerythema  sycosiforme  (Unna),  which  represent  somewhat 

1  Jamieson,  Diseases  of  the  Skin. 

2  Rietema,  "Rep.  Netherlands  Derm.  Soc'y,"  in  Brit.  Jour.  Derm.,  1898,  p.  268. 

3  Balzer  and  Stoianowitch,  Jour,  des  pracliciens,  Feb.  n,  1899,  p.  81. 

4  Jersild,  "Quelques  cas  de  palade  trait6s  par  les  rayons  chimiques  concentres," 
Annales,  1899,  p.  20. 

5  Jackson,  "Notes  on  the  Treatment  of  Alopecia  Areata,"  Jour.  Cutan.  Dis.,  Jan., 
1910. 

8 1  am  indebted  for  some  of  the  information  in  this  article  to  Robinson's  excellent 
resume  of  the  subject  in  Morrow's  System,  vol.  iii,  p.  873,  and  also  to  Hallopeau  and 
Leredde's  description,  Traits,  pratique  de  Dermatologie,  1900,  p.  391,  and  Sabouraud's 
recent  work. 

7  Quinquaud,  Bull,  de  la  Soc.  Med.  des  H8p.,  1888,  p.  395;  Annales,  1888,  p.  657, 
and  1889,  p.  99. 

8  Brocq,  Bull,  de  la  de  Med.  des  HSp.,  1888,  p.  400,  and  Annales,  1889,  p.  467. 

9  Lailler,  Annales,  1889,  p.  100. 

10  Roberts,  These  de  Paris,  1889. 


FOLLICULITIS  DECAL  VANS 


ion 


varied  but  allied  conditions  (Ducrey  and  Stanziale),1  of  which  the  chief 
symptom  is  follicular  destruction  with  scarring.  Ulerythema  sycosi- 
forme  and  lupoid  sycosis  will  be  found  referred  to  under  Sycosis.  The 
acne  decalvante  of  Lailler  and  Roberts  and  Quinquaud's  disease  are  the 
same  affection.  The  various  cases,  not  considered  elsewhere,  can  be 
conveniently  divided  into  two  varieties,  both  doubtless  the  one  disease, 
with  differences  in  the  degree  of  follicular  inflammation. 

In  one — the  variety  especially  described  by  Quinquaud  (Quinquaud's 
disease)  and  which  probably  furnishes  the  most  cases — the  follicular 
inflammation,  sycosiform  in  character,  is  a  readily  perceptible  feature 
of  the  malady.  The  scalp, 
and  more  especially  ante- 
riorly, is  its  usual  site,  but  it 
is  also  observed  in  the  beard, 
and  may  even  occur  in  the 
pubic  and  axillary  regions. 
On  examination  the  inflam- 
matory lesion  is  noted  to  be 
a  small  papule,  scarcely  as 
large  as  a  pin-head,  or 
merely  a  red  follicular  eleva- 
tion; or  it  is,  as  in  the  typical 
cases,  distinctly  a  pustule, 
small,  and,  like  the  pustule 
in  sycosis,  usually  without 
basal  infiltration.  These  pus- 
tules dry  to  thin  crusts.  In 
some  instances  the  lesion  ap- 
pears to  be  a  mere  pin-point- 
to  pin-head-sized  crusted 
abrasion.  Whatever  its  char- 
acter, the  center  is  pierced 
by  a  hair,  as  in  sycosis.  This 

soon  loosens,  however,  and  falls  out,  and  finally  a  minute  cicatrix  results. 
The  lesions  may  be  discrete  and  scattered,  but  commonly  the  adjoining 
follicles  take  on  the  same  action,  and  gradually  there  presents  the  picture 
usually  seen  when  the  patient  seeks  advice:  there  is  a  central,  dime- 
to  silver-quarter-sized  or  larger,  irregularly  rounded,  depressed,  bald, 
cicatricial  patch,  white  and  often  glistening,  usually  smooth,  and  the 
peripheral  portion  studded  here  and  there  with  the  minute  red  follicular 

1  Ducrey  and  Stanziale,  Giorn.  ital.,  1892,  p.  239;  abs.  in  Annales,  1893,  p.  498 
(8  personal  cases  and  a  review  of  the  subject).  In  a  recent  valuable  paper  on  alopecias 
with  atrophy  ("pseudo-pelade"  variety)  Brocq,  Lenglet,  and  Ayrignac  (Annales,  1905, 
pp.  i,  97,  and  209)  review  and  analyze  reported  cases  (29)  and  22  new  cases  (Brocq); 
about  80  per  cent,  of  the  cases  were  males,  and  only  i  case  was  observed  in  a  child; 
syphilis  had  no  etiologic  relationship,  but  tuberculosis  has  been  a  somewhat  frequent 
association;  the  infiltration  was  made  up  chiefly  of  lymphocytes,  but  plasma-cells,  mast- 
cells,  and  eosinophiles  were  also  found,  and  a  number  of  pigment-cells  in  the  papillary 
zone  and  corium  was  a  constant  finding;  bacteriologic  investigations  have  disclosed  noth- 
ing definitely.  Griinfeld.  "Ueber  Folliculitis  Decalvans,"  Archiv,  1909,  vol.  xcv,  p.  333, 
reports  5  cases  (3  case  illustrations),  reviews  the  subject,  and  gives  full  bibliography. 


Fig.  252. — Folliculitis  decalvans  (courtesy  of  Dr. 
G.  T.  Jackson). 


IOI2  DISEASES   OF   THE   APPENDAGES 

elevations,  pustules,  or  crusted  points.  In  this  manner  the  malady  ad- 
vances, leaving  destroyed  follicles  and  cicatricial  tissue.  Occasionally 
some  of  the  central  follicles  may  have  been  missed,  and  the  area  thus 
shows  one  or  two  islets  of  hair  centrally.  The  disease  is  generally  ex- 
tremely slow  in  its  progress,  and  there  may  be  periods  of  quiescence; 
and  in  some  cases,  after  a  time,  the  malady  ends  spontaneously,  but  this 
is  not  its  ordinary  course,  for,  as  a  rule,  it  is  slowly  progressive  or  appears 
at  new  points.  As  the  follicles  are  destroyed  there  is  no  new  hair  growth; 
in  fact,  the  destruction  usually  involves  all  the  dermic  tissues.  In  most 
instances  there  are  no  subjective  symptoms — occasionally,  in  some  cases, 
slight  itching. 

In  the  other  variety  of  folliculitis  decalvans,  the  pseudopelade  of  the 
French,  the  follicular  inflammation  is  not  so  apparent,  and  the  patch 
simulates  alopecia  areata.  A  slight  rosy  tint  or  faint  redness,  with  a 
trifling  amount  of  tumefaction  surrounding  the  follicles,  indicative  of  a 
mildly  inflammatory  action,  is  noted,  and  the  hairs  at  the  involved  spot 
or  point  can  be  readily  withdrawn,  or,  as  in  the  other  variety,  drop  out 
spontaneously.  Robinson  noted  that  the  extracted  hairs  have  a  glossy 
sheath,  which  is  thickened  and  extended.  The  malady  may  present  but 
one  or  two  spots,  or  it  may  be  disseminated,  and  with  small  areas.  The 
process  leaves  behind  polished  cicatricial,  hairless  areas,  smooth  and  ivory- 
like.  When  an  area  has  reached  the  size  of  a  silver  quarter,  it  usually 
presents  the  following  appearance:  On  first  sight  it  strongly  suggests 
alopecia  areata;  it  is  observed  to  be  white,  smooth,  glossy,  with  cicatricial 
thinning  and  obliteration  of  the  follicular  openings;  depressed,  especially 
centrally,  and  with,  on  close  examination,  a  slightly  raised,  rose-tinted 
or  pale-red,  tumefied  border,  from  which  some  of  the  hairs  can  usually 
be  easily  extracted;  not  infrequently  there  is  a  slight  keratotic  tendency 
in  the  follicular  outlets  of  the  border,  and  there  is,  if  the  part  has  not 
been  recently  washed,  a  faint  suggestion  of  branny  scaliness.  The  patch 
bears  a  slight  resemblance  also  to  lupus  erythematosus,  except  that  the 
cicatricial  thickening  usually  observed  in  this  latter  affection  on  the  scalp, 
the  dull  white  color,  and  the  characteristic  border  are  wholly  wanting. 
While  the  patches  are  sometimes  well  rounded,  as  in  an  instance  recently 
observed  by  myself,  they  are  often  irregular,  and  spread  by  jutting  out 
here  and  there!  Quinquaud  observed  some  cases  in  which  the  inflam- 
matory characters  were  still  less  marked  than  here  described,  or  almost 
entirely  lacking,  the  sole  symptoms  consisting  of  falling  of  the  hair, 
with  disappearance  of  the  pilosebaceous  glands,  and  a  resulting  faintly 
cicatricial-looking  plaque. 

Etiology  and  Pathology — The  malady  is  rare.  It  is  more 
common  in  males,  and  usually  develops  between  the  ages  of  thirty  and 
forty  years  (Brocq).  Dubreuilh's1  4  cases  of  the  pseudopelade  variety 
were  women.  The  patients  under  my  own  care  were  mostly  adult 
males  and  past  thirty.  The  cases,  for  the  most  part,  are  found  among 
the  working-classes.  Payne2  has,  however,  recently  described  a  rather 
markedly  inflammatory  and  somewhat  anomalous  example  in  a  young 

1  Dubreuilh,  "Des  alopecies  atrophiques,"  Annales,  1893,  p.  329. 

2  Payne,  Brit.  Jour.  Derm.,  1895,  P-  IO1- 


FOLLICULITIS  DECALVANS  IOI3 

girl  aged  fourteen.  Patients  usually  seem  in  good  health,  and  it  is  diffi- 
cult to  assign  a  cause.  Payne's  case  was  the  subject  of  hereditary  syphilis. 
Fournier  (quoted  by  Payne)  also  observed  one  similar  instance.  These 
2  instances  must,  I  believe,  be  considered  exceptional,  however,  as  the 
malady  is  scarcely  suggestive  of  a  syphilitic  nature.  Besnier  believes 
that  gastric,  hepatic,  and  intestinal  disturbances  have  an  etiologic 
bearing.  Quinquaud  found  various  organisms,  one  of  which  he  consid- 
ered etiologic;  animal  inoculation  experiments  were  partially,  but  not 
wholly,  confirmatory  of  its  causative  relationship.  His  findings  lack 
corroborative  testimony,  however,  although  there  is  scarcely  a  doubt 
that  the  disease  is  a  parasitic  one. 

Histologically,  according  to  this  same  observer,  evidences  of  a  mildly 
inflammatory  process  are  disclosed;  in  the  earliest  stage  of  the  lesion, 
consisting  of  a  collection  of  young  cells  encompassing  the  hair-follicle, 
especially  at  its  upper  part;  the  same,  but  only  to  less  marked  extent, 
is  observed  about  the  sebaceous  glands,  and  also  in  the  immediately 
adjacent  rete  and  corium.  The  subsidence  of  the  inflammatory  action 
is  followed  by  atrophic  changes  in  all  the  dermal  parts,  hair-follicles 
and  sebaceous  glands  disappearing. 

Diagnosis. — The  diagnostic  characters  are  the  hairless,  atrophic, 
or  cicatricial  spot  or  plaque  and  the  bordering  inflammatory  follicular 
lesions;  these  serve  to  distinguish  it  from  alopecia  areata;  and  these 
with  the  other  differences,  already  referred  to,  from  lupus  erythematosus. 

Prognosis  and  Treatment.— The  malady,  as  already  indi- 
cated, is  usually  a  persistent  one,  with  little  if  any  tendency  to  spon- 
taneous cure.  It  is  also  rebellious  to  treatment,  but  proper  measures 
are  of  benefit  and  may  bring  about  a  disappearance  of  the  eruption. 
Constitutional  treatment  seems  of  questionable  value,  but  both  cod- 
liver  oil  and  the  hypophosphites  with  iron  and  arsenic  may  prove  of 
benefit.  Payne's  case  improved  under  potassium  iodid  and  mercury. 

The  local  treatment  is  essentially  that  of  sycosis,  a  somewhat  kindred 
affection.  The  surrounding  hair  should  be  clipped,  that  in  the  per- 
ipheral inflammatory  lesions  extracted  (Pringle),  and  an  advantage 
also  accrues,  I  believe,  from  depilating  the  surrounding  healthy  follicles. 
A  saturated  solution  of  boric  acid,  with  3  to  20  grains  (0.2-1.35)  °f 
resorcin  to  the  ounce  (32.),  is  of  service  in  some  cases,  supplemented 
with  a  resorcin-salicylic  acid  salve:  1$.  Ac.  salicylici,  gr.  v-x  (0.33-0.65); 
resorcin,  gr.  iij-x  (0.2-0.65);  ung.  aquae  rosae,  3iv  (16.).  Painting  on  a 
salicylic  acid  collodion,  2  to  5  per  cent,  strength,  also  occasionally  seems 
to  act  well.  White  precipitate,  calomel,  and  sulphur  ointments,  from 
10  to  60  grains  (0.65-4.)  to  the  ounce  (32.)  of  vaselin,  may  also  be  tried. 
Hallopeau  and  Leredde  recommend  an  ointment  made  up  of  50  grains 
(3.)  of  /5-naphthol,  24  grains  (1.5)  of  salicylic  acid,  5  drams  (20.)  of 
vaselin,  and  2^  drams  (10.)  of  talc.  As  some  of  the  cases  are  easily  irri- 
tated, a  smaller  quantity  of  naphthol  would  be  advisable  at  first.  The 
scalp  or  affected  parts  should  be  frequently  washed  with  soap  and  water, 
preferably  the  tincture  of  green  soap,  and  a  mild  antiseptic  applied  every 
day  or  so  to  the  region  generally. 


IOI4  DISEASES   OF  THE  APPENDAGES 

SYCOSIS  VULGARIS 

Synonyms. — Sycosis;  Non-parasitic  sycosis;  Folliculitis  barbae;  Sycosis  cocco- 
genica;  Acne  mentagra;  Mentagra;  Fr.  Sycosis  non-parasitaire;  Ger.  Bartfinne. 

Definition. — A  chronic  inflammatory  affection  of  the  hair-fol- 
licles of  the  bearded  and  mustache  regions,  due  to  microbic  infection. 

As  the  disease  is  now  known  to  be  microbic,  the  term  non-parasitic, 
formerly  used  to  distinguish  it  from  parasitic  sycosis  or  sycosis  due  to 
the  ringworm  fungus,  is  no  longer  applicable. 

Symptoms. — The  disease  may  involve  only  a  part  of  the  hairy 
region  of  the  face,  as,  for  instance,  a  portion  of  the  upper  lip,  especially 
just  under  the  nasal  orifices,  or  the  entire  mustache  region ;  or  it  may  be 
more  or  less  limited  to  the  chin  or  cover  the  bearded  sides  of  the  face; 
finally,  in  extensive  cases,  the  whole  surface  covered  by  the  mustache 
and  beard  may  be  involved,  and  in  extreme  instances  even  the  eyebrows 
also  are  the  seat  of  the  lesions.  In  my  experience  the  bearded  part  and 
the  mustache  have  appeared  of  about  equal  frequency  in  being  the  sites 
of  the  eruption.  The  disease  begins,  as  a  rule,  slowly,  with  the  appear- 


Fig.  253. — Sycosis  vulgaris,  limited  to  region  immediately  under  the  nose,  usually  with 
a  nasal  catarrh  as  the  etiologic  factor. 

ance  of  a  variable  number  of  small  red  papules  or  papulopustules  or  tu- 
bercles, the  most  of  which,  or  all,  soon  become  pustular;  each  lesion  is 
pierced  by  a  hair.  The  pustules  are  small,  rounded,  or  acuminated  and 
yellowish  in  color,  with  but  little  tendency  to  spontaneous  rupture. 
Exceptionally  they  may  remain  for  the  most  part  papular.  At  first 
they  may  be  quite  discrete,  later,  from  the  accession  of  the  new  lesions, 
the  affected  part  becomes  quite  crowded,  and  the  inflammation  is  then 
usually  confluent,  with  some  infiltration  and  swelling,  and  beset  with 
the  numerous,  small,  projecting  lesions.  At  first  the  hairs  remain  firmly 
seated,  but  in  most  cases  in  the  follicles  which  undergo  more  pronounced 
suppurative  action,  they  loosen  and  can  be  readily  extracted;  and  some 
follicles  may  suffer  complete  destruction.  As  a  rule,  however,  in  spite 
of  the  rather  violent  aspect  of  the  disease,  but  comparatively  few  hairs 
are  lost,  and  positive  scarring  rarely  results.  When  so  closely  aggregated 
that  it  practically  amounts  to  coalescence,  a  portion  or  the  entire  region 
may  become  crusted,  under  which  there  may  be  a  slight  tendency  to 
fungate.  There  is  often  a  good  deal  of  infiltration  and  thickening,  and 
the  parts  are  of  a  bright  or  dark-red  color,  depending  upon  the  type  of 


SYCOSIS    VULGAR  IS 


IOI5 


inflammatory  action.    There  is,  however,  no  distinct  lumpiness  or  large 
cutaneous  swellings  as  in  tinea  sycosis  (ringworm  sycosis) . 

The  lesions  in  some  cases,  for  a  tune  at  least,  may  remain  more 
or  less  discrete,  and  the  area  of  disease  may  be  limited  to  two  or  three 
small  patches;  in  most  instances,  however,  new  lesions  arise,  form  new 
aggregations,  and,  by  still  further  accessions,  the  areas  become  confluent 
and  a  large  region  is  involved.  The  disease  may  remain  somewhat  lim- 
ited, or  it  may  go  slowly  from  worse  to  worse,  involving  more  and  more 
of  the  hairy  parts.  While  it  is  essentially  chronic,  the  inflammatory 
action  being  of  a  subacute  or  sluggish  character  with  sometimes  slight 
remissions,  there  are  often  acute  exacerbations. 


Fig.  254. — Sycosis  vulgaris  of  moderate  development,  involving  chin  and  to  a  slight 

extent  upper  lip. 

The  subjective  symptoms  are  rarely  marked  or  troublesome:  there 
may  be  a  variable  degree  of  pain  and  itching  and  a  sense  of  burning. 

In  rare  instances  the  disease  is  limited  to  the  outer  portions  of  the 
bearded  region,  beginning  with  all  the  appearances  of  an  ordinary  case; 
as  the  process  advances  it  leaves  behind  a  smooth,  furrowed,  or  keloidal 
scar,  total  destruction  of  the  hair-follicles,  and  permanent  loss  of  hair. 
It  usually  advances  in  one  direction,  and,  as  a  rule,  with  a  slightly  in- 
filtrated border.  This  variety  or  aberrant  form  has  variously  been  con- 
sidered a  distinct  affection,  called  lupoid  sycosis  (Milton) ,  sycosis  lupoi'de 
(Brocq),  and,  finally,  and  more  fully  described  by  Unna,1  under  the  name 
ulerythema  sycosiforme. 

1  Unna,  "Ueber  Ulerythema  sycosiforme,"  Monatshefie,  1889,  vol.  ix,  p.  134. 


ioi6 


DISEASES   OF  THE   APPENDAGES 


While  sycosis  is  a  disease  of  the  bearded  and  mustache  regions, 
and  is  so  understood  when  the  term  is  used,  in  exceptional  instances 
other  hairy  parts  of  the  body  are  the  seat  of  similar  follicular  erup- 
tion which  stops  short  at  the  hairy  borders;  when  such  occurs,  it  is,  as 
a  rule,  in  connection  with  eczematous  eruption  elsewhere. 

Etiology. — The  essential  factor  of  sycosis  is  microbic;  as  Bock- 
hart1  has  demonstrated,  the  pyogenic  cocci  (Staphylococcus  aureus 
and  albus)  are  the  usual  causative  agents,  and  hence  the  names  sug- 
gested, sycosis  coccogenica,  sycosis  staphylo genes.  In  one  instance, 
presenting  the  symptoms  of  ordinary  sycosis,  Tommasoli2  found  that 
instead  of  the  usual  micro-organisms,  a  bacillus  was  the  morbific  agent. 


Fig.  255. — Sycosis  vulgaris,  of  several  years'  duration;  involving  the  entire  bearded 

region. 

and  he  succeeded,  with  pure  cultures,  experimentally  in  proving  this  on 
himself  and  rabbits;  this  discovery  led  to  the  variety  designation  sycosis 
bacillo  genes. 

Accepting  the  microbic  origin,  it  should  be,  and  indeed  probably  is 
somewhat,  though  feebly,  contagious,  although  it  has  never  been  gen- 
erally so  considered.  I  have  occasionally  met  with  instances  in  which 
the  barber-shop  has  apparently  been  the  starting-point,  and  Brooke3 
and  others  have  given  evidence  of  its  contagious  character.  The  disease 
is,  as  to  be  inferred,  met  with  in  males  only,  and  usually  in  those  between 

1  Bockhart,  "Ueber  die  Aetiologie  und  Therapie  der  Impetigo,  des  Furunkels,  und 
der  Sycosis,"  ibid.,  1887,  vol.  vi,  p.  450. 

2  Tommasoli,  "Ueber  bacillogene  Sykosis,"  ibid.,  1889,  vol.  viii,  p.  483. 

3  Brooke,  "The  Contagious  Nature  of  Sycosis,"  Brit.  Jour.  Derm.,  1889,  p.  467. 


SYCOSIS    VULGAR  IS  IOI/ 

the  ages  of  twenty  and  fifty.  It  is  not  frequent.  It  is  observed  in  all 
walks  of  life,  but  is  more  common  among  the  poor,  and  especially  in  those 
whose  health  is  impaired.  In  many  cases,  it  is  true,  the  patients  seem  in 
good  condition.  Any  constitutional  disturbance,  such  as  gout,  rheuma- 
tism, dyspepsia,  etc.,  may  be  of  contributory  influence. 

Local  irritation  is  sometimes  of  etiologic  importance.  On  the  upper 
lip,  especially  the  subnasal  region,  it  is  often  due  to  the  secretion  from 
a  nasal  catarrh.  Seborrhea  is  also  at  times  a  factor,  and  occasionally 
the  disease  is  observed  to  follow  an  eczema  of  the  face.  Shaving  has  been 
suggested  as  a  factor,  but  inasmuch  as  this  procedure  is  often  a  necessary 
part  in  the  cure  of  the  malady,  it  can  scarcely  be  considered  etiologic. 
Jackson1  has  observed  that  those  whose  occupation  is  in  close  dusty 
rooms,  and  those  in  a  poor  condition  of  health,  furnish  the  largest  number 
of  cases.  The  disease  has  its  seat  essentially  upon  the  bearded  and  mus- 
tache regions,  but  occasionally  the  eyebrows  share  in  the  eruption.  I 
have  met  with  one  instance  in  which  the  scalp  and  hair-follicles  of  the 
forearms  and  dorsal  surfaces  of  the  fingers  were  all  involved,  presenting 
the  exact  symptomatology  of  the  disease  as  observed  on  its  usual  site — 
follicular,  and  stopping  at  the  edge  of  the  hairy  skin;  this  was  typically 
shown  on  the  backs  of  the  tiands  and  fingers,  intervening  hairless  parts 
being  entirely  free.  The  cause  of  ulerythema  sycosiforme  is  not  known — 
probably  an  ordinary  sycosis  with  an  added  infective  factor. 

Pathology. — The  micro-organisms  gaining  access  give  rise  to 
the  inflammatory  changes  and  the  clinical  manifestations.  It  can  be 
readily  understood  how  the  process,  starting  at  one  point,  can  soon 
involve  neighboring  follicles  by  continuous  and  repeated  inoculation. 
Tommasoli's  findings  indicate  that  there  may  be  other  organisms  than 
the  usual  pyogenic  cocci.  The  pathology  and  pathologic  anatomy 
have  been  especially  studied  by  Wertheim,2  Robinson,3  and  Unna,4 
whose  conclusions,  while  at  variance  in  minute  details,  are,  in  their 
essential  characters,  the  same.  The  disease  is  primarily  a  perifollicu- 
litis,  the  follicles  and  their  sheath  becoming  rapidly  involved  secondarily 
in  the  inflammatory  process.  The  changes  are  such  as  are  ordinarily 
observed  in  vascular  tissue  inflammation  resulting  from  these  organisms. 
The  hair-papilla  is,  as  a  rule,  not  destroyed,  so  that  hair  loss,  except  in 
very  chronic  and  markedly  suppurative  cases,  does  not  commonly  occur. 
The  resulting  pus  escapes  at  the  hair-follicle  opening,  or  through  the  epi- 
dermis immediately  adjacent.  Cocci  are  usually  to  be  seen  in  abundance. 
As  Wertheim  states,  each  follicle  really  becomes  a  minute  abscess.  In 
ulerythema  sycosiforme  the  hair-follicles  and  hair-papillae,  the  glandular 
structures,  and  the  connective  tissue  are  destroyed  and  give  place  to 
scar  tissue. 

Diagnosis. — The  disease  is  to  be  differentiated  from  eczema, 
which  it  sometimes  resembles,  and  with  which,  by  some  authors,  it  is 
thought  to  be  identical.  Eczema  rarely  stops  at  the  border  of  the  hairy 

1  Jackson,  "Sycosis:  A  Clinical  Study,"  Jour.  Cutan.  Dis.,  1889,  p.  13. 

2  Wertheim,  Wiener  med.  Jahrb.,  1861,  ii,  p.  87. 

3  Robinson,  N.   Y.  Med.  Jour.,  Aug.  and  Sept.,  1877,  and  Manual  of  Dermatology. 

4  Unna,  Histo pathology. 


J0l8  DISEASES   OF  THE  APPENDAGES 

region,  and  the  lesions  are,  with  some  exceptions,  not  pierced  by  hairs; 
eczema  is  apt  to  involve  the  entire  skin  of  the  affected  area,  the  follicular 
implication  being  secondary:  sycosis  involves  the  follicles  primarily, 
and  only  later,  when  closely  aggregated,  does  the  inflammation  present 
a  diffused  character.  When  the  latter  is  present  and  the  parts  are 
crusted,  it  is  usually  necessary  to  remove  the  crusts  and  sometimes 
allow  a  few  days  to  intervene  before  the  case  is  clear;  but  in  sycosis  the 
follicular  involvement  becomes  again  perceptible.  Eczema  itches, 
usually  intensely:  sycosis  rarely  does  to  any  degree.  A  history  of  chron- 
icity,  with  no  tendency  to  overstep  the  border-line,  and  with  but  little 
variability,  would  point  to  sycosis. 

Tinea  sycosis  can  scarcely  be  confounded  in  average  or  severe  cases; 
it  begins  usually  as  one  or  several  rings,  and  continues  so,  with  breaking 
of  the  hah-,  and  often  their  easy  extraction;  or  it  begins  in  this  manner, 
or  as  several  lumpy  nodules,  and  rapidly  invades  the  subcutaneous 
tissues,  and  then  presents  large,  nodular  swellings,  on  which  the  hair 
may  be  broken,  fall  out,  or  can  be  readily  extracted.  Such  conditions 
are  entirely  different  from  the  beginning  and  behavior  of  sycosis.  In 
obscure  cases  the  microscope  would  decide  (see  Ringworm). 

In  acne  the  evident  involvement  of  the  sebaceous  glands,  the  scat- 
tered lesions,  as  a  rule  over  the  face,  evolution,  and  course,  with  usually 
the  presence  of  blackheads,  will  prevent  its  being  mistaken  for  sycosis. 

Only  carelessness  could  lead  to  confusion  with  a  syphilitic  eruption; 
early  eruptions  of  syphilis  are  generalized,  with  other  corroborative 
symptoms,  and  late  syphilodermata  are  limited,  and  usually  serpiginous 
or  segmental  in  outline. 

Prognosis. — The  disease  is  obstinate  and  persistent,  with  no 
tendency  to  spontaneous  disappearance.  The  duration,  extent,  and 
character  of  the  inflammatory  process  must  all  be  considered.  Under 
proper  treatment,  however,  recovery  takes  place,  in  moderately  devel- 
oped cases,  sometimes  within  two  or  three  months,  but  frequently 
longer.  In  extensive  involvement  the  duration  of  treatment  may  be 
but  several  months  in  favorable  cases,  but  this  cannot  be  expected  in 
most  instances — it  is  usually  six  months  to  a  year.  An  opinion  as  to 
the  time  required  in  a  given  case  should  always  be  guarded.  A  good 
deal  depends  upon  the  patient's  care  and  perseverance  in  carrying  out 
the  treatment.  The  disease  often  shows  a  tendency  to  recurrence. 
The  hair  should  not  be  allowed  to  grow  for  months  after  apparent  cure, 
shaving  being  persistently  practised,  experience  teaching  that  this  tends 
to  prevent  relapses. 

Ulerythema  sycosiforme  is  extremely  rebellious — much  more  so 
than  the  ordinary  sycosis. 

Treatment. — The  plan  of  treatment  in  most  instances  consists 
of  external  means  alone.  The  state  of  the  general  health  should,  how- 
ever, be  inquired  into,  and  proper  treatment  instituted  to  bring  it  up 
to  a  normal  standard.  In  some  cases  there  is  an  underlying  constitu- 
tional debility,  which,  unless  corrected,  seems  to  add  to  the  obstinacy 
of  the  disease;  in  such  cases  cod-liver  oil  is  an  admirable  remedy,  the 
administration  of  which  not  infrequently  quite  perceptibly  aids  in  ob- 


SYCOSIS    VULGAR  IS  1 019 

taining  a  result  from  local  measures.  Such  tonics  as  iron,  quinin,  and 
manganese  will  at  times  also  apparently  have  a  favorable  influence. 
Arsenic  may  be  given  for  its  tonic  effect,  but  it  has  no  specific  action. 
A  special  value  has  been  claimed  for  calx  sulphurata,  given  in  doses  of 
from  yV  to  j  grain  (0.0065-0.016)  three  or  four  times  daily,  but  my 
experience  with  this  drug  has  not  been  at  all  favorable.  Sodium  sal- 
icylate  in  underlying  rheumatic  state  and  stomachic  and  digestive  tonics 
in  dyspeptic  cases  will  be  of  service.  Alcoholic  drinks,  indigestible  foods, 
tobacco,  excessive  coffee-  or  tea-drinking,  and  indulging  'in  the  many 
"bromo"  compounds  now  so  common — all  have  a  damaging  tendency. 
The  bowels  should  always  be  kept  free.  Nasal  catarrh,  if  present, 
should  receive  attention.  The  influence  of  hygienic  living  and  open-air 
life  and  exercise  is,  without  doubt,  of  value  from  a  therapeutic  stand- 
point. In  obstinate  and  extensive  cases,  especially  where  the  suppura- 
tive  factor  is  pronounced  staphylococcic  vaccine  should  be  tried — as  a 
rule,  the  results  are  disappointing,  but  exceptionally  its  action  is  of  con- 
siderable help. 

In  the  external  treatment  the  first  steps  are  to  clip  the  hair  short, 
free  the  parts  from  crusting,  if  present,  and  reduce  the  inflammatory 
action.  If  necessary,  the  crusts  can  be  removed  with  starch  poultices, 
but,  as  a  rule,  frequent  bathing  with  warm  water  and  soap  and  the  appli- 
cation of  plain  petrolatum  or  cold  cream  will  accomplish  this  end  in  a 
day  or  two.  Then  mild  soothing  applications  are  to  be  made  for  a  few 
days  until  the  activity  of  the  inflammatory  process  is  somewhat  allayed. 
This  may  be  accomplished  by  means  of  applications  of  an  ointment  of 
zinc  oxid,  of  salicylated  paste,  or,  in  fact,  by  means  of  any  of  the  other 
mild  ointments  or  lotions  mentioned  in  the  treatment  of  acute  eczema. 
As  soon  as  the  inflammatory  action  has  been  lessened,  and,  in  fact,  in 
almost  all  cases  from  the  very  beginning,  shaving  every  day  or  every 
second  day  should  be  insisted  upon  as  an  essential  part  of  the  treatment. 
This  will  not  be  without  pain  at  first,  which  is  by  no  means  unbearable, 
but  after  the  first  two  or  three  shavings  the  operation  is  not  especially 
painful.  It  materially  aids  in  rendering  the  treatment  effective  and  in 
shortening  the  time  required  for  a  cure,  and  this  the  patient  soon  recog- 
nizes himself.  I  value  this  so  highly  that  I  should  decline  to  treat  a 
case  unless  this  measure  were  acceded  to.  When  the  follicular  inflamma- 
tion is  of  a  markedly  pustular  character,  and  especially  if  the  hair  shows 
a  tendency  to  loosen,  depilation  may  be  practised;  this  tends  to  prevent 
the  permanent  destruction  of  the  follicles.  As  a  routine  procedure  for 
the  whole  diseased  area,  however,  depilation  is,  in  my  experience,  too 
painful  a  practice  to  take  the  place  of  shaving,  and  I  do  not  believe  of 
greater  therapeutic  value. 

In  the  management  of  the  external  treatment  of  sycosis  it  is  to  be 
kept  in  mind  that  as  patients  are  often  obliged  to  keep  to  their  business, 
the  applications  for  the  day-time  should  be  scanty  in  quantity,  or  such 
as  do  not  conspicuously  disfigure.  The  essential  part  of  the  treatment 
consists  in  application  of  antiseptic  ointments  and  lotions.  In  recent 
and  slight  cases  the  applications  to  be  described  will  usually  be  effective ; 
in  extensive,  long-continued,  and  obstinate  cases  these  are  also  to  be  used, 


1020  DISEASES   OF  THE  APPENDAGES 

but  may  be  supplemented  by  the  Rontgen-ray  treatment.  The  former 
will  be  referred  to  first.  Ordinarily,  the  plan  of  making  a  slight  applica- 
tion in  the  morning  and  applying  the  ointment  spread  upon  linen  or  lint 
as  a  plaster  at  night  may  be  adopted;  in  the  milder  case  the  night  appli- 
cations may  also  consist  of  simple  anointing.  In  mild  and  sluggish  types 
the  ointment,  more  especially  at  night,  is  to  be  gently,  but  firmly,  rubbed 
in.  When  lotions  and  ointments  are  used  conjointly,  the  wash  is  first 
dabbed  on  for  a  few  minutes,  allowed  to  dry,  and  then  the  salve  is  applied. 
The  parts  should  be  washed  once  daily  with  soap  and  warm  or  hot  water, 
in  irritable  cases  using  a  mild  toilet-soap,  and  in  sluggish  and  obstinate 
types  occasionally  using  sapo  viridis  or  the  tincture  of  sapo  viridis.  There 
is  no  set  guide  as  to  the  choice  of  a  remedy  among  those  commonly  em- 
ployed; as  a  rule,  in  markedly  inflammatory  cases  the  use  of  a  saturated 
boric  acid  solution  or  a  mild  resorcin  lotion,  0.2  to  i  per  cent,  strength, 
followed  by  a  soothing  ointment,  such  as  the  boric  acid  ointment  or  dia- 
chylon ointment,  will  be  most  likely  to  be  well  borne.  Later  other 
remedies  will  usually  be  demanded.  Often  enough  one  remedy  will  fail 
absolutely  to  influence  the  disease  favorably,  or  it  may  benefit  for  the 
first  week  or  two,  and  then  cease  to  have  any  favorable  effect;  in  either 
event  the  remedy  is  then  to  be  set  aside  and  another  tried;  later  a  change 
back  to  an  application  which  had  previously  benefited  can  sometimes 
advantageously  be  made. 

Although  occasionally  one  of  the  stronger  remedies,  such  as  a  strong 
sulphur  ointment,  can  be  used  at  the  start,  it  is  advisable,  except  in  the 
very  sluggish  cases,  to  begin  with  mild  treatment,  such  as  just  mentioned. 
A  very  weak  sulphur  ointment,  2  to  5  per  cent.,  is,  however,  a  safe  begin- 
ning application.  Or  mercury  oleate  can  be  used,  and  is  often  of  decided 
benefit,  prescribed  as  an  ointment  of  from  20  grains  to  i  or  2  drams 
(1.3-8.)  to  the  ounce  (32.)  of  ointment  base,  of  equal  parts  of  cold  cream 
and  simple  cerate,  or,  if  the  quantity  of  the  oleate  is  large,  with  all  cerate. 
Resorcin  is  commonly  used  as  a  lotion  conjointly  with  a  mild  salve,  as 
already  mentioned,  although  it  may  likewise  be  employed  in  the  form 
of  an  ointment.  The  strength  of  the  lotion  in  chronic  and  sluggish  cases 
should  be  from  i  to  10  per  cent.;  of  the  ointment,  from  5  to  10  per  cent. 

One  of  the  most  valuable  external  remedies  is  precipitated  sulphur, 
employed  as  an  ointment  in  the  strength  of  from  20  grains  to  2  drams 
(1.3-8.)  to  the  ounce  (32.)  of  petrolatum  or  cold  cream;  in  the  form  of  a 
lotion,  the  Vleminckx's  solution  applied  diluted  with  from  5  to  15  parts 
of  water  and  supplemented  with  a  mild  sulphur  or  a  boric  acid  salve  or 
cold  cream  deserves  mention.  Owing  to  its  odor,  this  lotion  is  not  a 
pleasant  remedy,  and  should  be  used  only  when  other  treatment  has 
proved  unsuccessful.  Hays  has  also  found  it  of  service.  A  compound 
ointment  as  follows  has  been  especially  useful  in  some  cases: 

fy     Sulphuris  praecipitati,  5j  (4-); 

Balsami  Peruvians,  3j  (4-); 

Unguenti  diachyli,  3vj  (24.). 

It  should  be  made  up  fresh  every  week  or  so,  as  the  color  becomes  grad- 
ually darker  and  the  ointment  less  efficient  from  chemical  change. 


SEB  ORRHEA  I O2 1 

Ichthyol  is  another  valuable  remedy  in  the  treatment  of  sycosis, 
employed  usually  as  an  ointment  in  the  strength  of  from  \  dram  to  2 
drams  (2.-8.)  to  the  ounce  (32.)  of  petrolatum,  cold  cream,  or  simple 
cerate.  In  weakest  proportion  it  is  also  a  safe  application  for  the  begin- 
ning treatment.  It  may  also,  conjointly  with  an  ointment,  be  employed 
as  an  aqueous  solution  in  from  2  to  10  per  cent,  strength.  It  may  like- 
wise be  used  in  an  ointment  of  sulphur,  with  advantage,  as  follows:  1^. 
Sulphuris  prsecipitati,  oss-iss  (2.-6.);  ichthyol,  3j-iss  (4--6.);  petrolati, 
q.  s.  ad  5j  (32.).  Ehrmann  warmly  advocates  the  treatment  of  this 
disease  with  a  10  per  cent,  solution  of  pyoktanin,  introduced  into  the 
diseased  follicles  by  cataphoresis — the  positive  electrode,  soaked  in  this 
solution,  is  applied  to  the  part,  and  the  cathode  held  in  the  hand. 

The  Rontgen-ray  treatment  is  occasionally  found  a  valuable  addi- 
tion to  our  means  of  treating  this  disease,  and  should  be  tried  in  per- 
sistent, extensive,  and  obstinate  cases.  The  parts  other  than  those  to 
be  treated  should  be  properly  protected  with  lead  foil.  It  need  not  be 
added  that  the  use  of  so  potent  an  agent  as  the  #-ray  requires  caution. 

3.  DISEASES    OF   THE    SEBACEOUS    GLANDS 
SEBORRHEA 

Synonyms. — Steatorrhea;  Stearrhea;  Acne  sebacea;  Ichthyosis  sebacea;  Fr.,  Acne" 
sebacee;  Seborrhee;  Ger.,  Schmeerfluss;  Gneis. 

Definition. — A  functional  disease  of  the  fat-producing  glands, 
characterized  by  an  excessive,  and  perhaps  abnormal,  secretion  of  fatty 
matter,  appearing  on  the  skin  as  an  oily  coating,  crusts,  or  scales. 

Since  the  writings  of  Unna  and  others  on  dermatitis  seborrhoica,  which 
have  led  to  a  withdrawal  of  many  cases  (see  Dermatitis  seborrhoica) 
heretofore  considered  to  be  rightly  placed  under  seborrhea,  there  is  much 
confusion  as  to  exactly  what  conditions  are  to  be 'properly  included  in 
this  disease.  Oily  seborrhea,  of  course,  belongs  here,  and  I  believe  also 
all  those  cases  of  fatty  crusted  or  scaly  conditions  which  lack  all  signs 
of  inflammatory  action.  The  division  line  is,  however,  an  ill-defined  one, 
and  there  is  a  growing  belief  that  all  cases  except  those  of  oily  seborrhea 
show  histologically  evidences  of  inflammation.1 

Symptoms. — Two  varieties  of  seborrhea  are  usually  found, 
designated,  according  to  whether  there  is  practically  only  oiliness  or 
oiliness  with  scale  or  crust  accumulation;  the  former  is  that  known  as 
seborrhoea  oleosa,  and  the  latter,  seborrhoea  sicca.  The  qualifying  term 
"sicca,"  or  dry,  in  my  judgment  is  in  the  present  state  of  our  knowledge 
an  improper  one,  as  those  cases  in  which  the  accumulation  is  truly  dry — 
not  oily  or  fatty — are  necessarily  relegated  to  dermatitis  seborrhoica. 
The  term,  as  here  employed,  will  not  refer  therefore  to  such  types,  but 
essentially  to  those  in  which  there  is  marked  or  moderate  oiliness,  with 
scale  accumulation  or  crusting  added,  and  in  which  there  are  no 
inflammatory  symptoms.  Such  cases,  I  believe,  exist,  although,  com- 

1  See  "Dermatitis  seborrhoica,"  and  also  Jackson  and  McMurtry's,  article  on 
"Seborrhcea  capitis,"  Jour.  Cutan.  Dis.,  1912,  p.  608. 


1022  DISEASES   OF  THE  APPENDAGES 

pared  to  those  belonging  to  seborrheic  dermatitis,  in  relatively  moder- 
ate number. 

Seborrhoea  oleosa  (known  also  as  hyperidrosis  oleosa  (Unna,  Brocq), 
acne  sebacee  fluente,  stearrhcea  simplex,  seborrhoea  simplex,  etc.)  is 
observed  upon  the  scalp  and  face,  usually  conjointly,  although  it  may 
be  relatively  extremely  slight  in  *ome  cases  on  one  or  the  other  of  these 
regions.  On  the  scalp  the  hair  and  skin  are  noted  to  be  oily  and  greasy; 
the  oiliness  may  be  slight  or  quite  perceptible,  and  may  involve  the  whole 
region,  or  be  mainly  upon  the  vertex  portion.  The  hair  looks  moist, 
sometimes  glistening,  and  is  often  slightly  sticky,  stringy,  or  with  a  tend- 
ency, in  women,  to  form  into  uncouth-looking,  slightly  agglutinated 
locks,  or  there  is  a  tendency  to  bunching  or  massing  together.  The 
skin  is  oily  to  the  touch,  pale,  often  leaden-looking,  and  sometimes  with, 
apparently  at  least,  rather  patulous  gland-ducts.  There  are  no  inflam- 
matory symptoms,  except  in  occasional  cases,  when  there  may  be  here 
and  there  slight  hyperemia,  patchy  in  character.  Itching  is  rarely  com- 
plained of  in  the  oily  variety.  If  of  long  continuance,  there  is  very  often 
a  tendency  to  hair  loss,  and  in  some  instances  finally  of  a  more  or  less 
pronounced  character. 

On  the  face,  the  favorite  site  for  the  oiliness  is  the  nose  and  its  imme- 
diate neighborhood;  not  infrequently,  however,  the  forehead  is  also  in- 
volved, and  occasionally  other  parts  of  the  face.  In  fact,  in  all  cases  there 
is,  as  a  rule,  a  slight  oiliness  of  these  several  regions,  or  the  entire  face, 
but  it  may  be  conspicuously  so  only  on  one  or  two  of  the  regions  named. 
The  skin  is  shiny,  glistening,  and  the  gland-ducts  often  patulous,  and  the 
whole  face  presents  a  pasty-looking,  soiled  aspect.  Not  infrequently  the 
nose  is  somewhat  congested,  and  usually  of  a  sluggish  red  tint.  In 
addition,  in  some  patients,  comedones  and  scattered  acne  lesions  are  to 
be  seen,  and  in  occasional  instances  there  is  a  disposition  shown  here 
and  there,  more  especially  on  the  scalp,  for  the  secretion  to  dry  and  cake, 
forming  thin  scaliness'of  dirty-gray  or  brownish-gray  color.  If  in  women, 
"the  malady  seems  to  be  often  associated  with  a  tendency  to  hypertri- 
chosis. 

Seborrhoea  Sicca. — In  infants  it  is  at  birth  more  or  less  general, 
though  variable  in  quantity,  and  constitutes  the  so-called  vernix  caseosa 
(also  ichthyosis  sebacea).  It  is  apt  to  remain  caked  on  the  scalp  for  some 
months,  and  while  it  must  be  looked  upon  as  physiologic,  not  infre- 
quently, from  irritation  produced  by  decomposition  or  from  harsh  at- 
tempts to  remove  it,  an  eczema  may  ensue.  In  children  and  adults  its 
usual  site  is  the  scalp  (seborrhoea  capitis).  In  this  form,  in  addition  to 
more  or  less  oiliness,  the  fatty  secretion  and  the  exfoliating  epidermic 
scales,  and  some  possibly  from  the  lining  membranes  of  the  gland-ducts, 
tend  to  accumulate  in  an  irregular,  thin,  or  somewhat  thick,  soft,  unctu- 
ous, waxy-looking,  gray  or  brownish  coating.  There  is  usually  a  variable 
amount  of  itching.  The  skin  beneath  the  crusts  is  not  hyperemic,  but 
of  the  usual  color  or  somewhat  paler  than  normal,  with,  in  some  cases,  a 
tendency  here  and  there  to  slight  redness  and  development  into  dermatitis 
seborrhoica.  The  gland-ducts  are  often  somewhat  stuffed  with  semi- 
solid  fatty  matter.  The  hair  is  greasy  and  oily,  sometimes  massed  or 


SEBORRHEA  1 02$ 

bunched,  and  practically  in  the  same  condition  as  noted  in  seborrhoea 
oleosa.  In  the  crusted  seborrhea  there  is  a  more  decided  disposition  to 
falling  of  the  hair  and  consequent  alopecia.  The  disease  varies  in 
degree.  It  may  be  slight,  with  a  variable  amount  of  oiliness,  and  small 
fatty  scale  or  crust  specks  or  small  filmy  fragments,  which  are  found  on 
the  scalp,  scattered  through  the  hair,  and  sometimes  falling  upon  the 
shoulders.  This  latter  illustrates  one  variety  of  the  condition  known  as 
dandruff — of  the  oily  or  greasy  form,  in  contradistinction  to  the  dry 
variety,  pityriasis  capitis  (one  form  of  dermatitis  seborrhoica). 

A  mild  degree  of  crusted  or  scaly  seborrhea  is  sometimes  seen  upon 
the  face,  occasionally  alone,  but  more  commonly  in  conjunction  with  the 
disease  upon  the  scalp ;  its  usual  site  is  about  the  nose,  and  sometimes  on 
the  bearded  region.  As  a  rule,  most  cases  of  a  greasy,  scaly  nature  about 
these  parts  present  a  slightly  or  moderately  inflammatory  basis,  and  be- 
long to  the  domain  of  dermatitis  seborrhoica.  The  surface  is  noted  to  be 
oily,  and  variously  coated  with  a  pasty,  dried,  greasy  film,  or  a  thin, 
cheesy  coating,  and,  especially  about  the  nose,  sometimes  with  dippings 
down  into  the  glandular  openings. 

Rarely  a  similar,  apparently  non-inflammatory,  condition  is  noted 
on  the  chest,  usually  over  the  sternum  and  between  the  scapulae,  and 
is  generally  of  irregular  patchy  or  circinate  formation,  with  projections 
into  the  follicles.  As  a  rule,  however,  an  inflammatory  element  is  added 
in  these  cases,  and  the  picture  is  then  that  of  dermatitis  seborrhoica. 

Crusted  seborrhea  is  also  sometimes  seen  upon  the  glans  and  corona 
of  the  penis,  beneath  the  prepuce,  where  the  secretion  is  usually  relatively 
active,  and,  if  permitted  to  collect,  forms  a  flaky,  irregular,  thin,  cheesy 
coating  which  undergoes  decomposition,  and  causes  more  or  less  irrita- 
tion or  a  positive  balanitis.  The  same  condition  may  arise  in  women, 
about  the  clitoris  and  vulvar  folds,  unless  the  parts  are  frequently 
cleansed,  and  a  vulvitis  results.  Occasionally  the  pubic  region,  like  the 
scalp  and  other  hairy  parts,  is  the  seat  of  a  flaky  or  thin  greasy  coating, 
conjointly  with  oiliness. 

Htiology. — Exclusive  of  the  seborrheic  condition  in  the  new- 
born and  early  infantile  life,  the  malady  is  most  frequent  between  the 
ages  of  fifteen  and  thirty,  when  the  glandular  structures  are  usually  most 
active,  although  it  is  not  uncommon,  especially  in  women,  toward  the 
climacteric.  It  is  met  with  in  both  sexes,  and  with,  upon  the  whole, 
but  little  preponderance  either  one  way  or  the  other.  Those  of  dark 
hair  and  complexion  are  the  usual  subjects  for  the  oily  variety.  General 
debility,  anemia,  chlorosis,  dyspepsia,  and  similar  disorders  are  to  be 
variously  looked  upon  as  contributory,  if  not  causative.  The  disease 
is  also  noted  to  develop  after  severe  constitutional  diseases,  especially 
after  the  various  exanthemata.  Scrofulosis  must  also  be  considered  as 
furnishing  a  good  basis  for  its  production.  Seborrhea  of  the  nose  is 
apparently  due  in  some  cases  to  intranasal  pressure  or  obstruction  (Seiler, 
Besnier,  Doyon,  and  others).  In  some  instances,  it  is  true,  the  disease 
seems  to  be  due  to  a  loss  of  tone  in  the  glands  and  skin,  and  to  be  entirely 
independent  of  any  constitutional  or  predisposing  condition.  The  view 
advanced  in  recent  years,  that  the  disease  is  of  parasitic  nature  and  con- 


IO24 


DISEASES   OF  THE  APPENDAGES 


tagious  (Unna,  Sabouraud,  and  others),  has  been  steadily  gaining  ground, 
and  its  occurrence  in  several  or  more  members  in  certain  families  bears 
as  much  upon  the  question  of  contagiousness  as  it  does  upon  hereditary 
or  family  tendency. 

Pathology. — Seborrhea,  as  observed  in  the  types  just  described, 
is  to  be  considered  as  a  disease  chiefly  and  probably  wholly  of  the 
sebaceous  glands,  and  functional  in  character.  Unna  and  Meissner 
would  have  us  believe  that  the  coil-glands  (sweat-glands)  secrete  the 

oil,  and  that  (Unna)  the  seba- 
ceous glands  are  not  involved 
in  this  malady,  except  secon- 
darily. Unna,  therefore,  sug- 
gests for  the  oily  form  the 
name  hyperidrosis  oleosa,  but 
Beatty's1  investigations  go  to 
show  that  at  least  in  the  oily 
form  and  the  vernix  caseosa 
the  secretion  is  not  a  product  of 
the  sweat-glands.  While  it  is, 
I  believe,  true  that  secretion 
from  the  sweat-glands  does 
contain  oil  at  times,  at  least, 
nevertheless,  one  needs  but  ex- 
amine a  case  of  seborrhea  of 
the  types  here  defined  and  the 
exit  from  the  sebaceous  gland- 
ducts  of  fatty  secretion  is  at 
once  evident.  Moreover,  its 
favorite  situations  are  those 
where  the  sebaceous  glands  are 
most  numerous  and  most 
highly  developed.  Sabouraud2 
does  not  state  it  too  strongly 


Fig.  256. — -Vertical  section  through  the 
scalp  of  a  newborn  child  suffering  from  sebor- 
rhoea  neonatorum  ( X  250) :  e,  Corneous  layer; 
m,  rete  mucosum;  5,  shaft  of  hair;  r,  root  of 
hair,  cut  obliquely;  i,  inner  root-sheath;  o, 
outer  root-sheath;  /,  hair-follicle;  g,  g,  en- 
larged sebaceous  glands,  with  ducts;  d,  d, 
corium;  v,  veins  in  the  corium  (courtesy  of 
Dr.  L.  Heitzmann). 


when  he  says  that  seborrhea 
has  two  essential  symptoms — 
an  overproduction  of  normal 
sebum  and  a  dilatation  of  the 
sebaceous  gland-duct  openings. 

The  oily  secretion  and  the  fatty  collection  found  in  the  gland-ducts 
and  also  that  upon  the  surface  are  chiefly  composed  of  fatty  matter, 
although  Elliot3  found  that  the  plugs  in  the  ducts  were  composed  of 
epidermic  cells,  derived  from  the  epidermic  lining  of  the  follicular  open- 
ing, impregnated  with  fatty  hyper  secretion.  Van  Harlingen,4  who  made 
some  careful  investigations,  concludes  that:  "(i)  The  sebaceous  secretion 

1  Beatty,  "Seborrhea,"  Brit.  Jour.  Derm.,  1894,  p.  161;  also  "The  Functions  of 
the  Glands  of  the  Skin,"  ibid.,  1893,  p.  97  (both  valuable  contributions). 

2  Sabouraud,  Annales  de  Vlnstitut    Pasteur,    1897,   p.    134;  and  Annales,  1897, 
P-  257- 

3  Elliot.  Morrow's  System,  vol.  iii  (Dermatology),  p.  789. 

4  Van  Harlingen,  "The  Pathology  of  Seborrhea  "  Arch.  Derm.,  1878,  p.  97. 


SEBORRHEA  1 025 

is  derived  from  fatty  metamorphosis  of  the  enchyma  cells  of  the  sebaceous 
glands.  These  cells  are  homologous  with  those  of  the  stratum  mucosum 
of  the  skin.  They  have  nothing  in  common  with  the  cells  of  the  horny 
layer.  (2)  Seborrhea  is  a  disease  of  the  sebaceous  glands,  characterized 
by  the  pouring  out  of  an  increased  quantity  of  sebum,  more  or  less  altered 
in  chemical  and  physical  composition.  In  comedo  and  seborrhcea  sicca, 
properly  so  called,  the  secretion  is  condensed  to  a  fatty  consistency, 
while  in  seborrhcea  oleosa  it  remains  in  an  oily  state.  In  each  of  these 
affections,  however,  microscopic  examination  shows  epithelial  cells  in  a 
state  of  more  or  less  complete  fatty  degeneration,  and  breaking  down 
into  granular  debris.  Horny  cells  are  found  only  adventitiously." 

Sabouraud  believes  that  seborrhea  is  due  to  a  short  microbacillus.1 
It  is  always  to  be  found  in  the  upper  part  of  the  hair-follicle,  and  a  sebor- 
rheic, cocoon  which  develops,  containing  the  bacillary  colony,  by  inter- 
fering with  the  function  of  the  hair-papillae,  gives  rise  to  the  secondary 
hair  loss  and  sometimes  permanent  alopecia.  Further  evidence  is,  how- 
ever, needed  before  Sabouraud's  conclusions  can  be  admitted.  Scham- 
berg2  found  this  bacillus  in  individuals  who  presented  no  trace  of  sebor- 
rhea. As  the  observations  of  Unna,  Sabouraud,  Brooke,3  and  others 
show,  the  seborrheic  process  often  has  an  influence  in  materially  influ- 
encing other  cutaneous  eruptions,  notably  eczema,  acne,  acne  rosacea, 
syphilis,  psoriasis,  etc. 

Diagnosis. — Oily  seborrhea  can  scarcely  be  mistaken  for  any 
other  disease;  the  oily,  greasy  character  and  appearances  and  the  region 
involved  are  sufficiently  distinctive.  The  crusted,  scaly  form  is  to  be 
differentiated  from  eczema,  dermatitis  seborrhoica,  psoriasis,  and  possibly 
ringworm.  The  rather  diffused  character  of  seborrhea,  the  greasy,  oily 
nature  of  the  scaliness  or  crusts,  the  absence  of  all  inflammatory  symp- 
toms, the  usually  dilated  gland-ducts,  containing  sebaceous  matter,  are 
points  of  difference  from  those  of  the  several  diseases  named;  moreover,  in 
these  latter  there  are  noted,  except  in  eczema,  rather  sharp  definition  to 
the  areas  and  inflammatory  action.  In  eczema  the  inflammatory  char- 
acter is  sufficient  to  prevent  error.  It  is  true,  however,  that  the  step 
from  seborrhea  to  dermatitis  seborrhoica  is  often  a  short  one. 

Prognosis  and  Treatment.— The  prognosis  of  seborrhea  is 
favorable,  although  it  must  be  said  that  the  disorder  is  sometimes 
obstinate,  and  that  there  is  a  strong  disposition  to  recurrence.  In 
moderately  severe  and  in  severe  cases  of  seborrhea  of  the  scalp,  of  pro- 

1  Tieche,  Archiv,  1908,  vol.  xcii,  p.  125  (with  brief  review  and  some  references),  has 
made  some  investigation  as  to  the  micro-organisms  of  the  scalp,  taking  tissue  from  the 
scalps  of  dead  bodies  as  soon  after  death  as  possible.     He  found  the  Malassez  spores  in 
48  cases — 96  per  cent.;  in  44  per  cent,  seborrhea  bacilli  were  present  in  numbers,  ab- 
normal forms  in  20  per  cent.;  hyphae  and  spores,  having  considerable  resemblance  to 
microsporon  furfur,  were  found  in  10  cachectic  subjects.     A  table  showing  the  relation- 
ship of  bacterial  and  fungous  growths  to  soil  (subjects)  is  added. 

2  Schamberg,  "Remarks  on  the  Microbacillus  of  Seborrhea,"  Jour.  Cutan.  Dis., 
1902,  p.  99. 

3  Brooke,  "The  Relations  of  the  Seborrheic  Processes  to  Some  Other  Affections  of 
the  Skin,"  Brit.  Jour.  Derm.,  1889,  p.  247;  see  also  literature  reference  to  Sabouraud's 
papers  in  connection  with  acne;  also  paper  by  W.  Anderson,  "On  Seborrhea  and  its 
Results,"  ibid.,  1900,  p.  276;  and  by  R.  W.  Taylor,  "The  Seborrheic  Process  and  the 
Early  Syphilitic  Eruptions,"  Jour.  Cutan.  Dis.,  1890,  p.  161  (with  2  good  cuts). 

65 


1026  DISEASES   OF  THE   APPENDAGES 

tracted  duration,  loss  of  hair  is  not  an  unusual  sequence,  although  in 
most  cases,  if  not  too  long  neglected,  a  regrowth  may  be  looked  for. 

In  some  instances  of  seborrhea  local  treatment  alone  is  required; 
in  most  cases,  however,  the  general  condition  is  below  the  normal  stand- 
ard; constitutional  remedies  are  to  be  administered  according  to  indica- 
tions. Chlorosis,  anemia,  and  digestive  disturbances  certainly  seem  to 
have  a  strong  predisposing  influence,  if  not  directly  causative;  and  a 
removal  of  any  of  these  several  conditions  will  often  have  a  favorable 
action  upon  the  disease,  or  make  it  more  promptly  responsive  to  suitable 
local  measures.  Iron,  strychnin,  quinin,  cod-liver  oil,  digestives,  and 
laxatives  are,  therefore,  to  be  prescribed  according  to  the  indications 
in  the  individual  case.  Arsenic  may  be  tried  in  rebellious  cases;  and 
ichthyol  (the  ammonio-sulphate) ,  in  doses  of  5  to  15  grains  (0.3-1.) 
three  times  daily,  is  highly  praised  by  Elliot  for  the  oily  variety.  A 
vaccine1  made  from  the  microbacillus  might  be  tried  in  obstinate  cases. 
In  instances  in  which  the  disease  is  practically  limited  to  the  nose,  the 
possibility  of  intranasal  pressure  or  obstruction  should  be  eliminated,  or, 
if  present,  appropriate  treatment  recommended. 

In  the  management  of  seborrhea  frequent  washing  with  soap  and 
water  is  usually  necessary,  in  order  that  the  parts  can  be  kept  free  from 
the  oiliness  or  crusting,  and  for  this  purpose  a  mild  toilet  soap  can  be 
used,  or  in  those  of  sluggish,  non-irritable  skin  the  tincture  of  green  soap. 
In  obstinate  scalp  cases  to  the  latter  can  be  added  10  to  30  grains  (0.65-2.) 
of  resorcin  to  the  ounce  (32.).  The  frequency  of  the  washing  depends 
upon  the  severity  of  the  disease  and  the  character  of  the  remedies  em- 
ployed; if  the  oil  or  fatty  accumulation  is  rapid,  once  every  two  or  three 
days  would  be  required  for  the  scalp  and  once  daily  for  the  face.  In 
fact,  the  face  requires  such  washing  as  a  routine  measure  once  daily,  and 
preferably  at  bed-time  and  before  the  application  of  the  selected  remedy. 
When  salves  are  employed,  a  certain  amount  of  added  messiness  results, 
especially  upon  the  scalp,  and  cleansing  becomes  more  frequently  neces- 
sary. After  the  disease  becomes  less  active  the  scalp  can  be  washed 
every  three  to  ten  days;  as  a  rule,  however,  frequent  shampooing,  con- 
joined with  remedial  applications  once  or  twice  daily,  is  often  necessary 
in  the  scalp  cases,  especially  those  of  the  markedly  oily  variety.  As  the 
condition  improves  treatment  can  be  less  frequent  and  gradually  inter- 
mitted, or  applications  made  at  intervals  of  several  days.  In  the  removal 
of  the  greasy  collection  in  infants  care  is  to  be  taken  that  the  skin  be  not 
irritated,  for  it  is  an  easy  matter  in  these  cases  to  start  up  eczema ;  strong 
soaps  should  not  be  used,  and  if  the  crusting  is  adherent,  as  it  often  is  on 
the  scalp,  it  can  be  softened  by  oil  applications,  or,  if  persistent,  with 
starch  poultices. 

The  chief  remedies  to  be  employed  in  the  external  treatment  of 
seborrhea  are  resorcin,  sulphur,  ammoniated  mercury,  salicylic  acid, 
and  boric  acid.  Resorcin  is  the  most  valuable,  and  is  prescribed  more 
frequently  and  satisfactorily  as  a  lotion,  i  to  10  per  cent,  strength, 

1  Savill,  Practitioner,  March,  1911,  p.  392,  reports  a  cure  of  a  chronic  case  of  sebor- 
rhcea  oleosa  of  the  scalp  with  vaccine  made  from  the  culture  of  the  microbacillus  of 
Sabouraud. 


SEBORRHEA  IO2/ 

made  up  with  i  part  alcohol  and  3  to  6  parts  water,  or  in  some  cases, 
especially  on  the  scalp,  the  pure  alcoholic  solution  seems  best.  If  too 
drying,  glycerin  can  be  added  to  the  aqueous  lotion,  and  castor  oil  to  the 
alcoholic  one — a  few  minims  to  the  ounce  (32.).  In  those  of  very  light 
or  gray  hair,  if  used,  it  should  be  carefully  and  in  scanty  quantity;  if 
used  freely,  the  hair  becomes  wet  with  it  and  there  often  results  a  dirty 
or  dingy-looking  staining.  Resorcin  may  also  be  used  in  ointment  form, 
made  up  with  vaselin  or  cold  cream,  of  about  the  proportion  of  20  to  60 
grains  (1.3-4.)  to  the  ounce  (32.).  Both  as  a  lotion  and  ointment  the 
weaker  strength  should  be  tried  first,  and  then  the  proportion  increased 
— for  occasionally  this  drug  is  found  to  act  as  an  irritant.  Sulphur  is 
applied  in  but  one  form  to  the  disease  as  it  occurs  upon  the  scalp — as 
an  ointment,  from  \  to  2  drams  (2.-8.)  of  precipitated  sulphur  to  the 
ounce  (32.)  of  petrolatum  or  benzoated  lard.  Ammoniated  mercury,  in 
a  strength  of  from  20  to  60  grains  (1.3-4.)  to  the  ounce  (32.)  of  ointment, 
is  likewise  a  valuable  application — upon  the  whole  probably  less  generally 
useful  than  the  sulphur  ointment,  but  colorless  and  more  elegant.  Sali- 
cylic acid  may  also  be  employed  alone  in  the  form  of  an  ointment,  from 
10  to  30  grains  (0.65-2.)  to  the  ounce  (32.),  but  it  is  more  frequently 
employed  with  sulphur  or  ammoniated  mercury  in  compound  ointments. 

As  a  rule,  the  lotions  are  much  more  efficacious  for  the  oily  form 
than  are  ointments,  and  probably  also  in  the  crusted  variety,  but  in 
the  latter,  when  scale  accumulation  is  at  all  rapid,  ointments  are  often 
demanded,  and,  indeed,  in  some  instances,  act  more  satisfactorily.  A 
good  plan  in  these  cases  is  to  use  a  lotion  up  to  within  a  day  or  two  of  the 
time  for  shampooing,  and  then  to  employ  a  pomade,  resuming  the  lotion 
after  the  shampoo.  Upon  the  whole,  petrolatum  is  a  good  base  for  the 
scalp,  and  often  somewhat  improved  by  i  or  2  drams  (4. -8.)  of  cacao- 
butter  to  the  ounce  (32.);  for  the  face,  cold  cream  can  take  the  place  of 
the  petrolatum.  Davis  commends  highly  a  "stearoglycerid  ointment" 
as  the  ointment  base,1  as  not  being  greasy  and  readily  wrashed  off.  In 
addition  to  the  lotions  already  named  which  may  be  used  for  the  disease 
upon  the  face,  the  sulphur  lotions  employed  in  acne  are  also  of  service 
in  some  instances ;  they  are  to  be  tried  in  weak  proportion  at  first,  as  this 
remedy  sometimes  irritates  in  these  cases.  Carbolic  acid  as  a  lotion  is 
also  useful  in  seborrhea  of  the  scalp,  but  has  the  disadvantage  of  odor; 
it  can  be  prescribed  in  i  to  3  per  cent,  strength,  preferably  in  alcohol, 
and  to  which,  if  found  too  drying,  a  few  minims  of  castor  oil  can  be 
added.  A  lotion  of  corrosive  sublimate  is  also  sometimes  of  service, 
both  for  scalp  and  face  cases,  and  of  either  variety;  it  may  be  used  in 
the  strength  of  i  or  2  parts  to  1000,  and  either  alone  or  with  the  resorcin 
lotion  as  a  base. 

In  the  treatment  of  the  disease  about  the  glans  penis  and  vulva 
frequent  ablutions — twice  daily  at  least — should  be  enjoined.  The 
milder  lotions  of  boric  acid  and  resorcin  have  special  application  on 
these  parts.  Also  weak  lotions  of  zinc  sulphate  and  tannic  acid;  of  the 
former,  i  to  3  or  more  grains  (0.065-0.2)  to  the  ounce  (32.),  or  of  the  latter, 
a  saturated  solution.  A  compound  lotion,  using  the  boric  acid  solution 
1  See  treatment  of  Alopecia  for  formula. 


I028  DISEASES   OF   THE  APPENDAGES 

as  a  basis,  with  the  zinc  sulphate  added,  and  if  there  are  any  abrasions, 
with  the  addition  of  10  or  15  grains  (0.65-1.)  of  finely  powdered  zinc 
oxid  or  bismuth  subnitrate  to  the  ounce  (32.),  often  acts  satisfactorily. 

ASTEATOSIS 

Synonyms. — Asteatodes;  Xerosis;  Asperitudo  epidermidis;  Fr.,  Asteatose;  Ger., 
Asteatose. 

Asteatosis  is  the  opposite  of  seborrhea,  and  is  characterized,  there- 
fore, by  a  diminution  in  the  amount  of  sebum  secreted  by  the  skin.  It 
can,  however,  scarcely  be  called  a  disease,  idiopathic  cases  being  scarcely, 
if  at  all,  known;  but  it  is  a  condition  which  is  associated  with  or  second- 
ary to  several  cutaneous  maladies,  such  as  ichthyosis,  prurigo,  pityriasis 
rubra  pilaris,  scleroderma,  dermatitis  exfoliativa,  long-continued  scaly 
eczema,  etc.  It  is  also  seen  in  old  age,  as  a  part  of  senile  changes  in  the 
skin.  It  is  sometimes  observed  as  a  local  affection  due  to  the  use  of 
agents  which  deprive  the  skin  of  the  fat  secretion,  as  on  the  hands  and 
forearms  of  laundresses,  who  are  obliged  to  keep  these  parts  more  or  less 
constantly  in  strong  alkaline  solutions,  or  who  use  strong  soaps.  In 
such  instances,  while  presenting  the  ordinary  dry,  harsh,  sometimes 
slightly  desquamating  skin  which  characterizes  the  affection,  the  con- 
dition is  not,  in  reality,  due  to  a  diminution  of  the  sebaceous  secretion, 
but  to  its  repeated  removal.  It  is  more  than  probable,  in  those  natur- 
ally having  unpleasantly  dry  skin,  that  the  dry  ness  is  owing  to  lessening 
of  the  secretion  of  both  sebaceous  and  sweat-glands. 

The  treatment  depends  primarily,  when  possible,  on  the  removal 
or  modification  of  the  etiologic  factor — either  a  disease  such  as  men- 
tioned or  the  use  of  strong  alkalis  or  soaps — and  in  supplying  to  the 
skin  that  fat  or  oil  which  it  needs  by  the  continuous  or  intermittent 
application  of  some  bland  oil,  such  as  olive,  linseed,  or  almond  oil  or  liquid 
petrolatum;  or  plain  ointments  are  sometimes  more  satisfactory,  the 
most  available  being  petrolatum,  cold  cream,  benzoated  lard,  with  or 
without  10  to  20  per  cent,  of  lanolin. 

MILIUM 

Synonyms. — Grutum;  Strophulus;  Strophulus  albidus;  Tuberculum  sebaceum; 
Pearly  tubercles;  Acne  albida;  Fr.,  Acne  miliare. 

Definition. — A  small  whitish  or  yellowish,  rounded,  pearly,  non- 
inflammatory formation,  situated  in  the  upper  part  of  the  corium. 

Symptoms. — The  favorite  sites  are  about  the  face,  especially 
about  the  eyelids,  although  they  may  occur,  although  much  less  fre- 
quently, on  other  parts,  more  particularly  on  the  penis  and  scrotum 
and  on  the  labia  majora  and  labia  minora.  The  lesions  are  usually 
pin-head  in  size,  whitish  or  yellowish,  often  with  a  somewhat  pearly 
luster,  and  sometimes  seemingly  more  or  less  translucent.  They  are 
rounded  or  acuminated,  project  slightly  above  the  surface,  and  are 
without  aperture  or  duct.  They  develop  slowly,  their  appearance 
being  insidious,  and  after  reaching  a  certain — variable — size,  usually 
remain  stationary  for  years.  In  number  they  may  be  scanty,  scarcely 


MILIUM 


1029 


more  than  several  being  present,  or  they  may  exist  in  greater  or  less 
profusion.  While  almost  invariably  irregularly  disposed,  exceptionally 
a  tendency  to  grouping  has  been  noted  (Crocker).  Their  presence  gives 
rise  to  no  disturbance;  there  are  no  subjective  symptoms,  and  unless  of 
large  size  or  existing  in  numbers  cause  but  slight  disfigurement.  Occa- 
sionally they  attain  greater  size,  or  two  or  three  may  become  bunched 
or  coalesce,  and  reach  the  dimensions  of  a  small  pea  or  larger.  In  rare 
instances,  and  more  especially  in  milia  of  some  size,  one  or  several  may 
undergo  calcareous  metamorphosis  from  the  deposit  of  carbonate  and 
phosphate  of  lime,  and  become  quite  hard  and  stony,  constituting  the 
so-called  cutaneous  calculi. 

Btiology  and  Pathology.— Milia  are  seen  at  any  age.  They 
are  not  infrequent  in  infants  (so-called  strophulus  albidus).  They  are 
of  common  occurrence  in  adolescence  and  early  adult  life,  especially 
in  women,  and  in  some  instances  are  associated  with  comedo  and  acne. 
They  have  been  noted  to  occur  at  the  sites  of  pemphigoid  lesions  (Baren- 
sprung,  Hebra,  Hallopeau,  Neisser,  Behrend,  Bowen,  and  others),  after 
erysipelas,  and  along  the  edges  of  scars.  In  most  cases,  however,  no 
cause  can  be  assigned. 

The  formation  is  situated  just  beneath  the  epidermis,  which  con- 
stitutes its  external  covering.  In  the  opinion  of  most  writers  the  affec- 
tion results  from  retention  of  sebaceous  matter  in  one  or  more  acini  of  the 
sebaceous  glands,  although  others,  among  wiiom  Virchow,  Rindfleisch, 
and  Unna,  hold  its  seat  to  be  in  the  hair-follicles.  According  to  Neu- 
mann and  others,  the  covering  proper  is  either  the  wall  of  the  hair- 
follicles  or  sebaceous  glands.  Robinson  believes  that  two  different  con- 
ditions have  been  described  under  this  name,  and  that  "where  the  for- 
mation is  superficially  seated,  contains  no  fatty  epithelium,  shows  no 
connection  with  a  sebaceous  gland,  and  no  duct  in  connection  with 
it,  it  is  a  case  of  miscarried  embryonic  epithelium  from  a  hair-follicle 
or  from  the  rete;  the  lesion  consisting  of  somewhat  lobulated  collec- 
tions of  corneous-like  cells,  the  whole  collection  being  surrounded  by  a 
more  or  less  perfectly  formed  capsule,  from  pressure  exercised  by  the 
growing  new  formation,  and  provided  with  septa  of  fibrous  connective 
tissue."  Philippson  also  holds  this  view. 

In  most  milia  the  contained  mass  is  made  up  of  closely  packed  seba- 
ceous matter,  with  a  disposition  in  some  instances  to  become  inspissated 
and  calcareous. 

Diagnosis. — Milium  is  to  be  distinguished  from  comedo  by  the 
absence  of  the  duct  orifice  and  blackish  point  of  the  latter.  Somewhat 
large  and  flattened  milia  may  present  a  faint  suggestion  of  xanthoma, 
but  this  latter  disease  (q.  v.)  is  of  so  entirely  different  nature  that  a  mis- 
take can  scarcely  occur.  The  central  depression  and  aperture  and  larger 
size  of  molluscum  contagiosum  lesions  will  prevent  its  confusion  with  the 
latter. 

Prognosis  and  Treatment.— Milia  are  persistent,  with  little, 
if  any,  tendency  to  spontaneous  involution,  except  in  infants,  in  whom, 
after  a  variable  time,  they  usually  disappear.  They  are  benign,  have 
no  prejudicial  influence,  and  are  rapidly  amenable  to  treatment. 


1030  DISEASES   OF  THE   APPENDAGES 

Occurring  in  infants  and  young  children,  the  free  use  of  soap  and 
water,  and  the  occasional  application,  by  rubbing  in,  of  mild  sulphur 
ointment,  from  20  to  40  grains  (1.33-2.65)  to  the  ounce  (32.),  will  often 
suffice  to  bring  about  the  disappearance  of  the  lesions.  In  others, 
and  more  especially  in  adults,  mild  operative  interference  is  necessary. 
This  consists  in  puncturing  the  little  growths,  squeezing  out  their  con- 
tents, and  in  the  larger  lesions  touching  the  interior  with  silver  nitrate 
or  a  weak  carbolic  acid  lotion,  from  20  to  30  grains  (1.33-2.)  to  the  ounce 
(32.)-  Electrolysis  is  an  available  and  satisfactory  method.  In  the 
rare  cases  in  which  the  contents  become  calcareous  superficial  curetting 
or  a  small  incision  and  shelling  out  the  contained  mass  will  be  required, 
followed  by  slight  cauterization  as  already  indicated.  In  older  children 
and  adults,  when  the  lesions  are  quite  numerous  and  somewhat  closely 
crowded,  the  use  of  a  peeling  paste  (see  Acne)  will  commonly  cause  them 
to  be  exfoliated.  The  careful  application  of  soft  soap  sufficiently  long 
to  produce  a  mild  dermatitis  is  also  likely  to  have  the  same  result. 

STEATOMA 

Synonyms. — Sebaceous  cyst;  Sebaceous  tumor;  Atheroma;  Wen;  Fr.,  Steatome; 
Kystesebace;  Atherome;  Ger.,  Follikelcyste;  Balggeschwulst;  Atherom;  Breigeschwulst; 
Griitzbeutel. 

Definition. — A  variously  sized,  elevated,  rounded  or  semiglob- 
ular,  soft  or  firm,  painless  tumor,  having  its  seat  in  the  skin  or  sub- 
cutaneous tissue. 

Symptoms. — The  favorite  regions  for  the  development  of  seba- 
ceous cysts  are  the  scalp,  face,  back,  and  scrotum.  They  are  usually 
of  slow  and  insidious  growth,  often  taking  months  to  reach  any  con- 
spicuous size.  After  attaining  variable  proportions,  from  a  pea  to  that 
of  a  walnut  or  larger,  they  may  remain  stationary.  The  overlying 
skin  is  normal  in  color,  or  it  may  be  whitish  or  pale  from  distention. 
In  some  a  gland-duct  orifice  is  seen,  but,  as  a  rule,  this  is  absent.  In 
the  former,  which  is  most  commonly  observed  on  the  back  and  neck, 
the  tumor  is  somewhat  flattened,  often  quite  markedly  so,  spreading  out 
laterally  rather  than  extending  upward.  In  that  in  which  the  duct  is 
obliterated  the  formation  is  usually  semiglobular  or  well  rounded,  and 
often  projects  considerably  above  the  skin  level.  A  rounded  growth 
similar  to  this  is  sometimes  observed  in  connection  with  the  Meibomian 
glands,  and  known  as  chalazion,  although  much  smaller  in  size. 

Sebaceous  cysts  may  exist  indefinitely  without  causing  any  dis- 
comfort except  their  inconvenience  and  disfigurement.  Exceptionally, 
however,  especially  in  the  enormously  distended  growths,  from  irrita- 
tion, traumatism,  or  some  change  in  their  contents,  they  become  slightly 
or  moderately  inflamed,  the  overlying  skin  reddens,  and  suppuration 
and  ulceration  may  result,  and  rarely  such  a  lesion,  in  old  people,  may 
finally  show  a  papillomatous  tendency  and  even  epitheliomatous  change. 
In  those  in  which  the  duct  is  not  obliterated  this  at  times  may  close  up 
temporarily,  the  tumor  fill  and  become  more  prominent;  later  the  orifice 
opening  again,  and  some  of  the  contents  finding  egress,  and  the  growth 
flattening  down  somewhat;  this  may  repeat  itself  from  time  to  time.  It 


STEATOMA  1031 

is  usually  from  the  smaller  patulous  sebaceous  cysts  that  cutaneous  horns 
sometimes  develop.  The  growths  are,  as  a  rule,  of  somewhat  doughy 
consistence,  although  with,  in  the  more  distended  tumors,  variable  elas- 
ticity; in  some  instances  they  are  quite  soft;  in  others  distinctly  hard. 
They  are  often  freely  movable.  The  integument  over  the  larger  cysts 
on  hairy  parts,  especially  the  scalp,  is  commonly  entirely  devoid  of  hair. 

In  most  cases  but  one  tumor  is  present,  although  it  is  not  at  all 
uncommon  to  see  two  or  three.  In  exceptional  instances — probably 
mostly  examples  of  multiple  dermoid  cysts1 — they  have  been  present 
in  numbers,  and  generally  scattered  over  the  surface,  and  usually  scarcely 
distinguishable  clinically  from  fibroma. 

Etiology  and  Pathology. — The  causes  of  sebaceous  cysts  are 
not  known,  although  thought  to  be  due  to  the  same  agencies  operable 
in  comedo,  such  as  duct  occlusion.  Torok  and  Chiari's  studies,  made  in- 
dependently, have  led  them  to  believe  that  the  majority,  if  not  more, 
of  steatomata  are  more  properly  dermoid  cysts,  and  arise  from  embryonic 
remnants  in  the  skin,  as  previously  indicated  by  the  investigations  of 
Heschl  and  Frank.  Virchow,  Robinson,  and  almost  all  others  have 
classed  them  with  retention  cysts,  and  this  is  the  prevailing  view  to-day — 
being  cysts  of  the  sebaceous  glands.  Winiwarter  would  include  them 
among  cysto-adenomata,  with  primarily  a  new  growth  of  gland  tissue 
and  subsequent  transformation  into  a  cystic  tumor.  The  growth  con- 
sists of  a  capsule  and  contents,  the  former  composed  of  fibrous  connective 
tissue.  The  contents  are  found  somewhat  variable  as  to  consistence 
and  substance;  usually  made  up  of  a  hard  and  friable,  or  cheesy  and  soft, 
sometimes  quite  fluid,  mass,  of  a  whitish  or  yellowish  color,  and  often 
with  a  fetid  odor.  For  the  most  part  they  contain  sebum,  epidermic  cells, 
cholesterin  crystals,  detritus  and  sometimes  hairs,2  and  occasionally 
lime-salts. 

Diagnosis. — A  sebaceous  cyst  is  usually  readily  recognized 
when  its  course,  slow  growth,  and  other  features  are  considered.  Those 
with  patulous  ducts  through  which  some  of  the  contents  can  be  squeezed 
out  scarcely  admit  of  difficulty.  The  closed  cyst  is  not  to  be  confused 
with  lipoma,  fibroma,  and  gumma.  The  lobular  character  of  the  fatty 
tumor  will  generally  serve  to  differentiate.  The  sites  of  fibromata  are, 
as  a  rule,  different  from  those  of  sebaceous  growths,  and  they  are  com- 
monly multiple,  whereas  the  latter  are  rarely  present  in  greater  number 
than  one  or  two,  or,  at  the  most,  several.  In  those  exceptional  instances 
— dermoid  cysts — a  microscopic  examination  may  be  necessary.  Gum- 
mata  grow  more  rapidly,  are  usually  painful  to  the  touch,  are  not  freely 
movable,  and  tend  to  break  down  and  ulcerate.  Cold  abscesses  can 
scarcely  be  confounded  with  steatomata,  although  those  instances  of  the 

1  Jamieson,  Edinburgh  Med.  Jour.,  Sept.,  1873,  p.  223  (250  tumors);  Maclaren, 
Edinburgh  Med.-Chir.  Soc'y  Trans.  (1886-87),  1888,  p.  77  (132  tumors);  Chiari,  Zeit- 
schriftfur  Heilkunde,  1891,  vol.  xii,  p.  189,  also  met  with  an  instance  in  which  several 
hundred  were  scattered  over  the  entire  surface;  Pollitzer,  Jour.  Cutan.  Dis.,  1891,  p. 
281  (150;  many  yellowish  and  simulating  multiple  xanthoma  in  appearance). 

2  In  a  case  under  my  observation  (reported  in  Philada.  Med.  Times,  March,  24, 
1885)  the  cyst,  on  the  bearded  part,  contained  a  coil  of  hair  which,  when  unwound,  was 
found  to  consist  of  two  hairs,  one  6  inches  in  length  and  the  other  4^  inches. 


1032  DISEASES   OF  THE   APPENDAGES 

latter  which  become  inflamed  and  suppurate  bear  some  suggestive  re- 
semblance. The  sebaceous  tumors  should  not  be  confused  with  the 
growths  of  molluscum  contagiosum. 

Prognosis  and  Treatment. — The  only  consequences  of  the 
presence  of  sebaceous  cysts  are  the  inconvenience  and  disfigurement. 
They  are  benign  formations,  but  show  no  tendency  to  spontaneous  dis- 
appearance. 

The  treatment  of  the  tumor  is  by  surgical  methods.  A  linear  incision 
is  made,  and  the  mass  and  enveloping  sac  are  dissected  out.  If  the  latter 
remain,  a  regrowth  almost  invariably  takes  place.  Other  plans  have 
occasionally  been  resorted  to,  such  as  slight  incision,  expulsion  of  the 
contents  by  pressure,  and  the  injection  of  some  irritating  fluid,  such  as 
tincture  of  iodin  or  silver  nitrate  solution.  Caustic  destruction  has  also 
had  some  use,  but  the  best  and  safest  plan  is  that  by  excision.  In  small 
or  beginning  tumors  a  slight  incision  and  expulsion  of  the  contents, 
and  then  the  application,  at  several  points  of  the  cavity,  of  the  electric 
needle  (electrolysis),  will  sometimes  suffice  to  bring  about  permanent 
removal. 

COMEDO 

Synonyms. — Blackhead;  Fr.,  Comedon;  Ger.,  Comedon;  Mitesser. 

Definition. — Comedo  is  a  disorder  of  the  sebaceous  glands  or 
gland-ducts,  characterized  by  yellowish  or  blackish,  pin-point-  or  pin- 
head-sized  puncta  or  elevations,  corresponding  to  the  gland  orifices. 

Symptoms. — Comedones  are  most  usually  observed  on  the  face 
only,  upon  which  they  may  develop  on  all  parts,  but  are  frequently 
in  greatest  number  and  sometimes  solely  to  be  seen  about  the  angles 
of  the  nose,  the  chin,  especially  near  the  mouth  angles,  and  at  the  sides 
of  the  temple,  particularly  toward  the  outer  canthus.  They  are,  how- 
ever, often  seen  scattered  irregularly  over  the  face  region,  and  may  be 
sparse  in  number  or  in  great  profusion.  The  back  is  also  a  not  infre- 
quent site,  and  in  exceptional  instances  they  have  been  observed  upon 
the  penis  (Lang).  They  appear  to  be  yellowish,  dirty  gray,  or  black  points 
or  dots.  They  may  be  on  a  level  with  the  skin,  or  scarcely  perceptibly 
depressed  or  somewhat  elevated  (acne  punctata).  They  are  frequently 
associated  with  oily  seborrhea,  the  parts  presenting  a  greasy  or  soiled 
appearance.  Even  without  the  seborrheic  association  the  blackheads, 
if  numerous,  give  the  face  a  dingy  or  dirty  aspect.  Acne  may  also  be 
present,  either  to  a  slight  or  marked  degree,  but  they  are  often  observed 
without  a  single  associated  inflammatory  lesion.  They  vary  somewhat 
in  size,  generally  larger  near  and  on  the  nose  and  on  the  back;  in  the  latter 
region,  when  present  at  all,  they  are  almost  invariably  large  and  numer- 
ous. In  such  cases,  too,  the  breast,  and,  in  some  instances,  the  abdomen 
as  well,  show  the  formations.  There  is  in  the  average  case  scarcely 
perceptible  elevation,  unless  the  amount  of  retained  secretion  or  accumu- 
lation is  excessive.  Upon  pressure  this  can  be  ejected,  the  small  rounded 
orifice  through  which  it  is  expressed  helping  to  give  it  a  rounded,  thread- 
like shape — hence  the  names,  "flesh-worms"  and  "grubs."  The  so-called 
double  or  multiple  comedo,  usually  upon  the  back,  and  not  at  all  infre- 


COMEDO  1033 

quent  upon  this  region,  to  which  Ohmann-Dumesnil1  first  directed  atten- 
tion, consists  simply  of  somewhat  closely  contiguous  blackheads,  which 
are  beneath  the  surface  intercommunicable,  having  a  common  glandular 
chamber. 

The  course  of  comedo  is  chronic,  the  condition  persisting  indefinitely 
or  being  somewhat  variable;  sometimes  the  plugs  loosen  and  are  dis- 
lodged by  the  muscular  motion  of  the  part  or  by  the  act  of  wa  hing. 
In  extremely  rare  instances  slight  atrophic  scarring  is  observed  to  de- 
velop at  the  follicular  orifices  (Lang,  Neumann).2  Not  infrequently, 
from  some  alteration  in  the  imprisoned  accumulation,  either  as  a  conse- 
quence of  pressure  or  possibly  from  a  chemical  change  or  an  added  micro- 
bic  factor,  inflammation  is  excited,  and  a  papular  or  pustular  acne  lesion 
results. 

Exceptionally  comedones  occur  as  distinct  and  usually  symmetric, 
densely  crowded  groups,  more  especially  upon  the  forehead  or  the  cheeks. 
This  peculiar  variety  or  anomaly  was  first  described  by  Thin,3  and  sub- 
sequently by  Crocker4  and  Wetherill;5  it  is,  however,  extremely  rare. 
There  is  no  tendency  to  suppuration,  and  the  affection  does  not  seem  to 
bear  the  relationship  to  acne  that  ordinary  comedo  does.  Moreover, 
they  are  usually  smaller  than  the  latter.  Crocker  states  that  dyspepsia 
is  the  most  common  cause,  and  as  "they  occur  chiefly  on  those  parts 
where  flushing  after  meals  is  most  marked,"  this  latter  is  probably  of  some 
etiologic  influence. 

Exceptionally,  too,  according  to  the  observations  of  Crocker,6 
Caesar,7  and  Colcott  Fox,8  somewhat  densely  crowded  comedones  occur 
in  very  young  children,  usually  on  the  forehead  and  occipital  region, 
against  which  the  hat-band  presses,  and  also  on  the  cheeks  in  infants — 
the  part  which  comes  in  contact  with  the  mother  in  nursing.  On  the 
forehead,  Colcott  Fox  states,  the  areas  tend  to  join  and  form  a  continu- 
ous band,  scarcely  a  follicle  escaping.  It  would  appear  that  warmth  and 
moisture  were  partly  etiologic,  and,  according  to  Crocker,  Colcott  Fox, 
Haddon,  and  others,  it  sometimes  develops  simultaneously  in  several 
of  a  family,  and  also  in  schools,  suggesting  a  contagious  or  bacterial 
factor.  So  far  as  I  know  no  similar  cases  have  been  reported  in  this 
country. 

IJtiology. — The  contributory  factors  of  comedo  are  essentially 
those  of  acne — disorders  of  digestion,  constipation,  chlorosis,  men- 
strual irregularities,  lack  of  tone  in  the  muscular  fibers  of  the  skin,  with, 

1  Ohmann-Dumesnil,  Jour.  Cutan.  Dis.,  1886,  pp.  33  and  193,  and  Monatshefte, 
1888,  p.  57  (with  2  plates,  containing  13  cuts),  and  St.  Louis  Med.  and  Surg.  Jour., 
1888,  Jan.,  Feb.,  March. 

-  Cited  by  Crocker,  Diseases  of  the  Skin. 

3  Thin,  "Grouped  Comedones,"  Lancet,  1888,  ii,  p.  712. 

4  Crocker,  "Symmetrically  Grouped  Comedones,"  ibid.,  1888,  ii,  p.  813. 

5  Wetherill,  "Symmetrically  Grouped  Comedones,"  ibid.,  1889,  i,  p.  169. 
8  Crocker,  Lancet,  1884,  i,  p.  704. 

7  J.  Caesar,  ibid.,  1884,  i,  p.  1188  (letter  communication). 

8  Colcott  Fox,  ibid.,  1888,  i,  p.  665;  Harries,  Brit.  Jour.  Derm.,  igii,  p.  5,  reports  4 
cases  of  grouped  comedones,  in  young  children,  aged  six  months,  nine  months,  one  and 
one-half  years,  and  three  and  one-half  years  (chiefly  on  the  cheeks);  suggests  that 
pressure  and  friction  against  the  soiled  garment  of  the  mother  might  be  of  some  import 
in  its  production. 


1034 


DISEASES   OF  THE  APPENDAGES 


often,  the  infrequent  use  of  soap  and  working  in  a  dirty  and  dusty 
atmosphere.  Contact  with  tar  oils  and  petroleum  products  are  of  im- 
port in  some  instances.  In  some  cases  a  predisposing  constitutional 
element  seems  entirely  wanting.  It  is  most  common  at  the  developing 
age,  from  puberty  up  to  thirty,  when  the  cutaneous  glandular  structures 
are  most  active.  It  is  observed  in  both  sexes,  but  more  frequently, 
according  to  my  experience,  in  males.  The  microbacillus  of  Unna, 
Hodara,  and  Sabouraud,  referred  to  in  acne,  is  looked  upon  by  these 
observers  as  of  causative  influence.  The  small  parasite — demodex  follic- 

ulorum  (acarus  folliculorum)  of  Henle 
and  Simon — often  found  in  the  seba- 
ceous mass  is  without  etiologic  signifi- 
cance, as  it  is  also  found,  in  healthy 
follicles,  although  the  same  or  a 
similar  organism  is  pathogenic  in  dogs 
in  provoking  a  follicular  inflammation. 
Pathology — Pathologically  the 
initial  step  in  the  production  of  a 
comedo  is  a  blocking-up  of  the  gland- 
opening.  Unna  believes  this  to  be 
due  to  a  thickening  of  the  corneous 
layer,  both  at  the  outlet  and  within 
the  duct;  and  that  the  microbacillus 
may  be  the  exciting  factor.  Kaposi 
is  inclined  to  believe  that  this  in- 
crease within  the  duct  is  due  to  the 
irritation  of  the  lanugo  hair,  which, 
instead  of  finding  egress  at  the  orifice, 
impinges  against  the  opposite  duct- 
wall;  he  bases  this  view  upon  the 
demonstration  made  by  Biesiadecki 
that  this  latter  often  happens,  due 
to  the  fact  that  the  hair-follicle 
often  stands  out  almost  at  right 

angles  from  the  sebaceous  gland-duct.  It  is  possible,  too,  that  a  relaxed 
condition  of  the  arrectores  pilorum  muscles  may  also  be  instrumental 
in  their  production  by  permitting  the  secretion  to  collect  and  harden. 
The  comedo  plug  is  composed  of  epidermic  cells  and  debris  with  seba- 
ceous matter;  this  latter  may  accumulate  to  a  considerable  extent  within 
the  gland,  and  from  pressure  cause  atrophic  destruction  of  the  structure 
(Barensprung).  To  this  pressure  atrophy  Ohmann-Dumesnil  ascribes 
the  origin  of  the  single  glandular  chamber  with  the  multiple  ducts 
(multiple  comedo),  although  During1  believes  that  it  is  due  to  previous 
destruction  from  suppurative  acne  lesions.  The  plug  frequently  con- 
tains organisms  other  than  those  already  named,  but  of  no  pathogenic 
import,  and  occasionally  one  or  more  minute  lanugo  hairs.  The  outer 
layer  of  the  sebaceous  mass  is  usually  somewhat  firm,  composed  of  epi- 
dermic horny  material.  According  to  Colcott  Fox,  in  the  peculiar  com- 
1  During,  Monatshefte,  1888,  p.  401. 


Fig.  257. — Comedo,  showing  dis- 
tention  of  duct  and  slight  glandular 
disintegration  (greatly  magnified) 
(courtesy  of  Dr.  T.  C.  Gilchrist). 


COMEDO  1035 

edo  eruption  in  children  the  plug  is  apparently  formed  from  the  epithelial 
lining  of  the  follicle  and  not  from  sebum.  The  dark  point  which  or- 
dinarily marks  the  comedo  is  probably  in  some  instances  due  to  accumu- 
lation of  dirt,  but  as  it  often  occurs  in  those  in  whom  this  is  scarcely  pos- 
sible, I  am  inclined  to  share  Unna's1  opinion  that  it  is  due  to  pigment 
(ultramarine)  derived  from  the  secretions.  It  is  probable,  too,  that 
exposure  to  air  and  light  may  have  some  influence  in  its  production. 

Diagnosis. — A  condition  so  well  known,  and  in  which  the  pa- 
tients usually  make  the  diagnosis  themselves,  certainly  offers  no  difficulty 
in  its  recognition.  It  can  scarcely  be  confounded  with  milium,  as  in  this 
latter  there  is  no  open  outlet,  no  blackish  point,  and  the  contents  cannot 
be  readily  squeezed  out,  unless  the  lesions  had  been  previously  punc- 
tured or  incised. 

Prognosis  and  Treatment — As  a  rule,  with  proper  manage- 
ment, the  tendency  to  blackhead  formation  cannot  only  be  materially 
lessened,  but  removed.  This  presupposes,  however,  persistence  and 
cooperation  on  the  patient's  part.  It  is  true  that  some  cases  are  obsti- 
nate, and  the  ducts  sometimes  fill  up  again  and  again  before  success  is 
reached.  The  general  management  is  practically  the  same  as  in  acne, 
the  digestion  and  the  condition  of  the  bowels  often  needing  attention, 
and  not  infrequently  in  women  advice  as  to  proper  regulation  and  treat- 
ment of  menstrual  irregularities.  The  most  useful  and  most  frequently 
prescribed  remedies  are  cod-liver  oil,  in  strumous  and  debilitated  sub- 
jects, and  iron,  arsenic,  mix  vomica,  and  other  tonics;  ergot  is  sometimes 
useful  in  those  cases  in  which  there  is  lack  of  muscular  tone.  Hygienic 
measures,  such  as  general  and  local  bathing,  calisthenics,  and  open-air 
life  are  of  service.  Upon  the  whole,  the  most  commonly  efficient  general 
treatment  consists  of  laxatives  and  digestives,  with  supervision  of  the 
dietary,  general  bathing,  and  sufficient  exercise.  In  recent  years  favor- 
able action  has  been  reported  from  the  use  of  acne  bacillus  vaccine. 

The  local  treatment,  which  is  also  practically  similar  to  that  of  acne 
(q.  v.),  is  of  essential  importance,  and  in  some  cases  the  sole  measure 
indicated.  It  has  in  view  a  removal  of  the  sebaceous  plugs  and  stimula- 
tion of  the  glands  and  skin  to  healthy  action.  A  procedure  of  value 
consists  in  steaming  nightly  the  parts  for  from  five  to  fifteen  minutes, 
or  the  application  of  water  as  hot  as  can  be  comfortably  borne;  washing 
with  ordinary  toilet-soap  in  some  cases,  and  if  the  skin  is  not  oversensitive, 
with  green  soap  or  its  tincture.  The  soap-washing  should  precede  the 
steaming  or  hot-water  application.  The  application,  two  or  three 
times  weekly,  of  a  fairly  strong  faradic  current — sufficiently  strong  to 
produce  slight  muscular  action — has  been  of  material  advantage  in  many 
of  my  cases.  The  daily  use  of  an  exhaust  cup, — cupping-glass  not  over 
an  inch  opening, — going  over  the  face  thoroughly,  is  often  of  great  service 
not  only  as  a  measure  of  massage,  but  it  tends  to  empty  some  follicles 
and  loosen  the  secretion  in  others.  The  plugs  are  also  to  be  removed 
by  mechanical  means — by  lateral  pressure  with  the  finger-ends  or  by 
means  of  a  fenestrated  curet-shaped  or  a  watch-key-like  instrument 

1  Unna,  "Woraus  besthet  der  schwarze  Punkt  der  Comedpnen?"  Virchow's  Archiv, 
1880,  vol.  Ixxxii,  p.  175;  also  Unna's  Histopathology. 


1036  DISEASES   OF  THE  APPENDAGES 

now  to  be  had  in  the  shops.  Such  removal  may  often  be  facilitated  by 
first  insinuating  a  fine  needle  and  gently  loosening  the  plug  from  the  em- 
brace of  the  gland-duct.  The  ducts  should  be  again  emptied  as  soon  as 
they  refill,  which  may  occur  several  times.  Just  before  the  remedial 
application,  after  the  hot- water  washing,  etc.,  the  parts  should  be  dashed 
with  cold  water.  These  adjunct  and  preliminary  measures  are  to  be 
supplemented  by  remedial  applications,  which  are  essentially  the  same 
as  those  employed  in  the  treatment  of  acne.  The  sulphur  preparations 
are,  upon  the  whole,  the  most  useful,  although  exceptionally  they  seem 
to  aggravate  the  condition.  Of  the  mercurials,  corrosive  sublimate  is 
the  best,  in  the  strength  of  from  |  to  3  grains  (0.033-0.2)  to  the  ounce 
(32.)  of  water,  applied  nightly,  and  sometimes  twice  daily.  When  slight 
roughness  or  bran-like  scaliness  supervenes  or  any  irritation  of  the  skin 
arises,  active  remedial  treatment  is  to  be  relaxed  and  soothing  applica- 
tions made  for  a  few  nights. 

A  paste-like  application,  warmly  commended  by  Van  Harlingen1 
as  of  special  value  in  loosening  the  sebaceous  plugs,  is  one  consisting 
of  acetum,  oij  (8.);  glycerin,  oiij  (12);  kaolin,  oiv  (16.).  This  is  spread 
over  the  surface  at  night,  the  eyes  being  kept  shut  during  its  applica- 
tion, owing  to  the  pungency  of  the  vinegar.  For  other  applications 
the  reader  is  referred  to  the  article  on  Acne,  the  best  among  which  will 
be  found  to  be  the  lotion  of  zinc  sulphate  and  potassium  sulphuret,  and 
the  stronger  resorcin  lotions  and  pastes. 

Patulous  ducts  can  often  be  made  somewhat  smaller  by  the  electric 
needle  (electrolysis) ;  also  by  a  course  (8  to  10)  of  mild  to  moderate  ex- 
posures to  the  x-ray. 

ACNE 

Synonyms. — Acne  vulgaris;  Acne  disseminata;  Acne  simplex;  Fr.,  Acne;  Ger., 
Acne  vulgaris;  Akne;  Finnen. 

Definition. — An  inflammatory  disease,  usually  chronic,  of  the 
sebaceous  glands  of  the  face,  face  and  shoulders,  upper  trunk,  and  occa- 
sionally of  the  back,  characterized  by  papules,  tubercles,  or  pustules, 
and  sometimes  nodules,  or  a  combination  of  these  lesions,  and  commonly 
met  with  between  the  ages  of  thirteen  and  thirty. 

Symptoms. — The  most  common  site  for  the  disease  is  the  face, 
and  it  is  generally  limited  to  this  region;  in  many  cases,  however,  it 
is  not  infrequent  to  see  several  lesions,  and  sometimes  a  large  number, 
on  the  neck  and  shoulders  as  well,  and  occasionally  some  on  the  upper 
trunk;  exceptionally  the  back  is  the  chief  seat,  extending  from  the  neck 
to  the  sacrum,  and  in  rare  instances  the  eruption  may  be  limited  to  this 
latter  region,  with  lesions  also  on  the  anterior  surface  of  the  trunk. 

The  eruption  may  be  insignificant,  consisting  of  but  several  or 
more  scattered  lesions,  or  it  may  be  abundant;  in  average  cases  there 
are  usually  30  to  40  present.  Exceptionally  the  eruption  may  appear 
somewhat  acutely,  a  moderate  or  large  number  of  lesions  presenting  in 
the  course  of  one  or  two  weeks;  as  a  rule,  however,  it  begins  slowly  and 
insidiously.  The  eruption  is  generally  made  up  of  small  pale-red,  bright 
1  Van  Harlingen,  Handbook  of  Skin  Diseases. 


ACNE 


1037 


or  dark-red  pin-head  to  pea-sized  or  larger  papules  and  some  pustules. 
The  base  is  slightly,  moderately,  or  markedly  inflammatory.  Taking 
a  common  example  of  the  disease,  there  will  be  noted,  irregularly  scattered 
over  the  face,  usually  more  numerous  on  the  forehead,  chin,  and  over  the 
lower  jaw,  30  to  50  pin-head-  to  pea-sized  papules,  tubercles,  or  pustules, 
or,  more  frequently,  a  mixture  of  these  lesions  (acne  vulgaris) ,  and  in  the 
various  stages  of  evolution  and  involution  or  subsidence;  interspersed 
are  usually  to  be  seen  comedones  (blackheads),  and  not  infrequently  the 
same  formation  or  the  blocked-up  gland-duct  is  readily  recognizable 
in  the  center  of  the  apex  of  the  smaller  papules.  The  lesions  may  be 
somewhat  acute  in  character,  with  a  hyperemic  inflammatory  base, 
or  they  may  be  sluggish;  or  some  are  distinctly  inflammatory  and 
others  but  sluggishly  so. 
In  many  of  these  cases  the 
skin  seems  relaxed,  thick, 
dirty,  and  greasy,  usually 
from  a  slight  or  moderate 
oily  seborrhea  which  fre- 
quently coexists;  in  such 
instances  particularly  the 
gland  outlets  are  often  large 
and  quite  conspicuous.  If 
a  pustular  lesion  is  squeezed, 
a  mixture  of  pus  and  seba- 
ceous matter  is  discharged, 
and  occasionally  a  small 
thickened  mass  which 
faintly  suggests  a  core.  In 
the  course  of  several  days 
or  a  few  weeks  pustular 
lesions  have  dried  or  been 
broken  and  discharged  and 
partly  or  completely  dis- 
appeared; papules,  and 
tubercles  if  present,  will 
have  gradually  vanished  by 
absorption,  or,  as  more 
commonly  occurs,  they  be- 
come pustular,  and  rapidly 

or  slowly  dry  or  discharge,  and  disappear,  usually  without  leaving  a 
trace  more  than  a  reddish  stain,  which  finally  fades.  During  this  time, 
however,  new  lesions  are  presenting  and  going  through  the  same  evolu- 
tion and  involution  stages.  Thus  the  case  goes  on,  with  slight  or  marked 
fluctuations  between  better  and  worse — slight  and  relatively  few  in  num- 
ber at  times,  sluggish  or  inflammatory  and  the  lesions  numerous  at  other 
periods.  In  many  cases,  after  some  months  to  several  years,  or  more, 
the  eruption  may,  and  frequently  does,  begin  to  decline,  the  new  lesions 
gradually  diminishing  in  numbers,  and  finally  the  patient  is  entirely  free. 
In  other  instances  there  may,  on  the  average,  be  but  5  to  10  lesions 


Fig.  258. — Acne  of  small  papular  and  papulo- 
pustular  type,  with  numerous  comedones — "black- 
heads." 


1038 


DISEASES   OF  THE  APPENDAGES 


present,  and  with  intervals  of  several  days  or  a  few  weeks  in  which  no 
eruption  at  all  is  to  be  seen;  several  cropping  out  irregularly  when  the 
patient  suffers  from  digestive  disturbance,  constipation,  and  in  girls  and 
women  at  the  menstrual  epochs.  On  the  other  hand,  in  some  patients 
100  or  200  or  more  are  found,  here  and  there  close  together  or  irregularly 
scattered,  not  only  over  the  face,  but  the  shoulders  and  upper  part  of  the 
trunk.  In  occasional  cases  the  hyperemic  element  is  quite  pronounced, 
and  if  the  lesions  are  near  together,  the  condition  and  appearances  ap- 
proach those  of  acne  rosacea. 

The  above  is  the  usual  picture  encountered,  and  generally  no  scarring, 
or  no  perceptible  scarring,  results,  the  patient  finally  recovering  without 


Fig.  259. — Acne  of  the  papular,  pustular,  and  indurated  or  boil-like  type,  with 
a  general  "muddy"  complexion,  in  a  woman  aged  twenty-two,  of  several  years'  dura- 
tion; some  minute,  pit-like  scars  left  by  former  lesions  are  noticeable  on  the  cheeks. 

a  trace  of  the  previous  eruption.  This  is,  however,  unfortunately  not 
always  so,  as  slight  tissue  destruction  or  atrophic  changes  producing  per- 
manent marks  sometimes  occur,  and  in  such  cases  this  tendency  dis- 
tinctly predominates  so  that  the  marks  are  usually  quite  numerous. 
The  large,  purulent,  deep-seated  lesions  and  the  dermic  abscess  type  to 
be  referred  to  often  leave  very  distinct  cicatrices. 

The  so-called  clinical  varieties  are  named  from  the  predominant 
type  of  lesions  present,  and  from  the  accidental  or  coincident  character 
of  the  inflammatory  process  and  the  resulting  changes.  Thus  an  acne 
lesion  usually  begins  by  a  blocking-up  (comedo)  of  the  sebaceous  gland 
outlet  and  a  mild  degree  of  hyperemia  and  inflammation  results,  which 


ACNE 


1039 


causes  a  slight  elevation,  generally  with  a  central  blackish  or  dirty  gray 
or  yellowish  point,  and  the  majority  or  most  of  the  lesions  may  exhibit 
but  little  tendency  to  advance  beyond  this  stage,  and  such  instances 
constitute  acne  punctata.  As  a  rule,  however,  the  inflammation  is  of 
higher  grade  or  the  lesion  progresses,  producing  a  more  prominent, 
usually  small  pea-sized,  reddish,  papular  elevation,  probably  due  to  peri- 
follicular  infiltration,  with  but  little  tendency,  in  most  of  the  papules, 
to  advance  to  suppuration,  and  thus  is  presented  acne  papulosa.  If 
the  inflammatory  action  is  still  more  intense,  or  continues,  or  probably 
if  micro-organisms  invade  the  lesions,  they  or  the  most  of  them  tend  to 
advance  rapidly  to  central  suppuration,  especially  toward  the  apex. 


Fig.  260. — Acne  of  the  back — showing  pustules,  papules,  and  blackheads;  the  scar- 
ring which  is  often  quite  marked  in  back  cases  is  not  conspicuous  in  this  instance 
(courtesy  of  Dr.  M.  B.  Hartzell). 

and  pea-sized  or  larger  formations  present,  which  show,  under  the  thinned 
epidermal  covering,  pustulation;  such  cases  represent  the  so-called  acne 
pustulosa.  In  some  patients  the  inflammation  begins  somewhat  deeply, 
and  is  felt  as  subcutaneous  nodules,  which  grow  larger  and  toward  the 
surface,  and  then  remain  as  small  or  large  pus  cavities,  very  slowly  under- 
going resolution,  or  finally  break  and  discharge,  and  then  may  again 
fill  up;  others  show  pustulation,  and  at  the  same  time  the  base  becoming 
markedly  inflammatory  and  hard — acne  indurata.  In  some  instances, 
fortunately  not  common,  of  the  smaller  lesion  cases,  usually  small  papu- 
lar, or  less  frequently  pustular,  as  the  lesions  disappear  they  leave  a 
pit-like  atrophy  or  depression — distinct  though  not  large  scars — and 


IO4O  DISEASES   OF  THE  APPENDAGES 

this  represents  the  type  known  as  acne  atrophica.  When  such  tendency 
does  exist,  it  is  exhibited  by  most  of  the  lesions.  On  the  other  hand,  in 
some  such  cases  slight  connective-tissue  new  growth  may  follow  their 
disappearance  and  present  as  minute  or  small  scar-tissue  or  keloidal 
elevations — acne  hypertrophica.  In  other  instances,  not  very  numerous, 
and  usually  observed  in  those  of  cachectic  and  depraved  condition,  the 
gland  itself  seems  to  be  the  seat  of  the  chief  inflammatory  and  suppurative 
changes,  and  furuncular  or  sluggish  abscess-like  formations  result,  which 
may  show  but  little,  or  an  extremely  slow,  tendency  to  break  through; 
many  of  these  lesions  are  of  the  nature  of  dermic  abscesses,  usually  of  a 
cold,  sluggish  character,  and  sometimes  of  more  general  distribution — 


Fig.  261. — Acne  of  back — somewhat  large  papulopustular  and  nodular  type,  with  some 

scarring. 

acne  cachecticorum.  Under  this  latter  name,  but  preferably  under  the 
designation  of  acne  scrofulosorum,  is  also  to  be  included  a  sluggish  papular 
or  papulopustular  acne  of  livid  red  color,  pea-  to  cherry-sized,  observed 
associated  with  strumous  symptoms,  and  commonly  occupying  the 
trunk  and  extremities,  and  less  frequently  the  face  also;  slow  in  evolution, 
and  sometimes  slight  superficial  destruction  occurring  under  the  crust 
and  leaving  scars. 

Acne  cases  are  occasionally  encountered  in  which  the  eruption  is 
almost  entirely  or  wrholly  limited  to  the  trunk,  usually  or  more  par- 
ticularly the  back  and  the  breast,  and  in  such  instances  the  eruption, 
as  a  rule,  consists  of  numerous  variously  sized  papular,  papulopustular, 


ACNE  IO4I 

more  or  less  indurated  sluggish  lesions,  with,  in  some,  a  tendency  to  the 
dermic  abscess  type;  many  comedones,  some  double  and  multiple,  are 
also  generally  present.  The  eruption  is  sluggish  and  persistent,  old 
lesions  going  slowly  and  new  presenting;  considerable  scarring  is  some- 
times noted. 

The  lesions  in  acne  are  discrete  and  scattered,  but  occasionally  a 
tendency  is  exhibited  here  and  there  toward  the  formation  of  several 
somewhat  closely  set  groups;  in  such  the  base  seems  almost  continuous, 
as  in  some  of  the  iodid  and  bromid  eruptions.  In  the  dermic  abscess 
variety  this  tendency  to  contiguous  formation  is  also  now  and  then 
observed.  While  most  lesions  probably  have  their  beginning  in  a  block  - 
ing-up  of  the  gland  outlet,  this  is  not  demonstrable  in  all,  and  more  es- 
pecially not  in  the  deep-seated  formations. 

Acne  artificialis  is  a  term  applied  to  the  acne-like  eruption  pro- 
duced by  the  ingestion  of  the  iodin  and  bromin  preparations,  also  named 
iodid,  or  iodin  acne  and  bromid  or  bromin  acne;  and  from  the  external 
use  of  tar  (acne  picea,  acne  picealis)  in  occasional  instances.  This 
latter  is  likewise  met  with  in  those  who,  in  the  course  of  their  work,  are 
brought  into  frequent  contact  or  live  in  an  atmosphere  strongly  impreg- 
nated with  tar  or  tarry  products.  Tar  acne  results  from  a  blocking-up 
of  the  follicular  openings  with  this  product.  With  tar  acne  furuncles 
are  often  associated.  Chrysarobin  is  noted  at  times  to  bring  about 
follicular  inflammation  and  acne-like  lesions.  Workers  in  petroleum 
and  paraffin  products  are  also  occasionally  the  subjects  of  acneiform, 
furuncular,  and  abscess  formations.  These  several  artificial  eruptions, 
which  may  be  limited  or  more  or  less  general,  are  referred  to  under  the 
head  of  Dermatitis  medicamentosa  or  Dermatitis  venenata. 

Another  variety  or  acne-like  eruption,  often  limited  to  the  face, 
as  in  2  of  my  cases,  sometimes  seen  on  the  face,  scalp,  neck,  and  shoulders 
also,  and  in  others  upon  the  extremities  as  well,  and  deserving  of  the  name 
of  acne  urticata  (Kaposi,  Teuton,  Lowenbach,  and  others),1  already  given 
to  it,  is  that  in  which  the  lesions  suggest  both  acne  and  urticaria.  Pre- 
ceded, as  a  rule,  by  itching,  they  begin  as  small  or  ordinary  sized  pinkish 
or  reddish,  urticaria-like  elevations  or  distinct  wheal-like  lesions,  which 
enlarge  somewhat  and  soon  exhibit  slight  central  vesiculation,  which 
dries  to  a  thin  crust,  during  which  time  the  urticaria-like  basis  usually 
has  entirely  disappeared.  Beneath  the  crust  some  necrotic  or  atrophic 
action  takes  place,  and  when  it  drops  off,  a  small  depressed  scar  remains. 
If  the  formation  is  squeezed  before  crusting  and  desiccation  ensue, 
there  appears  a  small  amount  of  serum,  but  no  pus.  The  course  of  a 
lesion  is  generally  run  in  from  one  to  two  weeks,  but  new  eruption  con- 
tinues to  appear  and  the  disease  lasts  indefinitely.  It  is  not  a  frequent 
variety,  nor  is  it,  I  believe,  a  true  acne,  but  probably  a  type  (Kaposi)  of 
acne  varioliformis;  its  clinical  symptoms  and  behavior  are  somewhat 
similar.  Lowenbach's  investigations  give  it  a  middle  position  between 

1  Kaposi.  Pathologic  und  Thcrapie  der  Haulkrankheilen,  4.  Auflage,  Wien,  1893, 
p.  529;  Teuton,  Verhandlung.cn  der  Deutschen  Dermatologischen  Gesellschaft ,  VI.  Con- 
gress, 1899,  p.  7  (this  paper  covers  all  varieties  and  types  of  disease  described  under  the 
name  acne,  with  full  bibliography);  Lowenbach,  Archiv,  1899,  vol.  xlix,  p.  29  (with 
histologic  study,  reference  to  allied  diseases,  and  bibliography  of  same). 
66 


1042  DISEASES   OF  THE  APPENDAGES 

acne  varioliformis  and  urticaria  perstans.  The  several  cases  under  my 
care  were  all  neurasthenic  girls  between  eighteen  and  twenty-five,  and 
of  weak  digestion.  The  cause  is  not  known;  micro-organisms  have  been 
found,  but  with  no  uniformity.  In  all  my  cases  and  those  of  others 
(Kaposi,  Teuton)  digestive  disturbances  were  noted.  Its  anatomic 
seat  is  about  the  hair-follicle.  The  disease  is  stubborn  and  rebellious 
to  treatment. 

Under  the  name  of  acne  keratosa1  Crocker  has  described  4  cases 
of  a  rare  affection,  one  of  which  had  been  previously  recorded  by  Jamie- 
son,  possessing  some  of  the  features  of  acne.  The  eruption  is  seen  on 
the  face,  on  the  chin  and  cheeks,  and  commonly  near  the  corners  of  the 
mouth.  Red,  tender,  firm  lumps,  persistent  in  character,  are  first  seen, 
on  which  pustulation  usually  presents,  and  dries  to  a  crust.  Sometimes 
the  covering  epidermis  is  detached  by  the  underlying  lymph.  On  re- 
moval of  the  crust,  one  or  several  soft  or  horny  conic  "pegs,"  about 
•j^-  inch  long,  which  produce  irritation,  are  found  embedded;  their  re- 
moval is  followed  by  gradual  but  very  slow  disappearance  of  the  lesion, 
usually  leaving  scars.  New  formations  appear  from  time  to  time,  and 
the  disease  goes  on  almost  indefinitely.  In  some  cases  there  is  an  irre- 
sistible desire  for  the  patient  to  pick  at  them,  resulting  in  excoriations, 
as  in  Brocq's2  patients.  The  lesions  have  their  seat  in  the  sebaceous  gland 
or  hair-follicle.  The  cause  of  the  disease  is  unknown,  and  treatment, 
similar  to  that  of  ordinary  acne,  not  very  satisfactory. 

The  course  of  acne  is  almost  always  persistent,  individual  lesions 
disappearing  after  a  variable  time — several  days  to  several  weeks, 
according  to  character,  but  new  lesions  making  their  appearance  irreg- 
ularly from  day  to  day  or  week  to  week.  In  average  examples  scarring 
does  not  result.  As  already  remarked,  cases  vary  much  in  the  number, 
features,  and  behavior  of  lesions.  Some  are  so  slight,  the  lesions  so  few, 
and  the  parts  often  free,  that  they  scarcely  are  entitled  to  be  considered 
a  disease;  on  the  other  hand,  many  are  troublesome  and  disfiguring  to 
a  repulsive  degree.  As  the  patient  advances  toward  full  growth  and 
enters  adult  age  in  many  instances  the  tendency  disappears,  but  this  is 
by  no  means  true  in  all. 

Ordinarily  there  are  no  subjective  symptoms  in  average  acne  cases, 
occasionally  slight  beginning  soreness,  and  when  the  inflammation  is 
marked  there  may  be  tenderness,  especially  upon  pressure.  Excep- 
tionally there  is  moderate  itching,  particularly  just  as  the  lesion  is  about 
to  appear. 

I^tiology.3 — The    disease    is    a    frequent   one.    The   causes  are 

1  Crocker,  "Acne  Keratosa,"  Brit.  Jour.  Derm.,   1899,  vol.  xi,  p.   i;  Jamieson, 
"Peculiar  Ulcerative  Eruption  of  the  Face,  Associated  with  the  Formation  of  Horny 
Plugs,  Accompanied  with  Pain  and  Apparently  Developing  in  the  Sebaceous  Glands," 
ibid.,  1893,  vol.  v,  p.  141. 

2  Brocq  reported,  under  the  name  "L'acne  excoriee  de  jeunes  filles,"  Paris,  1898,  a 
somewhat  similar  condition,  in  which,  however,  there  were  no  horny  pegs. 

3  Bearing  upon  some  etiologic  factors  named  and  treatment:  Lomry,  "Untersuchun- 
gen iiber  die  Aetiologie der  Acne"  (bacteriologic) ,  Dermatolog.  Zeitschr.,  Aug.,  1896 — full 
abstract  in  Brit.  Jour.  Derm.,  1896,  vol.  viii,  p.  453;  Hodara,  "Ueber  die  bacteriologische 
Diagnose  der  Acne,"  Monatshefte,  1894,  vol.  xviii,  p.  573;  Jacques,  "De  1'etat  sebor- 
rheique  de  la  peau  et  des  ses  rapports  avec  les  dermatoses,  notamment  avec  1'acne; 


ACNE  1043 

varied.  The  pus  organisms  are  credited  with  being  etiologic,  but  recent 
investigations  (Unna,  Gilchrist,  Hodara,  Sabouraud,  Beck,  Fleming, 
Engman,  and  others)  point  rather  to  a  special  bacillus — acne  bacillus. 
Sabouraud  believes  the  bacillus  brings  about  the  seborrhcea  often 
noticed,  and  to  this  is  added  a  special  coccus  (Staphylococcus  albus 
butyricus)  for  the  acne.  The  evidence  so  far  seems  to  indicate  that  the 
bacillus  and  Staphylococcus  albus  are  both  factors,  the  former  more  or 
less  specific  in  most  cases,  the  latter  specific  in  some  cases,  but  usually 
contributory. 

Admitting  a  parasitic  agent,  which  now  seems  fairly  well  assured, 
there  are  to  be  considered  the  predisposing  causes  which  bring  about 
the  proper  condition  of  the  skin  (proper  soil)  for  parasitic  invasion  or 
prejudicial  action,1  and  without  which  predisposing  or  contributory 
causes  the  parasitic  agents  may,  in  many  persons  at  least,  be  found  in  the 
skin  without  becoming  pathogenic.  These  seem,  indeed,  in  certain 
cases  distinctly  etiologic;  such  are  digestive  disturbances  (producing 
reflex  hyperemia  of  the  parts  (Crocker)),  constipation,  menstrual  irregu- 
larities, chlorosis,  general  debility,  lack  of  tone  in  the  muscular  fibers 
of  the  skin,  and  scrofulosis.  And  as  external  factors  may  be  mentioned 
working  in  a  dusty  or  dirty  atmosphere,  lack  of  cleanliness,  the  infre- 
quent use  or  entire  abstention  from  the  use  of  soap  for  the  face.  In  fact, 
anything  which  tends  to  block  up  the  gland  outlet  has  an  etiologic  bear- 
ing. Drug  and  trade  factors  have  already  been  referred  to — bromin 
and  iodin  preparations,  tar,  and  petroleum  products.  Indulgence  in 
the  so-called  "bromo"  proprietary  headache  medicines  is  not  an  infre- 

etude  de  pathogenic  et  de  traitement,"  These  de  Paris,  1892 — abs.  in  Annales,  1892, 
p.  1047;  Mitour,  "Etude  sur  la  nature  et  le  traitement  de  la  dyspepsie  accompagnee 
acne,"  These  de  Paris,  Jan.,  1896;  Sabouraud,  "La  seborrhoee  grasse  et  le  pelade," 
Annales  de  I'Institut  Pasteur,  1897,  p.  134;  Schiitz,  "Klinisches  iiber  Akne  und  der 
seborrhoischen  Zustand,  Archiv,  1895,  vol.  xxx,  p.  203;  S.  Mackenzie,  "Etiology  and 
Treatment  of  Acne"  (with  discussion  thereon),  Brit.  Jour.  Derm.,  1894,  vol.  vi,  p.  304; 
Unna,  Histopathology,  1896,  pp.  357,  361;  Gilchrist,  Trans.  Amer.  Derm.  Assoc.  for 
1899,  p.  97;  and  Jour.  Cutan.  Dis.,  1903,  p.  107  (with  histologic  and  bacteriologic 
illustrations,  review  and  bibliography  as  to  these  subjects) ;  Fleming,  "On  the  Etiology 
of  Acne  Vulgaris  and  its  Treatment  with  Vaccines,"  Lancet,  April  10,  1909,  p.  1035; 
and  "Vaccine  Treatment  of  Acne  Vulgaris,"  Brit.  Jour.  Derm.,  1910,  p.  6;  Engman, 
"Bacteriology  in  Certain  Diseases  of  the  Skin,"  Jour.  Cutan.  Dis.,  1910,  p.  553;  and 
"Treatment  of  Acne  Vulgaris  with  Acne  Bacillus  Suspensions,"  Interstate  Med.  Jour., 
1910,  xvii,  No.  12;  Gilchrist,  "Vaccine  Therapy  as  Applied  to  Skin  Diseases,"  Jour. 
Cutan.  Dis.,  1910,  p.  568;  Towle  and  Lingenfelter,  "Vaccine  Therapy  in  the  Treatment 
of  Diseases  of  the  Skin  at  the  Massachusetts  Hospital,"  Jour.  Cutan.  Dis.,  1910,  p. 
583;  Lasseur,  "Le  Traitement  de  1'acne  pustuleuse  par  les  Vaccines,"  Annales,  1910, 
p.  377;  Lovejoy  and  Hastings,  "Isolation  and  Growth  of  the  Acne  Bacillus,"  Jour. 
Cutan.  Dis.,  191 1,  p.  80;  Morris  and  Dore,  "Treatment  of  Acne  by  Vaccines,"  Brit. 
Jour.  Derm.,  1911,  p.  311  (review  of  organisms  and  therapy;  regard  vaccine  treatment  as 
an  adjuvant,  occasionally  brilliant,  used  both  vaccines  separately  or  mixed,  choice 
depending  upon  active  organism;  bibliography);  Haase,  Jour.  Amer.  Med.  Assoc.,  Aug. 
17, 1912,  p.  504  (gives  a  good  review  of  the  subject  of  bacterial  findings,  with  references) ; 
Lovejoy,  "Treatment  of  Acne  with  Stock  and  Autogenous  Acne  Bacillus  Vaccines," 
Amer.  Jour.  Med.  Sci.,  1912,  p.  693. 

Varney  and  Clark,  Jour.  Cutan.  Dis.,  1912,  p.  72,  found  a  micrococcus  with  unusual 
characteristics  as  a  factor  in  a  resistant  dermatitis  resembling  acne  vulgaris — 5  cases  are 
described;  these  were  uninfluenced  by  the  usual  acne  therapy,  but  were  responsive  to 
the  vaccines  made  from  the  organism. 

1  Gilchrist  believes  that  many  of  the  constitutional  and  other  symptoms  often  found 
associated  with  the  disease,  instead  of  being  predisposing  causes,  as  commonly  thought, 
are,  in  fact,  probably  the  result  of  absorption  of  the  toxins  of  the  bacillus  acnes. 


1044 


DISEASES   OF  THE  APPENDAGES 


quent  cause  of  scanty  and  irregularly  appearing  lesions.  The  not 
uncommon  custom  of  taking  the  advertised  "blood-purifiers"  in  the 
spring,  most  of  which  contain  potassium  iodid,  is  another  element  which 
adds  to  dermatologic  practice.  In  fact,  I  have  met  writh  several  instances 
in  which  the  administration  of  the  iodids  or  bromids  was  the  starting 
causative  factor  in  the  production  of  rather  persistent  acne.  The  use 
of  irritating  soaps,  but  more  especially  soaps  containing  tar  or  its  de- 
rivatives, is  a  contributing  agent  in  some  cases. 

The  most  easily  demonstrable  contributory  causes  in  many  cases, 
and  which  patients  themselves  soon  recognize,  are  constipation  and  di- 
gestive disturbances.  Night  or  day  indulgence  in  indigestible  foods, 
in  beer  or  other  alcoholic  drinks,  will  often  provoke  a  fresh  outcropping 
in  those  with  acne  tendency.  It  is  probably  due  to  such  causes  that 
acne  of  rather  acute  character  is  occasionally  met  with  in  patients  who 
have  just  recovered  from  a  severe  illness — the  appetite  being  keen,  in- 
dulgence and  overeating  bring  about  indigestion  or  result  in  the  absorp- 
tion of  incompletely  digested  food.  It  is  especially  fermentative  dys- 
pepsia (Hallopeau,  Robin,  Leredde,  Elliot,  Barthelemy,  Jacques,  Mitour, 
and  others)  that  is  particularly  etiologic;  dilatation  of  the  stomach 
(Barthelemy)1  is  also  a  frequent  factor.  Excessive  tea-  and  coffee- 
drinking  and  too  free  use  of  tobacco  must  also  be  considered  to  have 
influence.  Circulatory  weakness,  as  evidenced  by  cold  feet  and  hands, 
is  credited  with  influence,  but  this  itself  is  doubtless  often  the  result  of 
digestive  difficulties.  Menstrual  irregularity  or  difficulty  or  other  uterine 
disorders  is  also  a  source  of  aggravation,  if  nothing  more,  in  some  cases, 
and  in  those  due  to  such  cause  a  special  tendency  to  appear  on  the  chin 
and  around  the  mouth  has  been  noted  by  some  observers  (Hallopeau 
and  Leredde).  Women  with  acne  are  almost  invariably  worse  at  the 
menstrual  period,  and  mild  cases  will  often  be  relatively  or  entirely  free 
in  the  interim.  Another  known  fact  is  that  the  disease  is  commonly  one 
which  belongs  between  the  ages  of  thirteen  and  thirty;  exceptionally  it 
begins  earlier,  and  not  infrequently  it  persists  after  the  latter  age,  but 
rarely  presents  for  the  first  time  after  that  period.  It  is  common  to  both 
sexes,  among  rich  and  poor,  but  it  is  somewhat  more  frequent  in  in- 
dividuals of  light  complexion,  and  in  those  leading  a  sedentary  life. 
Both  excessive  sexual  indulgence  and  sexual  continence  have  been  as- 
cribed as  factors,  but  with  scant  foundation. 

Pathology. — Acne  is  pathologically  an  inflammation  of  the  se- 
baceous glands,  which  may,  from  resulting  suppurative  action,  mean 
more  or  less  follicular  destruction.  The  attached  lanugo  hair-follicle 
is  usually  implicated,  and  it  is  alleged  by  some  writers  that  this  is  the 
primary  seat  of  the  inflammatory  action  or  irritation.  In  most  lesions 
an  important  step  in  originating  the  process  is  a  blocking-up  of  the 
glandular  outlet,  either  by  a  comedo  formation,  as  a  result  of  a  hyper- 
keratosis  (Unna),  or  from  extraneous  material;  in  the  production  of 

1  Barthelemy,  "Etiologie  et  Therapie  de  1'Acne,"  Arch.  gen.  de  med.,  1889,  ii,  p. 
641;  also  in  Monatshefie,  1889,  vol.  ix,  p.  406.  In  169  cases  especially  investigated 
as  to  dilatation  of  stomach  Barthelemy  claims  to  have  found  this  condition  in  165— -dys- 
pepsia in  all,  the  first  effect  of  improper  digestion,  according  to  this  author,  being  a 
seborrheic  condition,  and  then  the  implantation  of  a  pathogenic  organism. 


ACNE  1045 

the  former,  atony  of  the  muscular  fibers  of  the  skin,  and  especially 
the  arrectores  pili,  is  probably  an  important  factor.  Blocking-up  of 
the  glandular  outlet,  however,  is  not  sufficient  explanation,  for  it  is  not 
invariably  observed,  and  it  frequently  occurs  (see  Comedo)  without 
any  resulting  irritation  or  acne  lesion.  To  this,  therefore,  must  be 
added  as  yet  an  unknown  agent,  but  which  may  variously  be  micro- 
organisms, chemical  and  irritating  change  in  the  secretion  within  the 
gland  (Virchow),  or  some  poison  or  irritant  eliminated  by  the  glands 
(Leloir,  Hallopeau,  Leredde,  and  others),  probably  due  to  imperfect 
digestion;  the  first  named,  in  the  light  of  our  present  knowledge  of 
cutaneous  pathology,  being  most  probable  as  the  essential  element. 
The  various  conditions  named  in  etiology  prepare  the  soil  for  para- 
sitic invasion,  seborrhea  holding  a  prominent  place.  As  also  referred 
to  in  etiology,  ordinary  pyogenic  or  similar  organisms,  which  are  some- 
times, but  not  always,  present,  have  been  thought  to  be  the  pathologic 
exciting  factor,  but  this  has  been  called  in  question.  More  recently, 
as  already  stated,  a  special  bacillus,  which  Gilchrist  finds  has  pus-pro- 
ducing properties,  has  been  found;  it  is  somewhat  short  and  thick,  rod- 
like,  straight  or  curved,  and  sometimes  branching,  and  occasionally 
coccoid  in  form  (Unna,  Gilchrist).  Gilchrist  found  this  bacillus  in  every 
acne  pustule  examined. 

According  to  investigations  (Simon,  Virchow,  Hebra  and  Kaposi, 
Biesiadecki,  Leloir  and  Vidal,  Robinson,  Elliot,  Heitzmann,  Gilchrist, 
and  others),  the  inflammation  begins  either  in  or  around  the  gland, 
the  vessels  showing  engorgement;  in  the  latter  event  the  glandular 
structure  becomes  secondarily  involved.  Inflammatory  infiltration 
may  be  somewhat  limited,  and  chiefly  around  the  gland-outlet,  or  be 
periglandular,  or  it  may  be  quite  extensive  and  diffused,  and  even  in- 
volve several  glands.  Suppuration  generally  ensues,  but  this  is  a 
secondary  result,  and  not  necessarily  constant.  The  infiltration, 
which  may  be  superficial  or  deep  in  the  derma,  is  inflammatory  in  char- 
acter, with  sometimes  plasma-,  large  fusiform,  giant-  and  mast-cells, 
and,  when  suppuration  ensues,  with  leukocytes  added.  The  epithelial 
lining  usually  becomes  thinned,  extended,  and  may  disappear  entirely 
when  the  glandular  walls  give  way,  the  lesion  being  then  a  small,  variably 
sized,  dermic  abscess.  Leloir  and  Vidal,  who  are  among  those  who  be- 
lieve the  primary  inflammatory  changes  to  be  perifollicular,  have  noted 
in  some  instances  suppurative  foci  around  the  glandular  structure,  which 
eventually  rupture  into  the  cavity. 

The  contents  are  composed  of  seropurulent  fluid,  sebaceous  matter, 
and  tissue  debris.  In  the  larger  lesions  not  only  the  sebaceous  gland 
partly  or  completely  suffers  destruction,  but  the  hair-follicles  as  well. 
The  character  of  the  lesion  is  determined  by  the  activity  and  intensity 
of  the  process;  inflammatory  infiltration  around  the  gland-outlet  giving 
rise  to  the  smaller  papules,  and,  when  more  extensive  and  periglandular  as 
well,  to  larger  indurated  papules  and  tubercles;  and,  when  suppurative 
action  ensues,  to  the  pustule.  If  the  suppurative  action  is  abundant, 
the  small  dermic  abscess  results,  and  when  intense,  deep-seated,  and 
involving  several  glands,  the  large  dermic  abscesses  are  formed. 


1046  DISEASES   OF  THE  APPENDAGES 

Diagnosis. — There  is  rarely  any  confusion  possible  in  acne,  if  it 
be  remembered  that  the  eruption  is  always  follicular  and  limited  to 
certain  parts,  and  commonly  the  face  alone,  and  that  the  several  stages 
of  the  lesions,  from  the  blocked-up  gland-outlet,  or  comedo,  to  the 
papule  and  pustule,  are  usually  present,  not  grouped,  but  discrete  and 
irregularly  scattered.  A  history  of  some  duration  is  ordinarily  given. 
While  the  lesions  of  pustular  syphiloderm  bear  some  resemblance,  these 
are  almost  always  a  part  of  a  generalized  eruption,  with  other  symptoms 
and  a  different  course  and  history.  The  tubercular  syphiloderm,  and 
also  the  tuberculopustular  syphiloderm,  usually  late  manifestations 
and  somewhat  limited,  if  occurring  on  the  face,  are  to  be  differentiated 
more  especially  from  large  papular  acne  or  acne  indurata,  but  they  are 
differently  colored, — copper  or  ham  tint, — almost  always  grouped,  and, 
as  a  rule,  in  a  circinate,  segmental,  or  serpiginous  manner;  moreover, 
they  are  slow  in  evolution,  and  frequently  present  underlying  ulceration, 
and  leaving  behind  atrophy,  staining,  or  scarring.  The  dermic  abscess 
variety  of  acne  lesions  is  entirely  different  in  its  evolution,  behavior, 
and  course  from  a  gummatous  syphiloderm. 

An  acute  outbreak  of  acne  has  been  mistaken  for  a  beginning  variola, 
but  if  the  distribution  of  the  latter,  its  prodromal  and  accompanying 
constitutional  symptoms,  are  considered,  such  an  error  seems  scarcely 
possible.  Acne  is  to  be  distinguished  from  acne  rosacea  by  the  facts 
that  the  latter  is  more  or  less  diffusely  hyperemic,  with,  as  a  rule,  dilated 
vessels,  and  the  eruption  is  usually  predominantly  about  the  nose  and 
immediate  region;  in  extensive  cases  the  region  involved  is  an  ovalish 
area,  of  which  the  nose  is  the  center,  and  the  outer  boundaries,  the  chin, 
central  forehead,  and  middle  of  the  cheeks.  Acne  rosacea  is,  moreover, 
much  more  common  after  the  age  of  thirty,  whereas  ordinary  acne  then 
becomes  much  less  frequent.  Midway  types  are,  however,  met  with, 
which  partake  really  of  the  nature  of  both  diseases. 

Acne  limited  or  more  or  less  confined  to  the  back  differs  from  ordinary 
cases  simply  in  being  in  an  unusual  location,  but  its  features  are  the  same, 
commonly  of  a  more  pronounced  type  than  generally  seen  on  the  face; 
there  are  frequently  many  comedones. 

The  possibility  of  acne-like  pustules  from  bromin  and  iodin  prepa- 
rations is  not  to  be  lost  sight  of;  the  lesions  are  usually  a  brighter  red, 
with,  as  a  rule,  a  less  pronounced  base,  and  the  contents  are  somewhat 
thinner,  and  while  lesions  are  almost  invariably  on  the  face,  they  are 
often  seen  also  on  other  parts  on  which  acne  is  not  observed;  a  safe  plan, 
however,  in  suspected  cases  is  to  make  inquiry  as  to  the  ingestion  of  such 
drugs. 

Prognosis. — Acne  is  often  a  troublesome  disease,  sometimes 
rebellious  and  obstinate;  still,  upon  the  whole,  it  is,  I  think,  to  be  con- 
sidered one  of  the  more  favorable  of  the  cutaneous  maladies,  and  one  in 
which  the  results  of  well-directed  treatment  are  usually  gratifying. 
The  majority  of  cases  respond  quite  readily,  the  skin  clearing  up  in 
the  course  of  a  few  months;  in  others  again  somewhat  rapidly  at  first, 
and  then  more  slowly,  six  months  to  a  year  or  more  being  required  to 
bring  about  permanent  betterment.  Exceptionally  it  proves,  for  a  time 


ACNE  1047 

at  least,  most  intractable,  relief  being  slow  and  often  temporary.  If 
untreated,  it  frequently  continues  for  several  years  or  more,  in  the  ma- 
jority of  patients  a  spontaneous  disappearance  setting  in  as  adult  age 
is  reached.  There  are,  however,  many  exceptions  to  this,  and  the  state- 
ment that  all  cases  are  well  by  the  time  thirty  is  passed  is  not  supported 
by  the  experience  of  specialists.  Many  persist  indefinitely,  and  especially 
those  of  the  indurated  and  dermic  abscess  type,  and  more  particularly 
acne  of  the  back.  Scarring,  more  or  less  permanent  in  character,  re- 
mains in  some  instances.  To  a  great  extent  it  may  be  said  that  cure  de- 
pends upon  a  recognition  of  the  predisposing  cause  or  causes  and  their 
removal  or  modification. 

Treatment. — Both  systemic  and  local  treatment  are  essential 
in  most  cases;  in  patients  approaching  full  maturity,  and  showing  a 
tendency  to  spontaneous  disappearance,  local  applications  alone  will 
often  suffice.  In  many  instances,  however,  constitutional  medication 
is  of  greater  importance  for  permanent  effect  and  should  rarely  be 
omitted. 

To  secure  the  best  results  each  case  must  be  studied  carefully  and 
all  possible  etiologic  elements  considered.  Constitutional  treatment 
must  be  selected  according  to  the  predisposing  influences  in  the  individual 
patient,  remembering  that  digestive  disturbances  and  constipation  are 
the  most  common  causative  factors.  The  value  of  exercise  in  the  open 
air,  calisthenics,  bathing,  and  other  hygienic  measures  cannot  be  over- 
rated. Free  bowel  action  is  of  essential  importance.  The  diet  should 
be  regulated,  the  food  being  plain  but  nutritious.  All  indigestible  or 
questionable  foods  are  to  be  interdicted,  especially  those  leading  to  fer- 
mentative indigestion.  For  dyspeptic  patients  and  for  those  whose  di- 
gestion is  weak  or  capricious,  bitter  tonics,  alkalis,  nux  vomica,  acids, 
pepsin,  pancreatin,  and  saline  and  vegetable  laxatives  are  to  be  variously 
prescribed.  Of  the  laxatives,  cascara  sagrada,  the  ordinary  aloin- 
strychnin-belladonna  pill,  rhubarb  root,  gray  powder,  calomel,  Hun- 
yadi  Janos,  Friedrichshall,  and  similar  waters  deserve  special  mention. 
A  mixture  composed  of  \  to  2  drams  (2. -8.)  of  sodium  benzoate  or  sodium 
bicarbonate,  2  drams  (8.)  of  tincture  of  nux  vomica,  2  to  4  drams  (8.-i6.) 
of  fluidextract  of  cascara  sagrada,  and  tincture  of  cardamom  to  make  up  3 
ounces  (96.),  of  which  a  teaspoonful  is  to  be  taken  after  each  meal, 
can  often  be  prescribed  with  advantage.  Another  combination  often 
of  service  and  in  very  general  use  is  a  saline  tonic,  known  usually  as 
the  "mistura  ferri  acida,"  made  up  of  i  ounce  (32.)  of  magnesium  sul- 
phate, 4  to  8  grains  (0.25-0.5)  of  iron  sulphate,  i  to  2  drams  (4.-8.) 
of  dilute  sulphuric  acid,  and  mint- water  to  make  4  ounces  (128.),  of 
which  a  tablespoonful  is  given  in  a  full  tumbler  of  water  about  twenty 
minutes  before  breakfast.  If  the  dose  of  this  latter  should  not  prove 
laxative,  it  can  be  given  also  in  the  evening  upon  retiring;  or,  and  ordi- 
narily to  be  preferred,  2  or  3  drams  (8.  or  12.)  of  sulphur  can  be  added. 

In  chlorotic  and  anemic  patients  preparations  of  iron  and  arsenic 
are  useful,  but  the  dose  should  be  small,  inasmuch  as  a  large  dosage  of 
these  drugs  is  likely,  by  tending  to  disturb  the  digestion,  to  aggravate 
rather  than  relieve.  Arsenic  has  no  specific  value  in  acne,  nor  has  sul- 


1048  DISEASES   OF  THE  APPENDAGES 

phur  internally  the  value  popularly  given  it;  calx  sulphurata  also  has 
failed  to  meet  expectations,  and  is  scarcely  employed  in  this  disease 
at  the  present  day.  In  debilitated  subjects,  and  in  those  of  strumous 
habits,  and  of  pale,  pasty-looking  skin,  cod-liver  oil,  in  doses  of  from  \ 
to  i  teaspoonful  three  times  a  day,  is  often  a  remedy  of  great  value, 
particularly  in  the  sluggish  atrophic,  indurated,  and  dermic  abscess 
types.  In  those  cases  of  acne  in  which  the  congestive  element  is  marked 
ichthyol  has  been  commended. 

Vaccine  Treatment.1 — Recently  Wright  and  others  have  claimed 
good  results  from  injection  of  staphylococcic  vaccine;  dosage  and 
frequency  were  to  be  based  upon  the  opsonic  index  of  the  blood.2 
Others  have  noted  only  slight  value  from  this  vaccine,  believing  this  to 
be  due  to  the  fact  that  it  is  not  the  staphylococcus,  but  bacillus  acnes, 
that  is  the  active  organism  in  the  production  of  the  disease.  Some  phys- 
icians who  still  consider  the  staphylococcus  of  some  etiologic  import 
employ  a  vaccine  made  from  both  these  organisms.  Fleming,  Western, 
Morris  and  Dore,  King  Smith,  and  others,  believing  some  cases  solely 
due  to  the  staphylococcus,  some  ^  to  the  acne  bacillus,  and  some  to  a 
mixed  infection,  have  employed  the  corresponding  vaccine  in  the  treat- 
ment, with  alleged  gratifying  results.  Many  investigators,  among  whom 
are  Gilchrist,  Fleming  and  Engman,  have,  however,  in  the  past  several 
years  been  employing  a  vaccine  made  from  the  acne  bacillus  only  with, 
it  is  claimed,  fairly  uniform  success.  On  the  other  hand,  some  careful 
observers  who  have  tried  the  vaccine  treatment  in  acne  cases,  have  not 
been  so  fortunate  in  their  results,  but  one  at  all  observant  must  concede 
that  occasionally  the  result  of  such  treatment  seems  strikingly  rapid 
and  brilliant.  Most  conservative  men  look  upon  it  as  yet  simply  as  an 
adjuvant  or  an  additional  remedy,  to  be  tried  in  extreme  or  persistent 
cases  in  which  the  usual  methods  fail.  Possibly,  as  Engman  and  others 
believe,  lack  of  uniform  success  with  treatment  is,  in  a  measure  at  least, 
rather  due  to  our  still  imperfect  knowledge  of  the  technic,  than  to  the 
method  itself.3  An  autogenous  vaccine  is  generally  thought  to  be  pref- 

1  For  literature  references  see  under  Etiology. 

2  This  study  of  the  index  is  too  tedious  and  uncertain  except  in  the  hands  of  a  trained 
expert;  and  it  is  now  generally  believed  that  it  can  usually  be  dispensed  with,  the 
effect  of  one  or  two  trial  doses  giving  sufficient  indication  of  frequency  and  quantity. 

3  Engman,  who  is  most  enthusiastic  in  its  use,  advises  the  following  technic: 
After  a  dose  of  3,000,000  to  5,000,000,  one  or  two  new  lesions  will  appear  within  forty- 
eight  hours,  generally  the  next  day;  if  more  than  three  appear  during  this  negative 
phase  the  dose  is  too  large.      About  seventy-two  hours  after  the  injection  the  come- 
dones are  expressed  and  all  the  lesions  opened.     The  manipulation  at  this  time  brings 
the  immunizing  blood  to  the  part,  since  it  is  at  the  height  of  the  "tidal  wave  of  im- 
munity."    The  large  cystic  lesions  are  opened  by  a  thin  cataract  knife  and  the  pus 
squeezed  out;  the  walls  of  the  lesion  are  in  this  way  rubbed  together  and  by  irritating 
them  fresh  immunizing  lymph  is  brought  into  the  cavity.     This  method  dries  them  up 
within  a  few  days.     The  patient  is  also  instructed  to  apply  hot  towels  to  the  face  twice 
daily  for  five  minutes,  so  as  to  cause  a  local  hyperemia.      On  the  fifth  to  the  seventh 
day  new  lesions  will  appear,  which  signify  another  stage  of  depression,  and  are  the  indi- 
cation for  a  second  dose  of  vaccine.    Another  dose  of  3,000,000  to  5,000,000  is  given;  in 
this  way  a  cure  is  completed.     Small  doses  sufficient  to  cause  a  short  negative  phase, 
beginning  with  about  3,000,000,  seem  with  us  to  be  the  best  method.     After  several 
doses  new  lesions  cease  to  appear.      If,  after  a  few  doses,  new  lesions  appear  after  the 
third  day,  a  larger  dose  of  7,000,000  to  10,000,000  should  be  given,  but  this  is  rarely 
necessary. 


ACNE  1049 

arable,  nevertheless  quite  a  number  of  experienced  investigators  have 
failed  to  see  much  difference  in  action  between  this  and  the  stock  vaccine. 

Local  or  external  treatment  is  of  essential  importance  in  the  man- 
agement of  acne.  The  remedies  used  are  of  antiseptic  character.  There 
are  three  methods  of  medication — by  powders,  by  lotions,  and  by  oint- 
ments. It  will  usually  be  found  that  no  one  method  of  application  can 
be  used  satisfactorily  in  a  given  case  without  occasionally  having  re- 
course to  another.  The  ordinary  case  will,  as  a  rule,  demand  for  a  suc- 
cessful issue  a  change  from  lotion  to  ointment  or  vice  versa.  The  method 
of  medication  with  powders  is  less  efficient  and  least  commonly  em- 
ployed. Upon  the  whole,  the  method  of  treatment  by  lotions  is  the  most 
generally  satisfactory,  intermitting  at  times,  and  using  an  ointment. 
The  action  of  remedies  is  enhanced  by  thorough  application.  Powders 
are  to  be  dusted  freely  over  the  parts;  lotions  are  to  be  dabbed  on  for 
five  or  ten  minutes,  going  over  and  over  the  affected  region  several  times, 
and  allowed  to  dry;  ointments  should  be  carefully  but  thoroughly  rubbed 
in  for  several  minutes  or  more,  and  the  excess  then  be  wiped  off.  What- 
ever the  method  of  application  selected,  as  soon  as  slight  irritation  or  a 
tendency  to  scaliness  results,  the  remedy  should  be  intermitted  for  one 
or  two  nights,  during  which  time  a  mild,  soothing  ointment,  such  as 
cold  cream  or  petrolatum,  is  to  be  applied,  and  all  other  measures  omitted. 
Scaliness  is  more  frequently  a  result  of  the  application  of  stimulating 
lotions;  salves  produce  at  times  redness  and  irritation,  but  unless  pushed 
or  very  strong,  the  grease  constituent  keeps  the  parts  free  from  visible 
epidermic  exfoliation.  Believing  that  seborrhea  of  the  scalp,  especially 
the  oily  variety,  is  probably  by  extension  a  factor  in  some  cases  of  acne, 
when  such  is  visibly  present,  it  is  a  good  plan  to  give  it  some  attention, 
more  particularly  as  to  shampooing  every  five  to  ten  days,  using  the 
medicated  soap  tincture  for  this  purpose. 

There  are  certain  general  directions  as  to  the  local  management. 
The  affected  part,  usually  only  the  face,  is  to  be  washed  with  a  mild 
toilet-soap,  or  in  extremely  sluggish  cases  with  green  soap  or  the  tinc- 
ture of  green  soap  instead  of  the  toilet-soap;  in  indolent  types  the  soap 
tincture  can  be  medicated  with  10  grains  (0.065)  or  more  of  resorcin  to 
the  ounce  (32.).  The  parts  are  then  to  be  thoroughly  rinsed  and  sponged 
for  from  five  to  ten  minutes  with  water  as  hot  as  can  be  comfortably 
borne,  wiped  dry,  and  then  the  remedial  application  made.  These 
procedures  are  best  carried  out  at  night,  in  the  morning  washing  with 
tepid  water.  In  severe  cases,  in  patients  desiring  a  rapid  impression  to 
be  made,  this  treatment  may  be  repeated  night  and  morning,  or  even  three 
tunes  daily,  until  the  parts  are  considerably  irritated  or  roughened, 
or  even  pushed  to  moderate  scaliness,  and  then  soothing  remedies  are 
applied  for  a  few  days.  When  such  an  active  method  is  employed,  the 
patient  should,  especially  if  the  weather  be  cold  and  windy,  be  more  or 
less  confined  to  the  house,  or  an  eczematous  dermatitis  may  be  brought 
about.  In  addition  to  these  preliminary  and  adjuvant  measures,  the 
blackheads  are,  as  far  as  practicable,  to  be  removed.  This  may  be 
accomplished  by  the  patient  by  pressure  with  the  finger-ends  or  with  a 
watch-key-like  instrument  procurable  in  the  shops,  or  best  by  the  phys- 


1050  DISEASES   OF  THE  APPENDAGES 

ician,  and  much  more  easily  and  satisfactorily  with  a  fenestrated  curet- 
shaped  comedo  extractor.  Opening  the  smaller  pustules  is  not  essential, 
and  even  many  of  the  larger  pustules  will  care  for  themselves,  but  the 
treatment  is  materially  aided  by  puncturing  or  incising  such  lesions  and 
pressing  out  the  contents.  The  cavity  of  the  indurated  lesions  can  be 
touched  with  carbolic  acid;  or  these  and  the  dermic  abscess  type  can  be 
washed  out  with  a  weak  carbolic  solution  or  with  hydrogen  peroxid.1 
G.  H.  Fox  has  been  a  strong  advocate  in  sluggish  cases,  in  which  the 
lesions  are  somewhat  superficial,  of  putting  the  skin  on  the  stretch  and 
scraping  it  with  the'  blunt-edged  curet,  using  more  or  less  pressure,  thus 
mechanically  breaking  and  evacuating  the  pustules  and  removing  many  of 
the  comedones;  considerable  temporary  disfigurement  and  irritation 
follow,  which  may  be  allayed  by  soothing  applications. 

The  remedial  applications  must,  of  course,  vary  somewhat  in  strength 
and  character  with  the  local  conditions.  Thus,  in  cases  in  which  the 
lesions  are  acute,  markedly  inflammatory,  hyperemic,  tender,  and  pain- 
ful, milder  applications,  such  as  are  of  a  soothing  nature,  are  called  for; 
the  boric  acid  lotion,  calamin-and-zinc-oxid  lotion,  and  similar  lotions 
used  in  eczema  may  be  temporarily  used.  One  of  the  most  satisfactory  is 
composed  of  40  grains  (2.65)  of  calamin,  80  grains  (5.35)  of  zinc  oxid,  i 
dram  (4.)  of  boric  acid,  and  water  to  make  4  ounces  (128.);  to  this,  if 
the  skin  is  very  dry,  can  be  added  2  to  8  minims  (0.13-0.5)  of  glycerin. 
Later,  when  the  inflammatory  aspect  has  abated,  the  addition  of  4  to  20 
grains  (0.27-1.33)  of  resorcin  is  advantageous.  In  the  average  patient, 
however,  the  eruption  has  usually  been  of  some  duration,  and  the  lesions 
are,  comparatively  speaking,  somewhat  sluggish,  and  will  demand,  even 
at  the  start,  remedies  of  a  slightly  or  actively  stimulating  character. 

The  most  valuable  remedy  in  the  external  treatment  of  acne  is  sul- 
phur or  its  compounds,  and  it  can  be  used  in  most  of  the  cases  with 
variable  advantage,  sometimes  slight,  oftener  pronounced;  in  some 
patients,  however,  the  skin  does  not  bear  it  well,  and  irritation  results; 
in  others,  for  some  unexplained  reason,  the  follicular  openings  blacken, 
and  the  comedo  element  of  the  case  becomes  more  conspicuous;  in  others 
again  the  remedy  has  no  effect  whatever.  In  mild  types  sulphur  may  be 
used  as  a  dusting-powder,  either  alone  or  mixed  with  an  equal  part  of 
boric  acid;  it  is  not,  however,  very  energetic  when  thus  employed.  The 
most  commonly  prescribed  sulphur  lotion,  and  one  that  is  often  extremely 
serviceable,  is  the  following,  known  to  most  dermatologists  as  "lotio 
alba": 

1$.     Zinci  sulphat., 

Potassii  sulphuret.,  aa  gr.  xxx-5iv  (2.-i6.); 

Aquae,  giv  (128.). 

The  most  frequently  prescribed  strength  is  i  dram  (4.)  each  of  the 
salts,  and  when  in  this  proportion  and  properly  prepared,  the  sediment 
which  forms  will  constitute  about  one-fourth  the  bulk;  when  shaken, 

1  While  it  is  my  experience  that  puncturing  and  incision  of  the  lesions  are  helpful, 
there  is  more  risk  of  slight  markings  being  left  when  this  method,  especially  incision, 
is  employed  than  if  the  process  is  left  to  nature. 


ACNE  IO5I 

the  lotion  is  milky  in  appearance,  hence  the  name;  it  is  entirely  free 
from  odor.  It  seems  difficult  to  have  it  properly  made,  due  doubtless 
to  a  deteriorated  or  a  dried-out  potassium  sulphuret.  The  weaker 
strength  is  prescribed  in  irritable  or  markedly  inflammatory  cases; 
the  strongest  when  the  others  have  failed  to  make  an  impression.  If 
too  drying,  i  or  2  minims  (0.065-0.133)  of  glycerin  can  be  added  to 
the  ounce  (32.).  This  lotion  may  be  made  still  stronger,  and  in  sluggish 
cases  more  efficient,  by  having  of  the  zinc  sulphate  6  to  20  grains  (0.4- 
1.33)  in  excess  of  the  potash  salt,  and  by  adding  resorcin,  20  to  100 
grains  (1.3-6.6)  or  more,  to  the  4  ounces  (128.).  Sulphuret  of  potassium, 
used  alone  in  lotion  form,  is  also  of  service,  but  its  odor  is  disagreeable 
and  cannot  be  entirely  disguised;  it  is  prescribed  as  follows:  20  to  40 
grains  (1.33-2.65)  of  potassium  sulphuret,  2  drams  (8.)  cologne  water,  i 
dram  (4.)  of  benzoin  tincture,  and  water  to  make  4  ounces  (128.);  after 
solution  of  the  salt,  filtering.  A  lotion  containing  precipitated  sulphur 
4  drams  (16.),  glycerin  20  to  40  minims  (1.35-2.65),  alcohol  i  or  2  drams 
(4.  or  8.),  with  4  ounces  of  water  (128.)  is  also  of  value.  Another  sulphur 
application  (Kummerfeld's  lotion)  of  which  I  can  speak  highly  is  that 
composed  of  4  drams  (16.)  of  precipitated  sulphur,  10  grains  (0.65)  of 
powdered  camphor,  20  grains  (1.35)  of  powdered  tragacanth,  and  2 
ounces  (64.)  each  of  lime-water  and  plain  water;  if  well  prepared,  this 
is  of  somewhat  thick,  creamy  consistence,  and  when  applied  makes  a 
good  coating.  There  remain  to  be  mentioned  two  other  sulphur  lotions 
which  have  proved  valuable  in  my  hands,  and  also  in  the  experience  of 
other  specialists:  1$.  Sulphur,  lot.,  3iv  (16.) ;  setheris,  f3iv  (16.) ;  alcoholis, 
q.  s.  ad  f§iv  (128.).  This  is  often  useful  in  those  cases  of  indurated 
and  sluggish  type,  and  especially  when  there  is  a  good  deal  of  oiliness. 
The  other  is  the  liquor  calcis  sulphuratae;  this  should  be  diluted  at  first 
with  i  o  to  15  parts  water,  and  then  rapidly  increasing  its  strength  accord- 
ing to  circumstances,  even  up  to  the  pure  solution ;  it  is  more  particularly 
useful  in  sluggish,  indurated,  and  dermic  abscess  cases. 

Sulphur,  usually  the  precipitated,  is  also  used  in  ointment  form, 
and  in  some  cases,  although  a  small  minority,  it  acts  better  than  the 
lotions;  it  is  prescribed  in  the  strength  of  i  to  2  drams  (4--8.)  to  the 
ounce  (32.)  of  benzoated  lard.  The  English  are  fond  of  an  ointment  of 
hypochlorid  of  sulphur,  a  dram  (4.)  to  the  ounce  (32.)  of  lard. 

Another  sulphur-containing  salve  which  often  proves  beneficial  is 
made  as  follows:  f  dram  (2.)  of  potassium  sulphuret  is  dissolved  in 
i  dram  (4.)  of  water,  and  to  this  is  added  \  dram  (2.)  of  zinc  sulphate, 
and  allowed  to  react;  it  is  then  stirred  until  the  sulphureted  hydrogen 
odor  entirely  disappears,  and  finally  rubbed  up  with  2  to  4  drams  (8.-i6.) 
of  cold  cream  or  cold  cream  and  lanolin. 

In  recent  years  ichthyol  has  been  added  to  the  therapeutics  of  acne, 
and  is  often  useful.  It  is  employed  in  lotion  or  ointment  form,  usually 
the  latter;  as  an  ointment,  i  to  3  drams  (4.-! 2.)  to  the  ounce  (32.)  of 
equal  parts  of  simple  cerate  and  rose-water  ointment;  or  as  a  lotion, 
about  the  same  strength  with  water.  It  seems  to  be  more  especially 
valuable  in  acne  of  a  pustular  and  pustulotubercular  type,  and  in  the 
latter  its  application  as  a  25  per  cent,  plaster  is  often  advantageous. 


1052  DISEASES   OF   THE  APPENDAGES 

A  compound  ointment  containing  both  sulphur  and  ichthyol  is  also  of 
value: 

fy     Sulphuris  praecipitati,  5ss-ij  (2.-8.); 

Ichthyol,  5j-ij  (4-8.); 

Adipis  vel  petrolati,  q.  s.  ad  5  j  (32.). 

In  extremely  sluggish  cases  this  same  ointment  with  i  or  2  drams  (4--8.) 
of  green  soap  (sapo  viridis)  to  the  ounce  (32.)  will  act  more  energetically; 
in  fact,  sapo  viridis  may  be  incorporated  in  any  of  the  ointments  named 
if  a  more  positive  action  is  desired. 

Resorcin  as  a  lotion,  from  5  to  30  or  more  grains  (0.32-2.)  to  the  ounce 
(32.)  of  water,  or  of  water  and  alcohol,  is  a  clean  and  often  useful  appli- 
cation. It  should  be  cautiously  used  at  first  in  the  stronger  proportions, 
as  exceptionally  it  provokes  an  eczematoid  dermatitis,  especially  if  used 
in  salve  form.  Boric  acid  is  likewise  valuable,  either  as  a  strong  alco- 
holic lotion  or  as  a  combined  lotion  with  resorcin.  The  following  has 
been  of  service: 

^.     Resorcini,  3ss-ij  (2.-8.); 

Acidi  bond,  5HJ  (4-~8.); 

Zinci  sulphatia  gr.  xx-xxx  (1.3-2.); 

Alcoholis,  f5ss  (16.); 

Aquae  destillatae,  q.  s.  ad  f5iv  (128.). 

The  lotion  of  calamin  and  zinc  oxid,  already  referred  to,  is  often  of  service 
in  the  more  stubborn  inflammatory  types,  if  strengthened  with  resorcin, 
5  to  20  or  more  grains  (0.35-1.35)  to  the  ounce  (32.). 

Salicylic  acid  is  a  remedy  for  occasional  trial  in  obstinate  cases,  from 
10  to  60  grains  (0.65-4.)  to  the  ounce  (32.)  of  ointment,  but  is  often  used 
as  an  addition — from  10  to  20  grains  (0.65-1.3)  to  each  ounce  (32.) — 
to  the  other  ointments  already  named ;  it  is  to  be  observed  that  the  addi- 
tion of  this  ingredient  renders  any  ointment  more  active. 

As  already  remarked,  sulphur  preparations  are  sometimes  without 
effect,  or  after  a  time  fail  to  influence  the  eruption.  In  such  instances, 
and  also  in  others,  the  mercurials  are  not  infrequently  prescribed.  Cor- 
rosive sublimate  is  the  most  valuable,  and  is  usually  the  active  agent  in 
almost  all  the  patent  toilet  lotions.  It  is,  of  course,  to  be  specially  noted 
that  in  changing  from  a  sulphur  to  a  mercurial  application  or  the  reverse, 
several  days  should  be  allowed  to  intervene,  or  else  there  occurs  a  tem- 
porary slight  staining  of  the  skin  from  the  formation  of  black  mercuric 
sulphid;  the  disfigurement  showing  itself  more  especially  by  a  darkening 
at  the  sebaceous  gland  outlets. 

Corrosive  sublimate  is  employed  as  a  lotion,  from  |  to  4  grains 
(0.016-0.25)  to  the  ounce  (32.)  of  water,  or  of  water  and  alcohol;  and 
such  a  lotion  is  materially  strengthened  by  the  addition  of  from  3  to  8 
grains  (0.2-0.5)  °f  zmc  sulphate  to  each  ounce  (32.).  The  following  is  a 
formula  frequently  used:  1$.  Hydrargyri  chloridi  corrosivi,  gr.  ij-xij 
(0.16-0.8);  zinci  sulphatis,  gr.  xx  (1.3);  tincturae  benzoini,  foij  (8.); 
aquae,  q.  s.  ad  foiv  (128.);  mix  and  filter.  Calomel  and  white  precipi- 
tate ointments,  3  to  10  per  cent,  strength,  are  also  at  times  of  service,  and 
may  often  be  alternated  with  the  corrosive  sublimate  lotion. 


ACNE  IO53 

Acne  of  the  back  or  trunk  is,  upon  the  whole,  treated  with  the 
same  preparations  as  that  of  the  face,  but  much  more  energetically, 
and  usually  with  stronger  applications.  Green  soap  or  tincture  of 
green  soap  washing  daily,  followed  by  the  remedial  application,  and 
then  a  dusting-powder  of  powdered  boric  acid,  with  20  to  30  grains  (1.35- 
2.)  of  salicylic  acid  to  the  ounce  (32.),  is  valuable.  Liquor  calcis  sul- 
phuratae  is  a  useful  application  in  some  cases  of  acne  of  this  region. 
Resorcin  in  strong  solution — up  to  i  dram  (4)  to  the  ounce  (32.)  of  equal 
parts  of  water  and  alcohol — sometimes  acts  with  energy.  A  fairly  sat- 
isfactory method  in  many  hands  has  been  with  formalin,  using  this 
at  first  much  diluted,  but  finally  in  sufficient  strength  to  produce  con- 
siderable irritation  or  a  mild  dermatitis,  the  plain  boric  acid  powder 
being  used  as  a  dusting-powder.  The  daily  use  of  a  compound  dusting- 
powder  (C.  N.  Davis),  consisting  of  about  \  dram  (2.)  of  precipitated 
sulphur,  about  10  to  20  grains  (0.66-1.35)  of  powdered  camphor,  and 
boric  acid  or  boric  acid  and  talc  to  make  the  ounce  (32.),  has  also  proved 
markedly  beneficial  in  some  cases.  The  undershirt  should  be  changed 
often  and  boiled  or  washed,  then  put  in  boric  acid  or  weak  formalin 
solution  and  dried. 

The  various  plans  here  outlined  will  usually  suffice  for  most  cases 
of  acne,  but  in  some,  where  more  rapid  action  is  desired  and  when  pa- 
tients remain  at  home  or  are  in  the  hospital,  the  exfoliating  pastes  or 
salves  can  be  used.  The  following  are  the  pastes  that  are  most  com- 
monly employed  for  this  purpose:  1$.  Beta-naphthol,  oss-ij-  (2. -4.); 
precipitated  sulphur,  oiv  (16.);  sapo  viridis,  oij  (8.);  and  rose-water 
ointment,  3ij  (8.)  (Lassar);  and  1$.  Resorcin,  5ss  (16.);  zinc  oxid,  3j  (4.); 
terra  silicea,  gr.  xij  (0.7);  benzoated  lard,  to  3j  (32.)  (Unna,  Isaak). 
This  is  smeared  thickly  on  the  face,  and  is  best  applied  spread  upon  lint; 
it  is  kept  on  for  fifteen  to  thirty  minutes,  and  then  rubbed  off  with  a 
piece  of  linen  or  absorbent  cotton  greased  with  oil  or  cold  cream,  and  then 
the  parts  washed  with  warm  water  and  soap,  followed  with  soothing 
applications,  such  as  cold  cream,  vaselin,  or  talcum  powder.  It  is  re- 
peated every  night  or  oftener  if  necessary,  and  in  a  few  days  sufficient 
dermatic  irritation  has  been  excited,  and  is  followed  by  desquamation. 
Repeated  applications,  two  or  three  times  daily,  of  a  25  to  50  per  cent, 
alcoholic  solution  of  resorcin  act  promptly  and  satisfactorily  in  some  cases 
in  bringing  about  exfoliation;  Bronson  has  also  found  this  plan  efficient. 
In  the  use  of  these  peeling  applications,  as  soon  as  the  exfoliation  and 
irritation  have  disappeared,  the  treatment  is  again  repeated,  and  so  on 
until  the  result  is  obtained. 

As  with  many  other  skin  diseases,  the  Rontgen  rays  have  been  used 
in  this,  and  sometimes  with  brilliant  results.  I  can  add  my  indorse- 
ment of  its  value.  Many  cases  can  be  managed  just  as  well  without  it. 
I  reserve  it  for  persistent,  rebellious  cases,  and  even  in  these  instances 
employing  it,  at  intervals  of  a  week  or  ten  days,  as  a  supplementary  meas- 
ure to  other  treatment.  A  soft  to  medium  tube  is  used.  The  exposures 
should  be  made  cautiously,  at  10  to  15  inches  distance,  and  for  three 
to  four  minutes  duration,  and  later,  if  necessary,  five  to  ten  minutes. 
It  is  best  not  to  push  its  use  to  the  point  of  reaction,  as  in  some  instances, 


1054  DISEASES   OF  THE  APPENDAGES 

when  too  much  action  is  brought  about,  and  exceptionally  in  other 
instances,  and  sometimes  even  after  but  a  few  short  irradiations,  dark 
freckles  result;  and  occasionally  (especially  if  treatments  extend  over  a 
long  period)  a  tendency  to  an  atrophic,  old-age,  somewhat  wrinkled  con- 
dition of  the  skin.  Down  is  also  sometimes,  according  to  patients' 
statements,  produced,  but  I  am  not  convinced  of  this.  These  blemishes 
gradually  lessen  and  disappear,  except  the  atrophic  wrinkled  condition, 
which,  if  pronounced,  may  remain  to  some  extent.  Eyes,  eyebrows, 
and  scalp  should  be  properly  protected.  The  protecting  box  or  casing 
can  be  so  arranged  as  to  protect  the  scalp  hair,  a  thin  covered  tin-  or 
lead-foil  band  can  be  placed  over  the  eyes  and  eyebrows.1 

Repeated  applications  of  the  high-frequency  current,  recently  com- 
mended, have  also  been  of  service  in  some  of  my  cases,  and  have  sup- 
planted the  faradic  and  galvanic  currents;  it  is  applied  by  means  of  a 
flattened  hammer  electrode,  and  this  is  held  f  to  \  inch  from  the  skin; 
and  the  application  should  be  sufficiently  long-continued  as  to  produce 
moderate  redness  or  reaction. 

ACNE  VARIOLIFORMIS2 

Synonyms. — Tuberculide;  Acne  rodens  (Vidal  and  Leloir);  Acne  necrotica  (Boeck); 
Lupoid  acne;  Necrotic  granuloma  (Johnston);  Acne  a  cicatrices  deprimee  (Besnier 
and  Doyon);  Folliculites  cicatricielles  necrosiques  (Hallopeau  and  Leredde). 

Definition. — An  eruption  commonly  characterized  by  lesions 
of  a  moderately  superficial,  papulopustular  type,  discrete  or  grouped, 
occurring  most  commonly  on  the  upper  part  of  the  forehead  and  scalp, 
sometimes  on  the  extremities  and  other  parts,  and  leaving  scars  some- 
what similar  to  those  of  variola;  in  other  cases,  especially  those  involving 
other  parts  than  face  and  scalp,  the  lesions  may  be  solidly  papular,  fre- 
quently follicular,  sometimes  with  an  exfoliating  scale. 

This  name  was  given  by  Hebra,  and  should  not  be  confounded  with 
the  similar  name  occasionally  found  in  the  French  literature  and  applied 
to  molluscum  contagiosum.  In  the  class  acne  varioliformis,  which  in 
my  belief  is  representative  of  the  tuberculides,  are  included  therein  the 
various  cases  described  under  the  names  of  acne  necrotica  (Boeck), 
acnitis,  folliclis  (Barthelemy) ,  necrosing  folliculitis,  impetigo  rodens 
(Devergie),  Pollitzer's  hidradenitis  suppurativa,3  acne  urticata,  Pro- 

1  For  details  as  to  apparatus,  technic,  etc.,  see  article  on  Radiotherapy  in  the  chap- 
ter on  General  Remarks  on  Treatment;  and  for  possible  detrimental  effects  see  *-ray 
dermatitis;  and  also  the  illustration  (Fig.  4)  of  its  evil  effects  in  Burnside  Foster's 
paper,  Jour.  Cutan.  Dis.,  1909,  p.  72. 

2  References  to  the  chief  literature  of  this  and  allied  diseases  are  to  be  found  in 
Bronson's  paper  ("Notes  on  Certain  Pustular  Diseases  Attended  with  Atrophy"),  Jour. 
Cutan.  Dis.,-iB<)i,  p.  122,  and  in  Fordyce's  articles,  ibid.,  p.  128,  and  ("A  Contribution 
to  the  Pathology  of  Acne  Varioliformis  Hebrae"),  ibid.,  1894,  p.  152,  (based  upon  2 
additional  cases) — all  with  illustrations;  also  in  Johnston's  paper  ("The  Cutaneous 
Paratuberculoses") ,  Philada.  MonMy  Med.  Jour.,  Feb.,  1899;  and  in  that  by  Lowen- 
bach  ("Acne  Urticata"),  Archiv,  1899,  vol.  Ixix,  p.  29.     These  several  papers  together 
cover  the  important  literature  pretty  fully. 

3  Hidradenitis  suppurativa:  Verneuil,  "Hydrosadenite  phlegmoneuse    et    absces 
sudoripares,"  Arch.  gen.  de  med.,  1864,  ii,  p.  537,  1865,  i,  p.  327;  Pollitzer's  paper, 
"Hydradenitis  destruens  suppurativa,"  Jour.  Cutan.  Dis.,  1892,  p.  9,  is  the  most  impor- 
tant on  this  disease,  and  reviews  the  literature  of  similar  or  allied  diseases,  with  refer- 


ACNE    VARIOLIFORMIS  1 05 5 

fessor  Duhring's  small  pustular  scrofuloderm,  acne  agminata  (usually 
on  face,  with  tendency  to  grouping),  the  acne  necrotisans  et  exulcerans 
serpiginosa  nasi  (folliculitis  exulcerans  serpiginosa  nasi)  of  Kaposi  (a 
grouped  and  spreading  papular  eruption  on  the  nose,  undergoing  necrosis 
or  purulent  change,  and  leaving  conspicuous  scarring),1  and  the  acne 
telangiectodes  of  Kaposi  (vascular,  sometimes  lupus-like  papules,  in- 
termingled with  acne  on  face,  and  frequently  terminating  in  scar  for- 
mation). Unna's  ulerythema  acneiforme  is  also  believed  by  Vidal, 
Leloir,  and  others  to  belong  to  acne  varioliformis.  The  essential  char- 
acteristics of  these  various  cases  are  usually  discrete,  sometimes  ag- 
gregated, pin-head-  to  pea-  or  bean-sized  papules  or  nodules,  slightly 
elevated,  rarely  deep-seated,  with  somewhat  flattened  top,  reddish  in 
color,  underlying  slight  necrotic  changes  with  consequent  central  depres- 
sion, and,  as  a  rule,  comparatively  insignificant  pus-formation,  followed 


Fig.  262. — Acne  varioliformis  of  a  somewhat  severe  and  grouping  type  (some  lesions 
scattered  through  the  forepart  of  the  scalp  also). 

by  slightly  depressed  or  varioliform  scars.  That  there  may  be  both 
pathogenic  and  histopathologic  differences  is  not  improbable,  but  there 

ences  to  date;  and  Barthelemy's  paper,  "De  1'acnitis,"  Annales,  1891,  p.  i  (disseminated 
with  colored  plates),  reads  as  if  it  were  the  same  disease,  and  it  is  generally  so  considered, 
but  Barthelemy  holds  a  contrary  opinion;  Dubreuilh,  ibid.,  May,  1892,  and  Arch,  de 
med.  exper.  et  d'anat.  patholog.,  Jan.  i,  1893  (2  cases,  with  review  of  literature  and  his- 
tologic  study).  See  also  case  reported  by  Bronson  (acne  varioloformis  of  the  extremi- 
ties), Jour.  Cutan.  Dis.,  1891,  p.  121,  and  histologic  examination  by  Fordyce,  ibid.,  p. 
128;  and  case,  "An  Unusually  Extensive  Folliculitis  and  Perifolliculitis:  its  Connection 
with  the  So-called  Tuberculides,"  reported  by  Trimble,  ibid.,  1907,  p.  256  (with  case 
illustrations  and  histologic  cut). 

1  Kaposi,  "Ueber  einige  ungewohnlichen  Former  von  Acne,"  Archil'.,  1894,  vol. 
xxvi,  p.  82;  E.  Finger,  "Folliculitis  Exulcerans  Serpiginosa  Nasi,"  Wiener  med.  Wochen- 
schr.,  Mar.  6,  1902,  with  review  of  the  literature;  Brandweiner  (blastomycosis 
and  its  relations  to  the  folliculitis  exulcerans  serpiginosa  nasi  of  Kaposi),  Archiv, 
1904,  vol.  Ixxi,  p.  49,  reports  a  somewhat  questionable  case,  presumably  Kaposi's  disease 
(with  literature  review)  Jin  which  he  found  organisms,  apparently  blastomycetes,  and,  on 
this  scant  foundation,  is  led  to  conclude  that  these  two  diseases  are  most  probably  iden- 
tical. 


1056 


DISEASES   OF  THE  APPENDAGES 


is  a  strong  family  clinical  resemblance;  their  appearances  and  behavior 
are  much  alike,  their  course  more  or  less  persistent  and  stubborn,  the 
scarring  about  similar  in  character,  and  the  plans  of  treatment  advised 
essentially  the  same.1 

Symptoms. — The  eruption,  which  in  average  cases  is  rather 
scanty,  consisting  usually  of  from  ten  to  thirty  lesions,  begins  by  the 
appearance  of  small  pale-red  maculopapules  or  papules,  scarcely  rising 
above  the  surface;  they  gradually  become  larger  and  more  elevated  and 
of  a  brighter  red,  which  commonly,  however,  soon  becomes  dull  red  in 
hue.  In  general  the  papule  or  small  nodule  is  pierced  by  a  hair,  which 
may  be  merely  downy  and  scarcely  perceptible,  or  on  the  scalp  and  other 


Fig.  263. — Acne  agminata;  six  to  eight  months'  duration;  showing  some  remaining 
lesions  and  scars;  stage  of  almost  complete  recovery. 

hairy  regions,  as  the  face,  it  is  one  of  the  larger  hairs;  not  infrequently, 
however,  it  is  entirely  free  from  a  hairy  filament.  The  lesion  is  sluggish 
in  its  course,  and  after  reaching  its  acme,  which  requires  several  days  to 
a  week  or  two,  it  often  flattens,  and  the  central  part  shows  pustulation, 

1  Crocker,  Brit.  Jour.  Derm.,  1903,  p.  292,  showed  a  case  (soc'y  demonstration) 
with  lesions  of  "acnitis"  of  the  face  combined  with  lesions  of  "folliclis"  on  the  elbows 
and  forearms;  and  the  cases  shown  as  folliclis  at  the  Internat.  Derm.  Congress,  at  Ber- 
lin, 1904,  that  I  saw  certainly  corresponded  to  what  Prof.  Duhring  had  described  as  the 
small  pustular  scrofuloderm. 

See  also  interesting  report  ("Folliclis  of  the  Skin  and  Conjunctiva,"  Jour.  Cutan. 
Dis.,  1905,  p.  337)  of  a  case  by  Anthony,  concerning  which  there  had  been  several  of 
these  various  diagnoses  made.  See  further  an  interesting  review  by  C.  J.  White,  "The 
Modern  Conception  of  Tuberculosis  of  the  Skin,"  Boston  Med.  and  Surg.  Jour.,  1905, 
vol.  cliii,  p.  291,  especially  the  parts  bearing  upon  "acnitis,"  and  "folliclis." 


ACNE    VARIOLIFORMIS  IO5/ 

usually  slight  in  character;  just  as  frequently,  however,  in  my  experience, 
no  positive  suppuration  is  noticeable,  the  apex  becoming  crusted  and 
sinking  down.  Sometimes  the  summit  is  vesicular  or  vesicopustular. 
In  whatever  manner  the  crust  results,  it  is  ordinarily  quite  adherent, 
and  after  some  days  is  detached,  accidentally  or  spontaneously,  and  un- 
covers a  somewhat  puckered  depression,  red  and  often  abraded  looking; 
this  gradually  heals,  the  redness  lessens,  and  the  process  is  at  an  end, 
leaving  on  its  site  a  pin-head-  to  large  pea-sized-,  usually  rounded, 
clean-cut,  variola-like  scar.  The  lesions  vary  considerably  as  to  size 
and  to  superficial  or  deep  involvement.  When  matured  they  are  from 
small  pea-  to  bean-sized,  and  in  some  cases  are  extremely  superficial, 
scarcely  seeming  more  than  crusted  abrasions;  in  others  they  seem  to 
pervade  the  whole  depth  of  the  corium.  They  are  often  close  together — 
almost  bunched  in  some  instances,  and  in  these  latter  the  scarring  is 
quite  disfiguring.  Exceptionally  they  are  grouped  in  a  linear,  circinate, 
and  even  serpiginous  manner.  In  other  cases  they  are  widely  apart,  and 
scattered  irregularly  over  the  involved  region.  While  often  (and  usually) 
present  in  scanty  or  moderate  numbers,  they  may  be,  exceptionally, 
quite  numerous.  The  course  of  the  disease  is  essentially  chronic,  new 
lesions  appearing  from  time  to  time.  Occasionally,  after  a  variable  period 
of  months,  spontaneous  cure  takes  place,  but,  as  a  rule,  it  is  chronic  and 
persistent. 

The  favorite  or  classic  sites  are  the  forehead,  just  at  the  edge  of  the 
hair,  and  the  scalp.  Other  parts  of  the  face,  and  especially  the  bearded 
region,  are  not  infrequently  its  seat,  either  alone  or  conjointly  with  the 
scalp.  The  eruption  is,  however,  in  some  instances  found  elsewhere,  es- 
pecially about  the  trunk,  anteriorly  and  posteriorly,  and  more  particu- 
larly the  upper  part.  It  is  also  found  upon  the  extremities,  either  in- 
dependently or  conjointly  with  face  or  scalp  involvement.  In  Pringle's1 
patient  the  disease  began  in  the  interscapular  region,  and  only  after 
some  time  involved  the  face,  and  later  still  extended  upward  over  the 
scalp.  I  have  had  cases  under  observation  in  which  the  eruption  was 
found  on  face  and  upper  extremities.  In  many  cases  there  are  no  sub- 
jective symptoms,  but  in  others  there  is  considerable  itching,  and  some- 
times sufficiently  marked  to  be  an  annoying  feature;  this  seems  to  be 
present  more  frequently  in  the  superficial  cases. 

Acne  agminata  type2  (acnitis  type  of  Barthelemy)  is  usually  limited 
to  the  face  and  forehead,  with  a  predominant  tendency  toward  abun- 
dance and  grouping  on  the  brows,  temples,  cheeks  below  the  orbits, 
upper  lip,  and  chin.  The  eruption,  in  addition  to  the  parts  named, 
may  also  be  exceptionally  seen  elsewhere  (in  Schamberg's  case  and  my 
case  there  were  some  lesions  on  the  wrists  and  hands,  and  several  on  the 
penis).  The  eruption  is  indolent,  and  the  lesions  may  undergo  involu- 

1  Pringle,  Brit.  Jour.  Derm.,  1900,  p.  298  (case  demonstration). 

2  In  this  country  this  rare  type  has  been  reported  by  Trimble  (  Jour.  Cut  an.  Dis., 
1908,  p.  309,  with  case  illustration),  by  myself  (case  presentation,  Philadelphia  Derm. 
Soc'y  Trans.,  ibid.,  p.  477),  and  by  Schamberg,  ibid.,  1909,  p.  14  (with  case  and  histo- 
logic  illustrations,  with  review  and  references);  Bowen,  Jour.  Cutan.  Dis.,  1910,  p.  693 
(case  demonstration),  reports  a  case  of  acnitis,  associated  with  lesions  suggestive  of 
lupus  nodules  and  erythema  induratum. 

67 


1058  DISEASES   OF  THE  APPENDAGES 

tion  with  or  without  suppuration,  almost  all  leaving,  as  a  rule,  depressed 
scars.  After  a  time,  usually  months,  the  process  may  gradually  dis- 
appear. 

Btiology. — The  malady  is  encountered  in  both  sexes,  and  most 
commonly  between  the  ages  of  thirty  and  fifty,  rarely  under  twenty. 
Syphilis  has  been  considered  to  be  a  factor  in  some  instances,  but  this 
I  believe  to  be  exceptional;  most  cases  are  observed  in  those  entirely 
free  from  this  disease.  Sabouraud1  believes  the  malady  due  to  the 
conjoint  action  of  his  microbacillus  of  seborrhea  and  staphylococci. 
The  latter  were  also  found  by  Fordyce  and  by  Teuton;  Fordyce  was 
inclined  to  consider  them  of  etiologic  importance;  Teuton,  that  they 
may  be  simply  accidental.  It  is  not  improbable,  too,  as  Johnston  and 
a  few  others  have  stated,  that  in  some  of  these  cases,  as  well  as  in  the 
variously  named  allied  or  aberrant  forms  referred  to,  instead  of  a  direct 
microbic  cause,  the  toxins  of  the  organisms,  among  which  are  the  toxins 
of  tubercle  bacilli,  may  be  also  etiologic;  this  latter  belief  indicating  a 
relationship  or  a  place  among  the  tuberculids,  and  which  is  in  accord 
with  my  own  views. 

Pathology. — It  seems  probable  that  the  eruption  is  the  result 
of  microbic  invasion.  It  is  to  be  considered  an  inflammation  of  the 
pilosebaceous  structures,  with  ensuing  destruction  of  the  follicle  and 
surrounding  derma,  Sabouraud,  as  already  intimated,  believing  that 
it  is  a  secondary  infection  upon  a  seborrheic  basis.  Fordyce  is  inclined 
to  the  opinion  that  the  more  frequent  occurrence  among  the  poor,  and 
its  appearance,  primarily  at  least,  in  the  majority  of  cases  on  the  forehead, 
which  is  exposed  to  pressure  by  unclean  hat-bands,  would  suggest  the 
probability  of  local  infection.  The  pathologic  histology  has  been  studied 
chiefly  by  Leloir  and  Vidal,2  Teuton,  Fordyce,  Sabouraud.  Their  gross 
findings  are  about  alike,  the  principal  difference  being  as  to  the  depth 
at  which  the  lesion  begins  or  involves,  and  this  is  probably  owing  to  the 
character,  size,  and  age  of  the  lesion  examined.  The  lesions  in  Pick's3 
case  had  no  connection  with  the  pilosebaceous  follicle,  and  his  findings 
indicate  that  this  is  not  always  the  starting-point.  Fordyce  found  that 
in  the  earliest  stage  the  lesion  had  its  seat  in  the  superficial  derma,  in 
this  respect  differing  from  the  hidradenitis  suppurativa  which  originates 
in  the  subcutaneous  tissue.  The  majority  of  lesions  were  perforated  by 
a  hair.  The  earliest  changes  noted  consisted  of  a  dense  round-cell  infil- 
tration about  the  hair-follicles,  generally  above  the  situation  of  the  se- 
baceous glands.  In  some  of  the  sections  Fordyce  found  the  sebaceous 
glands  surrounded  by  the  exudation,  while  in  others  they  were  quite 
free.  The  sweat-glands  were  uninvolved,  and,  in  fact,  outside  of  the 
inflammatory  zone.  The  process  extends  laterally  and  upward,  invading 
the  papillary  and  subpapillary  areas.  Cell  disintegration  and  infiltration 
of  the  outer  root-sheaths  occur,  and  all  the  layers  of  the  follicle  may  share 
in  the  destruction  produced  by  the  inflammatory  process.  Usually  the 

1  Sabouraud,  "L'acne  necrotique,"  Annales,  1899,  p.  841  (with  histologic  and  bao 
teriologic  illustrations). 

2  Leloir  and  Vidal,  Traite  descriptif  des  mal  de  la  Peau,  p.  23. 

3  Pick,  Archiv,  1889,  p.  551. 


ACNE    VARIOLIFORMIS  1059 

destructive  action  is  limited  to  the  upper  half  of  the  hair-follicle,  the 
lower  part  and  the  sebaceous  gland  remaining  almost  undisturbed.  The 
affected  tissue  is  gradually  separated  en  masse  by  a  process  of  dry  necrosis, 
but  less  markedly  so  than  observed  in  hidradenitis.  The  staphylococci 
were  found  in  the  lymph-vessels  and  free  in  the  tissues,  and  were  espe- 
cially numerous  about  the  middle  and  deeper  portions  of  the  hair-follicles 
within  the  external  and  internal  root-sheaths,  in  the  connective  tissue 
about  the  sweat-glands,  and  in  the  subcutaneous  connective  tissue. 

Diagnosis. — Acne  varioliformis  is  to  be  distinguished  chiefly 
from  a  pustular  syphilid  and  acne  vulgaris.  Its  localization,  in  a  large 
number  of  cases,  to  the  forehead  and  scalp  is  a  differential  point  of  value. 
The  sluggish,  indolent  character  of  the  lesions,  their  slow  course,  and 
the  comparatively  slight  suppurative  or  necrotic  action,  with  the  result- 
ing varioliform  scars,  are  more  or  less  distinctive  of  all  the  types  of 
acne  varioliformis.  Its  resemblance  to  a  papulopustular  syphiloderm  is 
sometimes  striking,  but  the  latter  is  almost  always  of  wide  distribution, 
and  is  commonly  associated  with  other  symptoms  of  the  disease.  The 
evident  involvement  of  the  sebaceous  gland  in  acne,  with  the  usually 
preceding  comedo  formation,  its  localization  on  the  face,  its  course,  and 
the  absence  of  tendency,  in  most  instances,  to  scar-formation,  are  points 
of  difference.  Folliculitis  decalvans  can  scarcely  be  confounded  with  it, 
as  this  is  only  seen  on  hairy  regions,  commonly  the  scalp,  leaves  cicatricial 
areas  of  alopecia,  and  with  the  periphery  studded  with  minute  inflam- 
matory sycosiform  pustules — the  characteristic  lesions  of  the  malady. 

Prognosis  and  Treatment.— As  a  rule,  most  cases  finally  yield 
to  remedial  measures.  It  is  prone  to  recur.  Untreated,  it  persists, 
sometimes  indefinitely,  although  in  other  instances  periods  of  quiescence 
or  entire  disappearance  are  noted. 

Treatment  consists  in  the  use  of  antiseptic  applications,  the  most 
valuable  being  3  to  6  per  cent,  ointment  of  ammoniated  mercury,  lotions 
or  ointments  of  resorcin,  5  to  25  grains  (0.35-1.65)  to  the  ounce  (32.), 
and  salicylic  acid  ointment  of  3  to  5  per  cent,  strength.  Fordyce  found 
an  ointment  containing  sulphur  and  naphthol  curative.  The  most 
satisfactory  treatment  in  my  experience  is  a  compound  lotion  of  resorcin 
in  a  saturated  solution  of  boric  acid  for  the  non-hairy  regions,  and  for 
the  hairy  parts  the  resorcin  lotion  conjointly  with  the  ammoniated  mer- 
cury salve.  The  lotion  is  to  be  applied  to  the  parts  generally,  and  the 
salve  subsequently  rubbed  into  the  lesion.  In  view  of  a  seborrheic  basis 
being  a  possible  factor,  as  contended  by  Sabouraud,  occasional  remedial 
application  for  this  disorder  after  the  acne  is  cured  is  advisable,  as  pos- 
sibly preventing  a  relapse.  As  to  constitutional  measures,  these,  if 
called  for,  are  to  be  based  purely  upon  indications  in  the  individual  case. 
Staphylococcic  vaccine  has  been  recently  employed  with  alleged  prompt 
and  favorable  action. 


io6o 


DISEASES   OF   THE  APPENDAGES 


ACNE  ROSACEA 

Synonyms. — Rosacea;  Gutta  rosacea;  Gutta  rosea;  Acne  erythematosa;  Fr., 
Acne  rosee;  Acne  rosacee;  Couperose;  Gcr.,  Kupferrose;  Kupferfinne. 

Definition. — A  chronic  congestive  disease  of  the  face,  more  com- 
monly limited  to  the  nose  or  nose  and  immediate  neighboring  parts 
of  the  cheeks,  characterized  by  passive  hyperemia,  later  by  slight  or 
marked  capillary  dilatation  and  enlargement,  and  frequently  by  more 
or  less  acne  or  acne-like  lesions,  and  in  some  instances  tissue  hyper- 
trophy. 

Symptoms. — The  disease  begins  with  slight  passing  redness  of 
the  part,  frequently  the  nose  only  at  first;  this  appears  after  exposure 


Fig.  264. — Acne  rosacea  of  a  not  uncommon  type,  showing  hyperemia,  dilated  capil- 
laries, and  acne  or  acne-like  lesions. 

to  cold  or  heat,  or  after  hot  drinks,  or  during  an  attack  of  indigestion, 
or  it  may  appear  independently  of  any  recognizable  influence.  The 
condition  subsides  sometimes  in  minutes,  sometimes  in  hours,  or  a  day 
or  two.  After  a  variable  number  of  recurrences,  or  after  weeks  or  a 
few  months,  the  hyperemia  becomes  persistent,  showing  aggravation 
upon  excitement,  exposure,  etc.  In  color  it  is  somewhat  variable 
between  bright  and  dull  red,  sometimes  with  a  venous  tint.  A  slight 
or  marked  oiliness  of  the  nose  is  frequently  to  be  noted;  also  sometimes 
enlarged  gland  openings.  Later,  upon  close  examination,  permanently 
dilated  capillaries,  several  or  more  in  number,  can  be  seen,  especially 
toward  the  alae.  The  redness  is  of  slight  degree  or  quite  pronounced, 


ACNE   ROSACE  A 


1061 


disappearing  entirely  upon  pressure;  and  the  part  is  somewhat  colder  to 
the  touch  than  normal.  This  condition,  representing  what  is  usually 
described  as  the  first  stage  of  acne  rosacea,  may  persist  as  such,  varying 
slightly  in  degree,  but  with  little  if  any  tendency  to  extension  or  to 
tissue  hypertrophy. 

In  most  cases,  however,  and  often  conjointly  with  the  earliest  ap- 
pearance of  the  passive  hyperemia,  acne  and  acne-like  papules,  nodules, 
and  pustules,  at  first  few,  later  in  numbers,  may  show  themselves.  Not 
infrequently  the  neighboring  part  of  the  face  within  the  malar  promi- 
nences also  exhibits  the  eruption ;  and  in  some  instances  the  middle  part 
of  the  forehead  and  the  chin  are  likewise  the  seat  of  hyperemia  and 
acne  lesions.  This  area — a  long  oval  with  the  chin  and  middle  forehead 


Fig.  265. — Acne  rosacea  (rhinophyma)  showing  marked  hypertrophy. 

as  the  end  boundaries  and  the  malar  bones  as  the  side  boundaries — 
is  that  beyond  which  acne  rosacea  seldom  extends  to  any  great  degree; 
it  may,  however,  sometimes  present  over  the  entire  face;  and  in  extreme 
cases,  especially  in  heavy  drinkers  and  those  with  an  associated  derma- 
titis seborrhoica,  even  the  bulbar  conjunctiva  may  exceptionally  show 
a  suffused  redness,  suggestive  of  telangietatic  points,  and  a  few  superficial 
phlyctenule-like  lesions.1  With  the  acne  lesions  there  is  usually  noted, 
about  the  nose  especially,  enlarged  gland-ducts  containing  oily  or  semi- 
solid  sebaceous  material,  and  in  occasional  cases  a  slight  tendency  to  mild 

1  Holloway,  "The  Ocular  Manifestations  Associated  with  Acne  Rosacea,  with  the 
Report  of  a  Case  of  So-called  Rosacea  Keratitis,"  Arch,  of  Ophthal.,  1910,  vol.  xxxix, 
No.  4  (with  review  of  the  subject  and  references). 


IO62  DISEASES   OF  THE  APPENDAGES 

seborrheic  dermatitis.  The  enlarged  capillaries  become  more  numerous 
and  may  be  seen  on  all  affected  parts,  more  especially,  however,  the  nose 
and  closely  adjacent  skin.  In  this  picture  is  to  be  found  what  is  usually 
described  as  the  second  stage  of  the  disease,  and  it  rarely,  as  observed 
in  this  country  at  least,  goes  beyond  this.  It  varies  somewhat,  and  may 
measurably  improve  under  favorable  conditions.  The  pustular  lesions 
are  somewhat  or  wholly  like  those  seen  in  ordinary  acne,  but  the  papules 
or  nodules,  especially  about  the  nose,  seem  more  like  tissue  indurations, 
and  the  suppuration  in  the  pustule  is  usually  close  to  the  surface  and 
rather  slight. 

In  exceptional  instances  the  disease  advances;  somewhat  soft  tissue 
hypertrophy,  diffused  or  nodular  in  character,  is  noted  on  the  nose, 
more  especially  toward  the  end  and  at  the  alae;  the  glandular  openings 
are  large,  the  blood-vessel  hypertrophy  more  marked,  some  small  vari- 
cosities  occasionally  presenting,  and  the  whole  organ  is  slightly  or  con- 
siderably enlarged,  constituting  the  so-called  third  stage  of  the  disease. 
The  same  characters  are  usually  to  be  seen,  but  to  a  less  degree,  in  the 
immediately  neighboring  skin;  it  is  only  exceptionally  that  distinct 
hypertrophic  tissue  changes  (other  than  vascular)  are  noted  elsewhere 
on  the  face,  usually  about  the  middle  forehead  and  chin.  In  some  of 
these  hypertrophic  cases  the  disease  is  limited  to  the  nose  region,  in 
others  there  may  in  addition  be  seen  on  other  parts  of  the  face  the  acne- 
like  lesions  and  telangiectases  of  the  more  common  type.  In  rare  in- 
stances the  hypertrophy  of  the  cutaneous  and  subcutaneous  tissue  of  the 
nose  assumes  disfiguring  or  even  immense  proportions,  and  presents 
more  or  less  lobulation,  and,  in  extreme  cases,  pendulous  masses — 
rhinophyma.  In  these  hypertrophic  types  the  color  is  often  a  deep  red 
or  purplish  red. 

As  a  rule,  there  are  no  subjective  symptoms,  although  there  are 
at  times,  in  those  cases  in  which  acne  lesions  are  numerous,  some  ten- 
derness and  soreness,  and  exceptionally,  more  particularly  in  those  ex- 
hibiting a  tendency  to  seborrheic  dermatitis  complication,  slight  itching. 

Etiology. — Acne  rosacea  furnishes  about  3  per  cent,  of  all  skin 
cases — a  less  relative  proportion  in  dispensary  practice  than  in  private 
practice.  It  is  closely  allied  to  acne  in  its  etiology,  except  as  to  the 
age  at  which  it  is  observed;  the  former  is  not  commonly  seen  before 
the  thirtieth  year,  and  most  of  the  cases  observed  earlier  are  usually 
of  the  nose,  and  associated  with  or  clearly  a  part  or  consequence  of 
oily  seborrhea  of  that  organ.  The  disease,  in  its  milder  grades,  is 
thought  to  be  more  common  in  women,  although  I  think  not  so  much 
so  as  is  generally  believed;  women,  being  more  sensitive  to  facial  dis- 
figurement, seek  advice  more  frequently.  The  hypertrophic  form  is 
rarely  seen  in  women.  Disturbance  of  the  digestive  apparatus  must  be 
considered  the  most  important  etiologic  element  in  the  large  majority 
of  patients,  and  such  disturbance  may  be  due  to  improper  food  or  im- 
properly cooked  food,  excessive  indulgence  in  alcoholic  drinks,  tea,  and 
coffee,  etc.  A  feeble  circulation,  debility,  and  gouty  diathesis  seem  also 
to  be  of  influence.  Inordinate  use  of  tobacco  is  a  possible  factor.  In 
addition  to  this  indirect  action  of  alcohol,  it  has  also  the  effect  of  produc- 


ACNE  ROSACE  A  1063 

ing  peripheral  vascular  dilatation,  and  its  free  use  is  responsible  for  many 
cases,  and  doubtless  for  almost  all  of  those  of  marked  hypertrophic  de- 
velopment. It  is  by  no  means,  however,  as  many  are  inclined  to  believe, 
the  sole  cause  of  the  malady,  for  not  infrequently  it  is  met  with  not  only 
in  those  of  temperate  habit,  but  in  total  abstainers,  even  rhinophyma 
having  been  observed  in  the  latter  (Hebra,  Jr.).  In  women  a  not  unim- 
portant factor  is  functional  or  organic  uterine  disorder,  and  in  such,  as 
well  as  in  others  of  this  sex  free  from  this  element,  the  disease  usually  is 
worse  at  and  preceding  menstrual  periods.  Another  cause  or  con- 
tributory factor  in  some  cases  is  to  be  found  in  intranasal  pressure  or 
disease  (Seiler,  Brocq,  Bergh,  Sticker),  giving  rise  to  vascular  and  lym- 
phatic obstruction.  Inflammation  of  the  hair-follicles  (sycosis)  just 
within  the  nares,  by  producing  constant  hyperemia  of  the  integument, 
also  tends  to  lead  toward  the  disease  (Jarisch,  Elliot).  There  are  also 
external  factors  in  many  cases,  such  as  lack  of  cleanliness,  cosmetic  and 
other  irritants,  exposure  to  cold  winds,  as  with  drivers,  cabmen,  etc., 
great  heat,  and  the  rays  of  the  sun.  In  some  patients  a  seborrhea  pre- 
cedes or  is  seen  in  the  course  of  the  disease,  and  may  in  some  cases  have 
etiologic  importance.  Unna  gives  this  factor  a  high  place,  or  rather  con- 
siders the  malady  in  many  instances  a  seborrheic  catarrh,  giving  it  the 
name  rosacea  seborrhoica.  With  others  (Jarisch,  Hallopeau,  Leredde, 
and  others)  I  believe  the  seborrheic  condition  is  often  secondary. 

Pathology.  —  The  first  stage  in  acne  rosacea  is  a  hyperemia, 
probably  angioneurotic  (Eulenberg,  Simon,  Auspitz),  but  in  some  cases 
in  consequence  of  a  seborrheic  process.  In  consequence  of  the  persistent 
hyperemia  and  irregular  periodic  aggravations  the  vessels  become  per- 
manently enlarged,  and  there  is  induced  in  many  cases  a  slight  hyper- 
nutrition  of  the  skin,  which  has  as  a  result  variable  hypertrophic  changes. 
The  sebaceous  glands  become  involved,  nodules,  first  of  a  gelatinous  and 
later  fibrous  character,  and  acne  or  acne-like  lesions  are  usually  super- 
added,  either  secondarily  or  as  a  part  of  the  pathologic  process.  The 
pathologic  anatomy  has  been  studied  by  many  observers  (Simon,  Biesia- 
decki,  Hebra,  Jr.,  Leloir  and  Vidal,  Rokitanski,  Piffard,  Elliot,  Dohi, 
and  others).1  The  markedly  hypertrophic  forms  are  especially  due,  in 
addition  to  the  above,  to  connective-tissue  growth  and  enlargement  of 
the  sebaceous  glands.  There  is  usually  noted  in  the  third  stage  a  pro- 
nounced hyperplasia  of  the  dermic  connective-tissue  elements.  The 
increased  vascular  dilatations  are  partly  the  consequence  of  the  chronic 
hyperemia,  and  partly  doubtless  to  a  blocking-off  of  some  of  the  return 
vessels  from  cicatricial  formations  resulting  from  follicular  suppuration 
and  destruction.  In  some  of  the  enlarged  vessels  the  walls  are  thinned, 
in  others  thickened,  with  considerable  surrounding  connective-tissue 
hypertrophy.  The  veins  show  enlargement,  and  sometimes  resemble 
cavernous  tissue  (Leloir  and  Vidal).  The  acne  or  acne-like  lesions  are, 
for  the  most  part  at  least,  similar  to  those  of  ordinary  acne,  to  which 
disease  it  certainly  seems  to  bear  relation,  although  this  is  of  late  denied 


(Wagner's  paper),  Archives  of  Clinical  Surgery,  1876-77,  vol.  i,  p.  21; 
Hebra,  Jr.,  Archiv,  1881,  p.  603  (with  histologic  plate  and  review  of  literature  with 
references);  Dohi  (2  cases),  ibid.,  1896,  vol.  xxxvii,  p.  371. 


1064  DISEASES   OF   THE   APPENDAGES 

by  others  who  consider  that  the  nodular  and  pustular  lesions  are  wholly 
different  from  those  of  the  latter  malady. 

Diagnosis. — The  diagnostic  characters  are  the  redness,  dilated 
capillaries,  and,  at  times,  the  connective-tissue  and  glandular  hyper- 
trophy, with,  in  most  cases,  acne  lesions  superadded;  the  limitation 
to  the  face,  especially  the  region  of  the  nose,  or  nose,  chin,  and  middle 
forehead;  the  evident  involvement  of  the  sebaceous  glands  in  most  in- 
stances; the  absence  of  ulcerative  tendency  and  the  history  of  the  case — 
these  are  points  of  difference  which  will  usually  serve  to  distinguish  it 
from  acne,  erythematous  eczema,  dermatitis  seborrhoica,  lupus  erythe- 
matosus,  tubercular  syphiloderm,  and  lupus  vulgaris. 

The  distinct  hyperemic  element  is  wanting  in  ordinary  acne;  its  dis- 
tribution is  irregular  and  general  over  the  face;  there  are,  in  most  in- 
stances, numerous  comedones,  and  there  is  no  dilatation  of  the  vessels, 
and,  as  a  rule,  its  subjects  are  younger.  Erythematous  eczema  is  never 
limited  to  the  acne  rosacea  region,  the  skin  is  somewhat  inflammatory 
and  infiltrated,  with  usually  slight  or  moderate  scaliness,  and  trouble- 
some subjective  symptoms,  and  no  dilated  vessels,  and  a  different  his- 
tory. Dermatitis  seborrhoica  is  frequently  seen  in  this  region,  but  it  is 
a  distinctly  oily  or  scaly  disease,  with  no  blood-vessel  dilatations,  and  is 
ordinarily  associated  with  a  seborrhoea  capitis;  there  is  often  variable 
itching  or  burning.  Lupus  erythematosus  is  sharply  defined,  wi+h,  as 
a  rule,  an  elevated  border;  there  is  slight  or  moderate  scaliness,  a  tend- 
ency to  central  thinning,  and  atrophy.  Both  the  tubercular  syphilo- 
derm and  lupus  vulgaris  may  bear  slight  resemblance  to  the  hypertrophic 
nodular  acne  rosacea,  but  they  generally  tend  to  ulcerative  action  and 
scarring  or  to  atrophic  change;  lupus  vulgaris  usually  begins  in  early 
life,  and  the  lesions  of  the  syphiloderm  almost  invariably  are  noted  to  be 
circinate  or  segmentally  grouped;  dilatation  of  the  capillaries  is  not  an 
essential  feature  of  either,  and  the  history  is  different  in  both  diseases. 

Prognosis. — The  disease  is  obstinate,  but  all  cases  are  favorably 
influenced  by  treatment;  the  mild  and  moderately  developed  types, 
under  proper  management,  with  the  cordial  and  persistent  cooperation 
of  the  patient,  are  usually  curable,  several  months,  and  sometimes  longer, 
being  required,  progress  toward  recovery  being  more  rapid  at  first. 
The  removability  of  the  etiologic  factors  will  naturally  have  much  to  do 
with  the  character  of  the  prognosis  given,  both  as  to  immediate  relief 
and  freedom  from  recurrence.  The  hypertrophic  forms  admit  of  im- 
provement, and  even  in  those  of  extreme  development  much  can  be 
accomplished  and  the  disfigurement  materially  reduced  by  surgical  pro- 
cedures. 

Treatment. — In  great  measure  this  is,  excepting  as  to  the  dilated 
capillaries  and  connective-tissue  hypertrophy,  closely  similar  to  that 
of  acne,  both  as  to  its  constitutional  management  and  local  medica- 
tion. Considering  the  possible  etiologic  factors  mentioned,  the  chief 
attention  is  to  be  directed  to  supervising  the  diet,  improving  the  diges- 
tion, a  free  action  of  the  bowels,  and  the  avoidance  of  the  predisposing 
and  exciting  influences.  In  women  inquiry  is  to  be  made  as  to  the  men- 
strual function  and  as  to  possible  functional  or  organic  uterine  disease. 


ACNE  ROSACE  A  1065 

The  diet  should  be  plain  but  substantial,  especially  avoiding  all  indi- 
gestible food,  such  as  mentioned  under  Acne;  the  avoidance  of  more  than 
slight  indulgence  in  tea,  coffee,  and  cocoa,  especially  the  first  named, 
and  the  absolute  prohibition  of  alcoholic  drinks  in  any  form.  The  use 
of  tobacco  should  also  be  kept  within  moderate  limits.  As  there  are 
no  special  remedies,  the  constitutional  treatment,  if  called  for,  is  to  be 
based  upon  a  correct  appreciation  of  the  etiologic  factors  in  the  individual 
case,  digestives,  laxatives,  tonics,  and  cod-liver  oil  being  most  usually 
prescribed.  The  morning  saline  mixture  and  the  compound  cascara 
mixture  to  be  found  under  Acne  are  often  of  service  in  those  constipated 
and  of  weak  digestion.  In  the  latter  a  prescription  of  hydrochloric  acid, 
strychnin,  and  pepsin  is  also  of  value,  along  with  the  daily  or  occasional 
administration  of  a  laxative.  Ergot  and  ichthyol  are  two  drugs  which 
have  some  support  for  internal  administration  in  this  disease,  the  former 
in  20-  to  6o-minim  (1.35-4.)  doses,  and  of  the  latter  (Unna,  Morris,  and 
others)  3  to  10  minims  (0.2-0.7)  three  times  daily,  but  I  have  not  been 
able  to  get  the  good  from  their  use  that  others  have. 

The  external  treatment  of  the  earlier  stages  and  the  hyperemic  and 
inflammatory  lesions  of  acne  rosacea  are,  as  already  stated,  very  similar 
to  that  of  acne.  Any  existing  intranasal  pressure  or  follicular  inflam- 
mation or  a  seborrhea  should  receive  attention.  The  same  general 
directions  as  to  preliminary  measures,  such  as  the  soap-and-water  wash- 
ing and  hot- water  sponging,  are  to  be  advised;  occasional  cases  in  which 
the  slightly  scaly  seborrheic  element  is  more  or  less  pronounced,  as  a 
rule,  only  admit  of  the  sparing  use  of  soap,  which  in  these  and  in  all 
others  should  be  employed  at  night.  Massage  is  not  advisable.  While 
the  remedial  applications  are  those  employed  in  acne,  there  are,  however, 
several  of  these  which,  in  my  experience,  are  more  generally  useful  than 
others.  In  the  cases  of  considerable  hyperemia  and  of  widespread 
distribution  of  an  irritable  type,  and  in  which  acne  lesions  are  somewhat 
numerous,  a  most  admirable  beginning  application  is  that  of  the  calamin- 
zinc-oxid  lotion.  This  is  to  be  dabbed  on  freely  and  allowed  to  dry  on; 
in  the  morning  the  parts  washed  off  according  to  the  usual  custom  of  the 
patient,  and  the  lotion  again  applied;  if  the  patient  goes  out,  the  powder 
which  dries  on  can  be  gently  wiped  or  rubbed  off.  Or  in  the  morning 
a  plain  talcum  powder,  made  skin  color  by  the  addition  of  a  few  grains 
(fractional  part  of  a  gram)  of  calamin  to  the  ounce  (32.).  Resorcin  added 
to  this  lotion,  i  to  5  or  more  grains  (0.065-0.35)  to  the  ounce,  increases 
its  strength.  This  treatment  is  to  be  continued  as  long  as  it  materially 
benefits,  and  then  recourse  be  had  to  the  lotion  of  zinc  sulphate  and  potas- 
sium sulphuret,  each  20  grains  to  2  drams  (1.35-8.)  to  the  4  ounces  (128.) 
of  water.  In  many  of  these  irritable  cases  this  wash  can  be  used  from  the 
beginning  in  the  weakest  strength,  and  gradually  increasing  if  it  does 
not  irritate.  Very  often  this  lotion  with  i  minim  (0.065)  °f  glycerin 
to  each  ounce  (32.)  will  add  to  its  permissibility  in  irritable  types.  Later, 
and  in  sluggish  cases,  alcohol,  \  to  i  dram  (2.~4.)  to  the  ounce  (32.), 
can  be  added  to  advantage,  and  in  such  cases  very  often  the  preparation, 
when  improvement  begins  to  lag  or  ceases,  can  be  rendered  more  active 
and  again  beneficial  by  having  an  excess  of  2  to  6  grains  (0.13-0.4)  of 


IO66  DISEASES   OF  THE  APPENDAGES 

zinc  sulphate  over  the  potassium  salt  in  each  ounce  (32.).  Very  often 
the  plan  of  using  the  calamin-zinc-oxid  lotion  in  the  morning  and  the 
stronger  wash  in  the  evening  has  served  me  well;  or  they  can  be  used  on 
alternate  nights.  If  irritation  or  slight  scaliness  ensues,  the  wash  can 
be  used  at  night  and  cold  cream  in  the  morning,  wiping  it  off  on  going 
out. 

Another  application  which  is  especially  useful  in  many  instances  is 
the  Kummerfeld  lotion,  formula  for  which  is  given  under  Acne;  it  should 
be  used  at  night  freely,  and  several  times  daily  when  possible,  and  occa- 
sionally intermitted  if  roughness  or  irritation  of  the  skin  results;  or  nowr 
and  then  replacing  it  with  an  application  of  cold  cream  or  with  the  cala- 
min-zinc-oxid lotion.  In  this  disease,  too,  probably  even  more  than  in 
acne,  the  liquor  calcis  sulphuratae  (Vleminckx's  solution)1  will  be  found 
of  benefit,  using  it  diluted  with  10  to  15  parts  of  water  at  first,  and 
rapidly  increasing  in  strength  until  irritation  or  trifling  exfoliation  is 
produced,  and  then  reducing  slightly  and  continuing,  intermitting  oc- 
casionally, if  necessary,  as  with  other  lotions  referred  to.  In  those 
cases  in  which  there  is  considerable  oily  seborrhea  the  sulphur-ether- 
alcohol  lotion  (see  Acne)  is  often  more  serviceable.  Other  lotions  re- 
ferred to  in  treating  acne  can  also  be  tried  from  time  to  time  in  obstinate 
types  in  which  the  above  are  without  result  or  cease  to  benefit.  In  this 
disease,  as  in  many  others,  an  application  benefits  for  a  time  only,  and 
then  is  to  be  set  aside;  its  resumption  later  will  often  again  prove  of  value. 

Ointments  are  not  so  generally  useful  as  lotions,  although  progress 
is  more  rapid  in  some  cases  when  one  temporarily  gives  place  to  the 
other.  They  are  to  be  applied  as  described  in  acne.  Precipitated  sul- 
phur ointment,  30  grains  to  2  drams  (2.-8.)  of  sulphur  to  the  ounce  (32.) 
of  cold  cream  or  benzoated  lard,  acts  satisfactorily,  for  a  time  at  least, 
in  some  instances.  The  ointment  made  with  a  strong  solution  of  zinc 
sulphate  and  potassium  sulphuret,  referred  to  in  Acne,  is  also  sometimes 
valuable  and  deserves  a  higher  position  ordinarily  than  the  plain  sulphur 
ointment.  Ichthyol  (Unna  and  others),  in  ointment  and  lotion  of  10 
to  25  per  cent,  strength,  is  often  of  striking  advantage  in  this  disease, 
but  often  fails  to  make  an  impression,  and  exceptionally  aggravates; 
and  it  is  difficult  to  say  in  what  particular  case  its  best  effects  are  to  be 
expected;  probably  in  those  of  markedly  hyperemic  type,  and  in  which 
suppurative  lesions  are  numerous.  It  will  often  act  more  satisfactorily 
as  a  lotion  than  as  an  ointment. 

White  precipitate  and  calomel  ointments,  20  to  60  grains  (1.35-4.) 
to  the  ounce  (32.)  of  ointment,  have  also  had  a  place  in  the  treatment, 
but  are,  as  a  rule,  much  inferior  to  the  applications  already  mentioned. 
Corrosive  sublimate  lotions  (see  Acne)  are  at  times  of  service.  Mer- 
curial plaster  kept  applied  (Hebra,  Kaposi,  Neumann)  as  constantly  as 
possible  is  often  of  value  in  cases  in  which  somewhat  hard  nodular  or 
papular  lesions  are  present.  Ichthyol  plaster,  25  per  cent.,  is  also  of 
service  in  such  instances.  Tannic  acid,  in  lotion  or  ointment  form,  is 
occasionally  useful;  the  former,  5  to  60  grains  (0.35-4.)  to  the  ounce 
(32.)  of  equal  parts  of  water  and  alcohol,  and  the  ointment,  of  10  to  20 
1  Stelwagon,  "Vleminckx's  Solution  in  Acne  Rosacea,"  Med.  News,  July  7,  1883. 


ACNE  ROSACE  A  IO6/ 

per  cent,  strength;  the  lotion  is  the  more  valuable.  I  have  used  it  in  the 
type  in  which  the  disease  was  more  or  less  strictly  limited  to  the  nose, 
with  some  oily  seborrhea  and  enlarged  glandular  openings.  In  this  class 
of  cases,  too,  electrolysis,  repeated  every  few  weeks,  freely  used  within 
the  openings  and  the  interspaces,  is  an  adjuvant  of  considerable  value, 
employing  a  current  of  2  to  5  milliamperes;  it  produces  irritation  lasting 
a  day  or  two,  and  the  condition  looks  temporarily  worse.  Multiple 
punctures  with  a  sharp-pointed  bistoury  are  also  of  value  in  these  cases, 
but  probably  no  more  so  than  electrolytic  punctures;  bleeding  should 
be  favored  by  hot-water  compresses,  followed  later  by  cold  compresses. 
The  application  of  electricity  (Cheadle,  Piffard,  and  others)  is  sometimes 
beneficial,  the  high-frequency  current  being  the  most  valuable.  It  is 
applied  in  the  same  manner  mentioned  in  Acne.  The  Rontgen-ray  treat- 
ment is  another  recent  plan  variously  commended,  and  has  sometimes 
proved  useful  in  some  of  my  cases,  especially  in  those  of  markedly  dilated 
and  pustulous  gland  openings,  and  those  of  a  hypertrophic  character; 
it  is  applied  in  the  same  cautious  manner  as  in  acne. 

Under  these  plans,  given  above,  the  most  disfiguring  elements  of 
average  cases — the  diffused  hyperemia  and  the  acne  lesions — can  be 
removed.  There  remain  in  many  instances,  however,  the  dilated  ves- 
sels, and  in  a  less  number  tissue  hypertrophy,  which  require  other  treat- 
ment. The  former  can  be  destroyed  either  with  the  knife,  cutting 
transversely  at  several  points,  or  cutting  down  their  length;  by  a  Paquelin 
microcautery  (Unna,  Elliot),  or  preferably  and  most  satisfactorily  by 
electrolysis  (Hardaway  and  others).1  The  electrolytic  method  is  essen- 
tially the  same  as  employed  in  the  removal  of  superfluous  hairs  (q.  v.); 
the  needle  may,  if  the  vessel  is  short,  be  inserted  along  its  length,  or  if 
long,  may  be  inserted  at  several  points  in  its  course.  It  is  usual  to  attach 
the  needle  to  the  negative  pole,  and,  upon  the  whole,  this  is  the  most 
satisfactory,  but  in  occasional  rebellious  cases  I  have  used  it  attached 
to  the  positive  electrode,  and  found  it  sometimes  effective;  in  the  latter 
instances  a  gold  or  iridoplatinum  needle  is  to  be  used,  for  reasons  stated 
(see  Hypertrichosis) .  The  strength  of  the  current  required  is  from  |  to 
2  milliamperes — about  2  to  6  or  8  wet  cells  and  3  to  12  dry  cells.  The 
needle  is  kept  in  from  several  to  thirty  seconds,  according  to  effect;  the 
blood  is  noticed  to  run  up  the  vessel,  and  the  latter  thus  apparently  disap- 
pears, but  as  soon  as  the  needle  is  withdrawn  and  the  gases  generated 
are  absorbed,  the  blood,  if  the  vessel  is  long,  returns  part  way;  new 
punctures  are  to  be  made  in  such.  The  appearance  of  a  distinct  blanch- 
ing at  the  point  of  insertion,  enlarging  to  the  size  of  a  small  pea,  should 
be  a  signal  for  withdrawal  of  the  needle,  otherwise  too  much  action  may 
follow.  Very  often,  from  the  resulting  hyperemia  after  a  series  of  punc- 
tures, the  vessels,  if  at  all  near  to  each  other,  can  no  longer  be  detected, 
and  further  operations  must  then  be  postponed.  Hot-water  applica- 
tions should  be  made  immediately  afterward  for  a  few  minutes,  followed 
by  cold.  The  electrolytic  procedure  is  to  be  frequently  repeated  until 
the  destruction  of  the  vessels  ensues.  Unfortunately,  there  often  exists  a 
tendency  to  new  vessel-formation  or  dilatation. 

1  Hardaway,  Arch.  Derm.,  1879,  vol.  v,  p.  356. 


1068  DISEASES   OF  THE   APPENDAGES 

The  slight  connective-tissue  hypertrophy  can  sometimes  be  re- 
duced by  multiple  punctures  and  scarification  (Hebra,  Neumann,  Veiel, 
Squire,  and  others)  and  by  electrolytic  punctures  (Hardaway) ;  whatever 
the  method,  it  must  be  frequently  repeated.  The  moderately  hyper- 
trophic  and  also  extreme  cases  I  have  sometimes  been  able  to  reduce 
by  electrolytic  destruction,  both  by  introducing  the  needle  down  into  the 
glands  (Brocq)  and  through  the  skin  between  the  glandular  openings, 
using  a  current  of  3  to  6  milliamperes — about  4  to  10  wet  cells,  and  6  to 
20  dry  cells — and  allowing  the  needle,  attached  to  negative  pole,  to  re- 
main in  for  twenty  to  forty  seconds,  in  order  that  slight  destruction  may 
result  and  cicatricial  contraction  ensue.  Minute  galvanocautery  punc- 
tures (Unna's  micro-Paquelin  or  galvanocautery)  are  also  useful.  Car- 
bon-dioxid  snow  as  a  superficial  cauterant  could  also  be  used  in  the 
milder  cases.  In  extreme  cases  of  excessive  connective- tissue  growth, 
however,  the  most  rapid  and  usually  quite  satisfactory  treatment  is  by 
ablation  or  decortication  with  the  scissors  or  knife;  the  condition  rarely 
recurs.1 

4.  DISEASES   OF   THE   SWEAT-GLANDS 
HYPERIDROSIS2 

Synonyms. — Excessive  sweating;  Idrosis;  Ephridrosis;  Sudatoria;  Polyidrosis; 
Fr.,  Hyperidrose. 

Definition. — A  functional  disturbance  of  the  sweat-glands  char- 
acterized by  an  increased  production  of  sweat,  and  which  may  be  local 
or  general,  slight  or  excessive,  acute  or  chronic. 

The  general  sweating,  which  may  be  a  part  of  a  serious  illness, 
symptomatic  in  character,  and  common  in  such  diseases  as  acute  rheu- 
matism, malarial  fever,  tuberculosis,  Graves'  disease,3  etc.,  although 
especially  interesting  in  view  of  the  possible  excretion  of  microbic  ele- 
ments or  toxins,  as  indicated  by  Eiselsberg,4  Brunner,5  Geisler,6  and  others, 
scarcely  belongs  to  the  domain  of  dermatology.  It  is  chiefly  with  those 
cases  which  we,  in  the  present  state  of  our  knowledge,  look  upon  as 
idiopathic  that  our  interest  lies,  and  more  especially  the  local  forms 
which  naturally  gravitate  to  dermatologic  practice. 

Symptoms. — General   hyperidrosis   as   an  idiopathic  affection  is 

1  Lassar,  "Ueber  Rhinophyma,"  Dermatol.  Zeitschrift,  1895,  vol.  ii,  p.  485. 

2  An  extremely  valuable  contribution  on  hyperidrosis  and  the  several  varieties  of 
morbid  sweating  is  that  by  Bouveret  ("Des  sueurs  morbides") ,  These  de  Paris,  1880,  with 
a  resume  of  literature  and  references;  also  interesting  paper  and  review  of  the  entire 
subject  and  several  varieties  by  Pooley,  "Anomalies  of  Perspiration,"  Ohio  Med.  Re- 
corder, 1880-81,  vol.  v,  pp.  241,  289,  337,  385,  and  441,  containing  a  large  number  of 
collected  cases,  with  many  literature  references.     Later  literature  will  be  referred  to 
in  the  course  of  the  text. 

3  Dore,  "Cutaneous  Affections  Occurring  in  Graves'  Disease,"  Brit.  Jour.  Derm., 
1900,  p.  353. 

4  Eiselsberg,  "Nachweis  von  Eiterkokken  im  Schweisse  eines  Pyasmischen,"  Berlin, 
klin.  Wochenschr.,  1891,  p.  553. 

5  Brunner,   "Ueber  die  Ausscheidung  pathogenes  Mikroorganismen  durch  den 
Schweiss,"  ibid.,  1891,  p.  505,  and  Arch.  klin.  Chirurg.,  vol.  Ixxx,  No.  2. 

6  Geisler,  "Ueber  die  Ausscheidung  der  Typhusbacillen  im  Schweisse,"  Wratsch, 
1893 — abs.  in  Baumgarten's  Jahresberichtt  1893,  voL  ix,  p.  238. 


HYPERIDROSIS  1069 

not  uncommon,  but  mostly  as  a  chronic  condition,  seemingly  natural 
to  certain  individuals.  The  sweating  may  be  moderate  or  excessive, 
and  always  more  marked,  as  a  rule,  on  those  regions  where  local  hyperi- 
drosis  is  usually  manifested,  as  axillae,  genitocrural  region,  hands,  and 
feet.  The  slightest  exertion  serves  to  increase  it  greatly,  and  while  always 
most  profuse  in  the  hot  season,  is  quite  excessive  during  the  winter  as 
well.  During  the  former  period  especially,  an  occasional  associated 
miliaria  or  erythema  intertrigo,  or  even  an  eczema,  due  to  the  irritating 
action  of  the  moisture  itself,  as  well  as  to  the  chemical  changes  which  the 
sweat  may  undergo,  is  not  uncommon.  Boil-formation  also  seemed  to 
be  favored  in  such  individuals.  While  the  secretion  may  not  have  an 
odor  at  first,  unless  frequent  changes  of  linen  are  made  and  frequent 
baths  taken,  it  usually  soon  becomes  offensive  (bromidrosis).  In  rare 
instances,  instead  of  the  sweating  being  general,  it  is  limited  to  a  small 
portion  of  the  surface  or  to  the  half  of  the  body  unilaterally,  as  described 
by  Teuscher1  and  others,  or,  as  in  a  case  reported  by  Kaposi,2  to  the 
upper  half  or  part  of  both  sides.  Cases  of  sweating  limited  to  half  the 
face  are  less  rare,  and  have  sometimes  shown  an  association  of  the  lesions 
of  hydrocystoma. 

The  chief  interest  lies,  however,  in  the  local  forms,  especially  the 
excessive  sweating  of  the  hands  and  feet,  and  for  which  professional 
advice  is  most  frequently  sought.  It  often  exists  on  the  hands  or  feet 
alone,  but  not  infrequently  conjointly.  The  condition  limited  to  both 
hands  (hyperidrosis  manuum)  is  not  uncommon,  more  especially  about 
the  palms,  and  the  sweating  may  be  persistently  copious  or  come  on  at 
irregular  times  or  in  consequence  of  some  excitement  or  perturbation. 
The  hands  are  noted  to  be  clammy  and  cold.  In  a  case  recently  under 
my  care  at  times  the  hands  were  perfectly  dry,  when  suddenly,  without 
apparent  cause,  they  would  become  rapidly  wet,  the  sweat  accumulating 
in  drops  and  dripping  on  to  the  floor.  In  exceptional  instances  a  few 
deep-seated  vesicles  are  occasionally  seen  about  the  fingers  and  palms 
(see  Pompholyx).  Such  persons  are  unable  to  wear  gloves  more  than 
from  a  few  minutes  to  an  hour  or  so,  without  their  becoming  permeated 
with  moisture;  and  everything  touched  by  them  is  apt  to  show  a  greasy 
mark.  As  a  rule,  the  condition  is  most  marked  when  the  patient  is 
tired,  nervous,  or  exhausted.  A  slight  or  moderate  tylosis  of  the  palms 
may  be  associated  or  develop  gradually. 

Sweating  of  the  feet  (hyperidrosis  pedum)  is  a  troublesome  and  often 
a  disgusting  form  of  localized  hyperidrosis.  It  varies  in  degree:  some- 
times moderate,  at  other  times  excessive.  The  feet  are  constantly 
damp  or  wet,  the  socks  or  stockings  become  moist  or  drenched  a  short 
time  after  they  are  put  on,  and  the  shoe  itself  often,  in  severe  cases, 
becomes  rapidly  water-soaked.  It  is  especially  pronounced  on  the  sole 

1  Teuscher,  Neurolog.  Centralblatt,  1897,  p.  1028,  records  several  cases  of  his  own 
and  cites  other  cases  with  literature  references. 

2  Kaposi,  "Hyperidrosis  spinalis  superior,"  Archiv,  1899,  vol.  xlix,  p.  321  (patient  a 
boy  aged  fifteen,  sweating  since  six;  kyphoskoliosis  since  his  eighth  year).     See  also 
interesting  paper  by  Caldwell  (a  review  of  the  neuroses  of  the  pneumogastric  nerves, 
with  some  account  of  the  anatomy,  physiology,  and  pathology  of  these  nerves;  also  of 
the  vasocenters  and  sweat-centers),  Virginia  Med.  Monthly,  1878-79,  vol.  v,  p.  565. 


1O/O  DISEASES   OF  THE  APPENDAGES 

and  between  the  toes,  and  may  be  limited  to  these  parts.  The  skin  is  apt 
to  be  macerated  and  soggy,  and  exceptionally  pompholyx  lesions  are 
seen  from  time  to  time.  In  many  cases — those  of  the  more  severe  type — 
the  skin  of  the  sole  and  neighboring  parts  is  noted  to  be  pinkish  red, 
sometimes  with  a  violaceous  tinge,  somewhat  puffy  or  irritated,  and  in 
some  cases  at  the  border,  which  is  usually  sharply  defined,  slightly  in- 
flamed, and  showing  a  few  ill-defined  vesicular  or  flattened  bullous  lesions; 
or  the  skin  at  the  edge  may  be  simply  macerated  and  abraded.  Unless 
the  foot-wear  is  frequently  changed  an  offensive  odor  soon  arises,  al- 
though in  these  cases  the  sweat  secretion  as  it  is  freshly  poured  out  is 
usually  odorless. 

In  the  axillary  and  genitocrural  regions  the  sweat  is  often  noted 
to  be  excessive,  and  necessitates,  more  particularly  in  women,  the  wear- 
ing of  dress-shields  to  prevent  soiling  of  the  garment,  but  which,  however, 
tend  to  increase  the  secretion.  In  extreme  cases  maceration  is  also  likely 
to  arise,  and  not  infrequently  chafing  or  an  eczematous  irritation  presents 
as  a  complication.  In  these  regions  the  sweat  often  undergoes  rapid 
chemical  change,  and  a  heavy,  offensive  odor  is  developed.  Hyperi- 
drosis  circumscripta  is  a  name  applied  to  the  condition  when  limited  to 
a  small  area,  examples  of  which  have  been  occasionally  observed.1 

The  localized  forms,  just  described,  as  with  the  general  forms,  may 
be  acute  or  chronic  in  character — more  usually  the  latter.  It  is  naturally 
more  marked  during  warm  weather  or  after  active  work  or  exercise. 
It  may  vary  somewhat  in  degree  from  time  to  time. 

Etiology. — Idiopathic  excessive  general  hyperidrosis  is,  as  a  rule, 
associated  with  debility,  and  probably  in  many  cases  is  in  reality  merely 
symptomatic  of  some  underlying  unrecognized  disease,  such  as  incipient 
Graves'  disease,  tuberculosis,  malaria,  etc.  The  causes  in  the  local 
forms  are  doubtless  varied  from  that  of  pure  idiosyncrasy  to  grave  sys- 
temic disturbance;  as  an  example  of  the  former  may  be  mentioned  a 
case  of  a  woman  reported  by  Hutchinson,2  in  whom  the  slightest  indul- 
gence in  tea-drinking  provoked  hyperidrosis  of  the  feet.  In  some 
families  there  is  a  hereditary  tendency  to  somewhat  free  general  per- 
spiratory secretion,  and  this  is  noted  to  be  a  factor  in  some  of  the 
localized  cases.  It  is  a  well-recognized  fact  that  in  those  of  impaired 
vigor,  and  especially  after  some  debilitating  disease,  such  as  influenza, 
which  leaves  great  prostration  and  nervous  weakness,  that  excessive 
sweating  is  most  frequently  observed — both  the  general  and  local  forms. 
Anything,  in  fact,  which  depresses  the  nervous  tone  may  be  of  etio- 
logic  import.  The  tendency  to  abnormal  sweating  and  excitability  of 
the  perspiratory  function  is  often  observed  in  neurasthenics.  Phys- 
ical or  mental  excitement  is  apparently  the  starting  impetus,  and  in 
developed  cases  always  an  aggravating  and  exciting  factor.  Lesser,3 
as  also  Morris,  Norman  Walker,  and  Pringle,  has  noted  that  most  patients 
with  hyperidrosis  of  the  feet  are  "flat-footed";  and  Hardaway  and  Alli- 

1  Sutton,  Jour.  Amer.  Med.  Assoc.,  Sept.  28,  1912,  p.  1193,  describes  an  extremely 
limited  case,  limited  to  a  small  area  near  the  inner  extremity  of  the  left  eyebrow. 

2  Hitchinson,  Archives  of  Surgery,  1899,  p.  56. 

3  Lesser,  "Schweissfuss  und  Plattfuss,"  Deutsche  med.  Wochenschr.,  1893,  p.  1070. 


H  YPERIDR  OSIS  I O/ 1 

son1  also  believe  that  the  malady  is  favored  by  malpositions  of  the  feet, 
especially  flat-foot  and  Morton's  foot.  While  the  local  form  may  be 
seen  at  any  age,  in  both  sexes,  and  in  all  ranks  of  life,  in  my  experience 
it  is  more  common  between  the  ages  of  twenty  and  forty,  and  more  fre- 
quent in  males.  Sweating  of  the  feet  seems  most  frequent  in  those  whose 
occupation  necessitates  prolonged  standing.  Circulatory  disturbances 
are  observed  to  be  influential  in  some  instances.  Some  eases  of  the 
localized  forms  have  been  recorded  which  were  due  to  some  nerve  irrita- 
tion or  injury,  central  or  truncal.  It  has  also  been  noted  in  connection 
with  malaria. 

Pathology. — The  close  relationship  of  the  nervous  system  to 
the  sweat  secretion,  and  therefore  to  its  pathologic  increase,  is  well 
known,  both  clinically  and  experimentally.  The  observations  of  Frankel,2 
Raymond,3  and  Ebstein4  show  the  association  of  unilateral  sweating 
with  changes  in  the  cervical  ganglia;  and  those  of  Bloch,5  Bouveret, 
and  others  with  disease  of  the  cerebral  cortex,  as  well  as  by  Windscheid,-6 
Bloch,  and  others  in  connection  with  facial  paralyses.  Cases  of  unilateral 
sweating  of  the  face  associated  with  headache  and  flushings  have  been 
observed  by  Campbell7  and  Jamieson.8  It  is  also  well  known,  through 
the  experiments  of  Claude  Bernard,  that  hyperidrosis  follows  paralysis 
of  the  sympathetic;  and  Brown-Sequard  and  others  have  shown  that 
excitation  of  the  sensory  nerves  would  provoke  sweating.  In  addition, 
Weir  Mitchell's9  observations  as  to  localized  sweat  disturbances  after 
gunshot  injuries,  and  also  Remak's10  after  traumatic  neuritis,  are  added 
proofs.  An  added  instance  to  many  others  not  here  referred  to  is  that  by 
Dehio,11  who  found  in  a  case  of  erythromelalgia  with  hyperidrosis  that 
after  resection  of  the  ulnar  nerve  not  only  did  the  excessive  sweating  cease, 
but  anidrosis  followed.  It  is  highly  probable,  therefore,  as  stated  by 
Crocker,12  that  injury  or  disease  which,  in  any  way,  either  directly  or  in- 
directly, disturbs  the  function  of  the  sympathetic  of  the  affected  region, 
is  the  proximate  Cause  of  the  excessive  secretion.  Very  often,  however, 
the  underlying  pathologic  factor  is  not  demonstrable  or  discoverable. 

Robinson,13  who  examined  a  number  of  sections  from  the  palm,  failed 

1  Hardaway  and  Allison,  "Warty  Growths,  Callosities,  and  Hyperidrosis  and  Their 
Relation  to  Malpositions  of  the  Feet,"  Jour.  Cutan.  Dis.,  1906,  p.  127. 

2  Frankel,  Zur  Pathologic  des  Halssympathicus,  Inaug.  Dissert.,  Breslau,  1874. 

3  Raymond,  "Des  ephidroses  de  la  face,"  Arch,  de  Neurologic,  1888,  pp.  51  and 
212  (a  good  paper  with  review  of  the  subject  and  bibliography). 

4  Ebstein,  "Ueber  einen  pathologisch-anatomischen  Befund  am  Halssympathicus 
bei  halbseitigem  Schweiss,"  Virchow's  Archiv,  1875,  v°l-  kiii,  P-  435- 

5  Bloch,  "Contribution  a  1'etude  de  la  physiologic  normale  et  pathol.  des  sueurs," 
These  de  Paris,  1880. 

6  Windscheid,  "Ueber  den  Zusammenhang  der  Hyperidrosis  unilateralis  mit  patho- 
log.  Zustanden  des  Facialis,"  Munch,  med.  Wochenschr.,  1890,  p.  882  (several  cases,  with 
review  of  similar  cases  and  literature  references). 

7  Campbell,  Flushing  and  Morbid  Blushing,  their  Pathology  and  Treatment,  London, 
1890,  p.  50. 

8  Jamieson,  Brit.  Jour.  Derm.,  1893,  p.  137. 

9  Weir  Mitchell,  Injuries  of  Nerves  and  their  Consequences,  Philada.,  1872,  p.  172. 

10  Remak,  "Neuritis  and  Polyneuritis,"  Nothnagel's  Specielle  Pathologic  und  Thera- 
pie,  vol.  xi,  i.  Halfte,  1899,  p.  130. 

11  Dehio,  "Ueber  Erythromelalgie,"  Berlin,  klin.  Wochenschr.,  1896,  p.  817. 

12  Crocker,  Diseases  of  Skin,  third  edit.,  p.  1090. 

13  Robinson,  Manual  of  Dermatology,  p.  77. 


IO/2  DISEASES  OF  THE  APPENDAGES 

to  detect  any  abnormality  either  in  the  size  of  the  glands  or  in  the  glandu- 
lar epithelium.  Virchow1  found,  however,  in  cases  of  hyperidrosis  con- 
nected with  phthisis,  the  glands  enlarged  and  the  epithelium  in  a  state  of 
fatty  degeneration.  While  the  amount  of  sweat  discharged  in  a  day  may 
be  considerable,  it  does  not  differ  chemically  from  normal  sweat. 

Prognosis. — The  prognosis  must  be  expressed  with  reservation. 
As  a  rule,  nothing  can  be  done  in  the  moderate  type  of  generalized 
sweating,  a  condition  apparently  normal  in  some  people.  In  the  ex- 
cessive generalized  variety,  usually  insidious  or  acute  in  developing, 
the  outcome  as  to  betterment  depends  upon  the  cause.  Localized  forms 
are  also  persistent  and  obstinate,  although  many  respond  to  treatment; 
the  foot  cases,  if  not  of  too  long  duration,  in  my  experience  offering  the 
most  promising  chances  for  relief,  in  a  number  of  such  instances  per- 
manent cure  having  been  effected.  Change  of  treatment — local  appli- 
cations especially — is  often  necessary  before  a  result  is  attained.  Par- 
oxysmal sweating  is  less  favorable  than  the  continuous  type.  Relapses 
are,  however,  not  uncommon.  In  all  cases  of  these  localized  forms  much 
can  be  done  in  the  way  of  improvement. 

Treatment. — The  excessive  general  sweating  accompanying  or 
following  the  systemic  fevers  and  debilitated  states  of  the  system  de- 
mands for  its  care  or  cure  treatment  of  the  particular  predisposing  or 
causative  condition.  Limited  areas  of  sweating  occasionally  seen  in 
malarial  and  nervous  diseases  are  likewise  to  be  treated  upon  general 
principles.  Astringent  liquid  applications,  such  as  below  indicated  for 
regional  hyperidrosis,  but  usually  somewhat  weaker,  are,  in  a  measure, 
palliative;  they  can  be  sprayed  on  or  dabbed  on;  and  sometimes,  when 
followed  by  one  of  the  dusting-powders,  the  effect  is  more  marked. 
By  such  measures  the  tendency  to  miliaria  and  chafing  noticed  in  these 
subjects,  especially  in  stout  people,  can  often  be  kept  in  abeyance.  In 
generalized  cases  Fox2  has  had  good  effects  from  rubbing  on  the  skin  a 
i  per  cent,  alcoholic  solution  of  quinin.  In  instances  of  doubtful  or 
unrecognized  cause,  such  systemic  remedies  as  ergot,  belladonna,  gallic 
acid,  the  mineral  acids,  quinin  in  full  doses,  and,  when  the  health  is  en- 
feebled, tonics  should  be  tried.  A  teaspoonful  of  precipitated  sulphur, 
twice  daily,  with,  if  the  laxative  action  is  too  marked,  an  astringent, 
has  been  extolled  by  Crocker.  I  have  noticed  a  favorable  action  in  a  few 
cases. 

In  the  localized  forms  external  applications  are  essential  and  more 
positive  in  effect  than  any  constitutional  treatment  that  may  be  pre- 
scribed, but  the  latter  should  not  be  ignored  in  the  management.  Fre- 
quent washing  is  essential.  The  external  treatment  consists  in  the  use 
of  lotions,  powders,  and  ointments.  Astringent  lotions  of  zinc  sulphate, 
tannic  acid,  and  alum,  from  \  dram  (2.)  to  an  ounce  (32.)  to  the  pint 
(500.)  of  water,  are  among  the  most  useful  at  our  command,  especially 
the  last  two.  They  are  to  be  applied  at  least  twice  daily,  the  parts  first 
having  been  washed  or  sponged  off;  following  the  lotion  a  dusting-powder 
of  boric  acid  with  from  5  to  30  grains  (0.32-2.)  of  salicylic  acid  to  each 

1  Quoted  from  Robinson,  loc.  cit. 

2  G.  H.  Fox,  Philada.  Med.  Times,  1883-84,  vol.  xiv,  p.  849. 


HYPERIDROSIS  1073 

ounce  (32.)  may  be  freely  dusted  over.  The  free  use  of  a  dusting-powder 
alone,  such  as  that  just  named,  will  be  found  beneficial  and  sometimes 
gives  considerable,  and  occasionally  complete,  relief,  especially  in  the 
axilla. 

Weak  lotions  of  formaldehyd  or  formalin  (40  per  cent,  solution  of  the 
gas),  i:  100,  can  often  be  used  with  advantage  for  cleansing  purposes, 
and  not  infrequently  with  some  therapeutic  influence  also;  but  for  the 
latter  stronger  applications  can  be  carefully  used,  increasing  the  strength 
gradually,  the  object  in  view  being  the  production  of  a  slight  surface 
hardening,  rather  than  positive  irritation.  Duhring1  warmly  commends 
the  application  of  tincture  of  belladonna,  diluted  or  full  strength,  care 
being  observed  in  its  use  as  to  toxic  effects.  Crocker  also  speaks  well 
of  belladonna  as  an  ointment  or  liniment.  In  foot  cases,  in  which  there 
are  no  abrasions  or  irritation,  Lesser2  speaks  highly  of  Fredericq's 
method  of  dusting  powdered  tartaric  acid  in  small  quantity  in  the  socks. 
It  is  to  be  employed  cautiously  in  those  of  delicate  skin.  I  have  person- 
ally had  no  experience  in  its  use.  Morrow,3  after  reviewing  the  several 
methods,  states  that  in  foot-sweating  he  has  obtained  the  best  results 
from  the  employment  of  foot-baths  of  a  strong  solution  of  extract  of 
pinus  canadensis  every  night,  and  the  use  of  powrdered  boric  acid,  or 
salicylic  acid  mixed  with  lycopodium,  oxid  of  zinc,  or  other  inert  powder 
constantly  applied  inside  the  stockings  and  shoes.  In  fact  this  latter 
use  of  boric  acid,  with  or  without  the  addition  of  salicylic  acid,  should 
be  employed  as  an  adjuvant  whatever  the  main  plan  adopted.  This 
is  an  essential  part  of  Thin's  method,  useful  in  this  affection,  as  well  as  in 
bromidrosis,  for  which  he  especially  advises  it. 

The  most  valuable  ointments  in  the  treatment  of  hyperidrosis, 
which  are  more  especially  applicable  when  the  disease  is  about  the  feet, 
are  diachylon-ointment,  advised  by  Hebra,  and  tannic  acid  ointment. 
The  latter  I  have  used  with  success  in  a  number  of  cases,  and  while 
not  equal  in  value  to  the  diachylon  salve,  is  more  readily  obtained  than 
a  good  preparation  of  the  latter.  The  method  of  application  is  the  same. 
The  tannic  acid  ointment  consists  of  from  i  to  2  drams  (4--8.)  of  tannic 
acid,  with  enough  prepared  suet  and  petrolatum  to  make  an  ounce  (32.). 
The  parts  should  first  be  washed  with  soap  and  water,  rinsed,  and 
rubbed  dry  with  a  soft  towel;  then  the  ointment  selected,  spread  thickly 
on  lint  or  other  suitable  material,  should  be  closely  adapted  to  the  surface, 
and  a  bandage  employed  to  keep  it  in  place.  This  dressing  is  to  be  re- 
applied  at  the  end  of  twelve  hours,  but  instead  of  washing  the  parts  they 
are  then  merely  to  be  rubbed  dry  with  a  dusting-powder  and  towel; 
this  is  to  be  repeated  for  a  period  of  from  ten  days  to  two  wreeks.  The 
epidermis  usually  exfoliates  after  the  tannic  acid  treatment — almost 
invariably  after  that  by  diachylon  ointment.  At  the  end  of  this  time 
the  parts  may  be  again  washed,  and  subsequently  the  dusting-powder 
used  freely  twice  daily  for  one  or  two  weeks.  This  plan  of  treatment 

1  Duhring,  Diseases  of  the  Skin,  third  ed..  p.  138. 

-  Lesser,  Hautkrankheiten,  tenth  ed.,  IQOO,  p.  180. 

3  Morrow,  Jour.  Culan.  Dis.,  1887,  p.  68  (gives  a  review  of  several  methods — those 
of  Brandon  (liquor  antihidrorrhoicus) ,  of  Fredericq  (finely  powdered  tartaric  acid),  and 
Stewart  {permanganate  of  potassium  solution  and  lead-plaster)). 

68 


DISEASES   OF   THE  APPENDAGES 

is  often  successful,  but  at  times  a  repetition  is  found  necessary;  in  other 
cases  it  relieves,  but  fails  to  cure.  Davis1  commends  the  following 
method  as  an  efficient  substitute  for  this  continuous  ointment  plan, 
and  much  less  troublesome:  A  lotion  consisting  of  a  dram  (4.)  each  of 
salicylic  acid  and  resorcin  to  the  ounce  (32.)  of  alcohol  is  painted  over 
the  parts  twice  daily,  and  in  a  week  or  so  results  in  marked  epidermic 
exfoliation;  this  is  then  followed  up  with  the  free  use  of  a  compound 
dusting-powder  of  10  grains  (.66)  of  carbolic  acid,  10  grains  (.66)  of 
camphor,  20  grains  (1.33)  of  sodium  salicylate,  and  i  ounce  (.32)  of 
talc.  For  other  plans  the  reader  is  referred  to  Bromidrosis. 

In  the  localized  forms,  but  more  especially  of  the  hands,  I  have 
observed  in  some  instances  benefit  derived  from  local  applications  of  the 
faradic  and  galvanic  current.  Occasional  exposure  to  the  #-ray  has 
also  had  a  drying  influence  in  the  few  instances  in  which  it  was  tried. 
Following  Hardaway  and  Allison's  observation,  any  existing  malposition 
of  foot  should  be  corrected  in  cases  of  hyperidrosis  of  this  region. 

ANIDROSIS 

Synonym. — Fr.,  Anidrose. 

Definition. — A  functional  disorder  of  the  sweat-glands  charac- 
terized by  diminution  or  suppression  of  the  sweat  secretion. 

Symptoms. — This  is  rarely  if  ever  seen  as  an  idiopathic  condi- 
tion, but  it  occurs  to  a  varying  extent  in  certain  systemic  diseases,  as 
in  diabetes,  and  also  in  some  affections  of  the  skin,  such  as  ichthyosis, 
eczema,  pityriasis  rubra  pilaris,  and  the  like;  also  in  the  affected  areas 
in  anesthetic  leprosy,  scleroderma,  keloidal  growths,  etc.  In  these  cases, 
however,  the  glands  resume  their  normal  activity  as  soon  as  the  skin 
returns  to  its  healthy  state.  Localized  sweat  suppression  has  been  ob- 
served to  follow  nerve  injuries  in  some  instances;  and  diminished  or  tem- 
porarily suppressed  secretion  has  also  been  noted  as  a  symptom  of  some 
of  the  graver  nervous  maladies.  In  certain  persons,  however,  the  skin 
is  noted  to  be  abnormally  dry,  the  sweat-glands  apparently  being  in  a 
state  of  inaction.  In  such  the  integument,  unless  frequently  washed  and 
oiled,  and  particularly  in  the  cold  season,  is  apt  to  be  slightly  harsh,  ap- 
proaching closely  to  the  mildest  form  of  ichthyosis — which  it  in  reality 
may  be.  These  subjects  are  frequently,  in  my  experience,  sufferers  from 
pruritus,  especially  during  the  winter  time  (pruritus  hiemalis) ;  and  also 
not  uncommonly  after  baths  (bath  pruritus) .  A  dry  skin  is  often  noted 
also  to  predispose  to  eczema,  and  if  the  parasitic  theory  of  that  disease  be 
accepted,  it  can  be  readily  seen,  from  the  dryness  and  tendency  to  crack- 
ing of  the  cuticle  and  the  absence  of  the  oily  coating  resulting  from  proper 
action  of  the  sweat-  and  oil-glands,  that  easy  lodgment  could  be  effected. 

Treatment. — This  is  to  based  upon  general  principles:  warm 
and  hot  water  or  vapor  baths,  general  toning  up  of  the  patient,  free 
drinking  of  liquids,  warm  clothing,  and  the  careful  administration  of 
jaborandi  and  other  diaphoretics.  In  most  cases  not  much  can  be 
accomplished  beyond  palliation.  In  some  instances  the  resulting  dryness 
1  C.  N.  Davis,  Personal  communication.  * 


BR  OMIDR  OSIS  I O/  5 

and  harshness  of  the  skin  are  to  be  remedied  by  the  scanty  use  of  oily  or 
ointment  applications. 

BROMIDROSIS 

Synonyms. — Osmidrosis;  Stinking  sweat;  Fr.,  Bromidrose;  Ger.,  Stinkschweiss. 

Definition. — Sweat  secretion  of  an  offensive  odor,  either  pri- 
marily or  secondarily  from  some  change  after  excretion. 

Symptoms. — While  bromidrosis  is  most  frequently  associated 
with  increased  secretion  (hyperidrosis) ,  it  is  not  necessarily  so.  The 
whole  body  sweat  of  some  persons,  even  if  normal  in  quantity,  pos- 
sesses a  heavy,  disagreeable  odor,  and  this  is  habitual  with  them,  and 
is  even  noticeable,  but  naturally  to  a  less  extent,  immediately  after 
bathing.  In  most  instances  coming  under  observation  the  regions 
commonly  involved  are  the  axillae,  genitocrural  regions,  and  feet;  the 
last  is  most  frequent,  or  is  the  one  for  which  advice  is  generally  sought. 
As  a  rule,  it  is  associated  with  increased  sweating,  but  this  may  not  be 
unusually  large  in  amount,  as  observed  in  hyperidrosis;  it  is  sufficient 
in  most  cases,  however,  to  keep  the  stockings  and  shoes  damp  and  the 
soles  of  the  feet  moist  and  sodden  looking.  In  other  instances  the  secre- 
tion is  excessive.  In  addition  to  the  symptoms  sometimes  presented  in 
cases  of  hyperidrosis — tenderness,  pumness,  pinkish-red  periphery,  oc- 
casionally with  vesicles  or  blebs  at  the  sides  of  the  foot,  just  on  or  close 
to  the  edge  of  the  sole — there  is  an  intense,  penetrating,  characteristic 
odor,  pathognomonic  to  one  who  has  once  known  the  smell.  It  is  hard 
to  describe,  and  has  been  variously  likened  to  the  odor  of  an  uncared-for 
goat,  putrid  cheese,  stale  urine,  etc.  A  room  or  car  in  which  such  a 
patient  is  or  has  been  soon  becomes  offensive,  and  the  odor  holds  for  a 
long  time  after  his  exit.  The  axilla  is  also  often  the  seat  of  abundant 
perspiration  with  disgusting  smell,  but  never  to  the  same  extent  nor  of 
the  same  penetrating  and  peculiar  character  as  that  of  the  feet. 

Etiology  and  Pathology. — The  same  factors  are  to  be  consid- 
sidered  etiologic  in  this  disease  as  in  hyperidrosis,  to  which  it  is  closely 
allied.  Chlorotic,  anemic,  and  nervous  individuals  are  its  most  com- 
mon subjects.  It  is  more  frequent  between  the  ages  of  twenty  and  forty, 
and  in  those  who  are  obliged  to  stand  a  greater  part  of.  the  day,  and  whose 
life  is  within  doors.  The  ingestion  of  certain  drugs  is  known  to  give 
the  sweat  peculiar  odors — some  not  necessarily  offensive.  Thus  the  odors 
of  asafetida,  sulphur,  onions,  garlic  are  noted  in  this  secretion  as  well 
as  exhaled  by  the  lungs;  musk,  copaiba,  benzoic  acid,  etc.,  also  are  de- 
tectable in  the  perspiration.  Hammond1  recorded  several  cases  of  nerv- 
ous disorders  in  which  the  odor  of  violets  and  pineapple  was  given  off 
during  paroxysms  or  emotional  attacks.  It  is  known,  too,  that  in  various 
systemic  diseases  the  sweat  secretion  has  an  odor  peculiar  to  each,  as  in 
small-pox,  cholera,  typhoid,  etc.2 

1  Hammond,  "The  Odor  of  the  Human  Body  as  Developed  by  Certain  Affections 
of  the  Nervous  System,"  Med.  Record,  1877,  vol.  xii,  p.  460. 

2  See  admirable  paper  by  Monin,  "Sur  les  odeurs  du  corps  humain,"  Paris,  1885, 
full  abstract  translation  in  Jour.  Cutan.  Dis.,  1885,  p.  211.     This  considers  the  various 
human  odors  in  health  and  disease,  and  from  certain  foods  and  drugs,  and  in  individuals 
of  different  climes  and  nationalities. 


IO/6  DISEASES   OF   THE   APPENDAGES 

Hebra  believed  that  the  odor  does  not  reside  in  the  sweat  as  secreted, 
but  that  it  is  due  to  some  chemical  change  after  excretion,  and  this 
doubtless  is  true  in  most  instances.  Thin1  also  took  this  view,  and  was, 
moreover,  of  the  opinion  that  the  odor  is  not  in  the  feet  themselves, 
but  in  the  socks  and  shoes,  in  which  the  secretion  has  soaked,  and  in 
which  develop  bacteria — Bacterium  foetidum— in  large  numbers.  Accord- 
ing to  Crocker,  similar  micrococci  can  generally  be  found  between  the 
toes  without  accompanying  bromidrosis.  Parkes2  looks  upon  the  foot- 
wear as  the  cause,  as  it  has  been  noted  that  soldiers  with  uncovered 
feet  never  present  the  disease.  The  most  probable  source  of  the 
odor  is  the  decomposition  of  the  fatty  acids  of  the  sweat,  to  the 
rapidity  of  which  the  Bacterium  fcetidum  may  materially  contribute; 
the  sweat  secretion  containing  some  oil,  as  Unna  and  Meissner  have 
pointed  out. 

Prognosis  and  Treatment.— As  the  troublesome  cases  of 
bromidrosis,  those  associated  writh  increased  sweating,  are  probably 
closely  analogous  to  hyperidrosis  or,  in  most  instances,  simply  examples 
of  the  latter  with  the  secretion  undergoing  rapid  decomposition,  spon- 
taneously or  from  an  added  external  bacterial  factor,  the  prognosis  is 
essentially  the  same  as  in  that  disease.  The  foot  cases,  which  are,  as 
a  rule,  those  which  apply  for  treatment,  can  always  be  much  benefited, 
and  if  an  acquired  condition  of  not  too  long  duration,  a  cure  is  usu- 
ally possible.  Absolute  cleanliness — -frequent  ablutions — and  frequent 
change  of  the  foot-wear  are  essential;  the  subject  of  the  affection  should 
have  several  pairs  of  shoes,  changing  daily,  so  that  the  pair  worn  can 
be  aired  or  remain  unused  for  a  few  days  before  they  are  again  worn. 
The  treatment  is  practically  the  same  as  that  employed  in  hyperidrosis 
(q.  P.),  the  best  plans  among  those  there  named  being  with  boric  acid 
powder  and  the  ointment  method.  Thin  strongly  commended  the  treat- 
ment with  boric  acid;  his  plan  is  as  follows:  The  feet  are  frequently 
washed  with  a  saturated  solution  of  boric  acid;  the  stockings  changed 
often,  and  washed  in  the  solution  and  dried;  cork  soles,  which  are  also 
soaked  in  the  solution  and  dried,  are  worn  in  the  shoes ;  and  powdered 
boric  acid  dusted  freely  in  the  stockings  and  shoes.  This  is  an  effectual 
plan  in  some  cases,  and  beneficial  in  all,  lessening  or  completely  abolish- 
ing the  disagreeable  odor. 

Various  other  methods  are,  however,  frequently  resorted  to.  The 
Germans,  especially  for  use  in  the  army,  extol  a  solution  of  chromic  acid 
of  5  to  10  per  cent,  strength;  according  to  action  and  severity  of  the 
disease  it  is  painted  on  once  in  three  to  six  weeks;  it  should  be  used  with 
care.  For  the  milder  cases  and  as  a  preventive  measure  they  also  com- 
mend anointing  with  a  2  per  cent,  salicylated  mutton  suet.  Duhring 
states  that  a  solution  of  potassium  permanganate,  i  to  3  grains  (0.065- 
0.2)  to  the  ounce  (32.),  used  as  a  wash,  often  acts  happily.3  The  for- 

1  Thin,  Brit.  Med.  Jour.,  Sept.  18,  1880,  p.  463. 

-  Quoted  by  Hyde  and  Montgomery,  Diseases  of  the  Skin,  seventh  ed.,  p.  135. 

3  Weiss,  "Hyperidrosis  Pedum  and  Its  Treatment  by  Baths  of  Permanganate  of 
Potash,"  Jour.  Amer.  Med.  Assoc.,  Aug.  6,  1904,  also  lauds  this  old  remedy  highly,  both 
in  hyperidrosis  and  bromidrosis;  using  it  nightly  as  a  foot  bath-,  ankle  deep,  for  fifteen 
minutes;  the  next  morning  applying  freely  a  dusting-powder  consisting  of  13  parts  potas- 


CHR  OMIDR  OS  IS 

maldehyd  lotions  referred  to  in  Hyperidrosis  are  valuable,  and  to  be 
tried  in  obstinate  cases.  Grosse1  and  Ullmann2  speak  well  of  a  powder 
of  i  part  tannoform  and  2  parts  talc,  both  in  hyperidrosis  and  bromi- 
drosis;  the  parts  are  first  washed  and  then  the  powder  applied  freely. 
In  obstinate  cases  Grosse  uses  a  plaster  made  with  25  per  cent,  of  tanno- 
form, and  prefers  it  to  Hebra's  plan  with  diachylon  ointment.  Upon 
the  whole,  the  most  effectual  plans  in  my  experience  are  those  with  the 
continuous  ointment  application,  and  Thin's  method,  with  3  to  10  per 
cent,  of  salicylic  acid  added  to  the  powder.  Instead  of  the  ointment, 
strapping  with  diachylon  plaster  can  be  practised.  For  particulars  as 
to  ointment  method  and  for  other  plans  sometimes  employed  the  reader 
is  referred  to  the  article  on  Hyperidrosis.  For  offensive  sweating  in  the 
axillae  and  in  the  genitocrural  region  the  powder  and  lotion  applications 
there  referred  to  are  prescribed.  X-ra,y  treatment  is  sometimes  helpful 
in  regional  cases. 

Constitutional  treatment,  when  demanded,  is  according  to  indica- 
tions, chlorosis,  anemia,  etc.,  receiving  their  appropriate  remedies. 
The  several  special  drugs  advised  in  Hyperidrosis  can  also  be  experi- 
mentally tried,  among  which  Crocker  considers  the  best  to  be  sulphur. 

CHROMIDROSIS 

Synonyms.-—  Colored  sweat;  Ephidrosis  discolor;  Stearrhcea  or  seborrhoea  nigri- 
cans  (Wilson  and  Neligan);  Fr.,  Chromidrose. 

Definition. — An  affection  of  the  sweat-glands  in  which  the  effused 
secretion  is  colored. 

Several  varieties  and  practically  diverse  conditions  have  been  from 
time  to  time  described  under  this  title,  all  of  which,  before  Le  Roy  de 
Mericourt's3  excellent  contribution  on  the  subject,  were  generally  looked 
upon  with  considerable  suspicion  and  of  probable  factitious  origin. 
It  is  now  known  that  the  effused  sweat  may  in  rare  instances  be  of 
various  colors.  Sometimes,  however — pseudochromidrosis,  red  chro- 
midrosis — the  color,  which  is  thought  to  be  excreted  with  the  sweat, 
is  due  to  some  external  factors — micro-organisms.  Indeed,  it  is  not  im- 
probable that  future  investigation  will  relegate  some  of  the  supposed 
true  cases  to  the  latter  class.  While  in  most  instances  the  color  is  in 
the  sweat  secretion,  in  others — in  the  minority,  in  which  there  is 
more  or  less  accompanying  greasiness — it  is  found  in  the  sebaceous 
secretion. 

Symptoms. — In  the  idiopathic  class  the  most  usual  color  is 
brownish  or  blackish  (melanidrosis) ,  often  with  a  bluish  shade,  although 
it  may  be  bluish  (cyanidrosis)  or  a  dirty  gray.  In  the  38  cases  collected 

sium  permanganate,  i  part  alum,  18  parts  each  of  zinc  oxid  and  calamin,  and  50  parts 
talc,  applying  also  between  the  toes,  and  keeping  these  slightly  separated  by  absorbent 
cotton.  The  bath  is  i  per  cent,  in  strength  for  the  first  three  baths,  and  then  of  gradu- 
ally increasing  strength  to  saturation,  in  warm  to  hot  water.  The  only  disadvantage  is 
the  staining.  The  average  course  of  treatment  is  two  weeks,  but  the  dusting-powder 
should  be  continued  longer. 

1  Grosse,  Klin.-therap.  Wochenschr.,  1890,  pp.  487  and  527. 

2  Ullmann,  Cent.  f.  d.  ges.  Therap.,  1899,  p.  257. 

3  Le  Roy  de  Mericourt,  Memoire  stir  la  Chromidrose,  Paris,  1864. 


10/8  DISEASES   OF   THE   APPENDAGES 

by  Foot,1  which  he  believed  to  be  authentic,  it  was  noted  to  be  black, 
blackish,  or  brownish  in  21,  blue,  bluish-black,  bluish-brown,  or  violet 
in  15,  and  yellowish-brown  in  2.  In  rare  instances  a  red  color  has  been 
noted,  as  in  a  case  of  a  man  reported  by  Dubreuilh,2  in  whom  the  right 
thumb  and  left  wrist  were  the  seat  of  the  manifestation.  The  most 
common  sites  are  about  the  eyelids,  especially  the  lower,  the  forehead, 
and  cheek.  The  breast,  neck,  back,  hands,  axillae,  groins,  and  genito- 
crural  region  are,  however,  more  rarely  noted  to  be  the  seat  of  the  dis- 
coloration. The  orbital  region  is  the  most  usual  one,  and  doubtless 
many  of  the  suspected  cases  of  artificial  penciling  of  this  part  are  in  reality 
unfortunate  victims  of  this  malady.  The  part  becomes  discolored,  as 
a  rule,  slowly,  the  secretion  gradually  collecting.  Examined  closely  it  is 
noted  to  be  of  a  grimy,  dirty  character,  consisting  of  a  powdery  or  granu- 
lar deposit,  and  gives  to  the  cloth  used  in  wiping  it  a  look  of  smuttiness, 
or  as  Mitchell3  expressed  it,  as  if  fine  lead-pencil  dust  were  upon  it. 
After  thoroughly  removing  it,  which  can  be  done  only  by  rubbing  and 
washing  with  some  force,  it  again  collects  slowly,  the  color  becoming 
gradually  more  and  more  pronounced.  Instead  of  remaining  localized, 
it  may  spread,  and  it  may  also  be  seen  involving  extensive  surface;  as 
a  rule,  however,  the  latter  is  rarely  observed,  the  condition  usually  limit- 
ing itself  to  a  circumscribed  region,  and,  as  remarked,  most  frequently 
the  orbital  regions.  White4  records  a  case,  a  male,  in  whom  it  was 
unilateral,  covering  half  the  trunk,  and  of  a  yellow  color;  the  patient 
was  aged  twenty.  In  rare  instances  the  color  has  been  noted  to  change; 
and  the  discoloration  has  also  been  observed  to  move  its  position. 

The  secretion  never  seems  very  abundant,  and  is  more  suggestive 
of  a  discolored,  oily  seborrhea  than  of  a  true  sweating.  Crocker,5  in  3 
cases,  noted  it  to  be  largely  composed  of  flaky  and  granular  fat,  and  from 
appearances  more  of  the  nature  of  seborrhea  than  sweat  secretion.  In 
most  subjects  the  condition  is  noted  to  vary  somewhat,  being  more  in- 
tense when  the  patient  is  not  in  good  health  or  when  nervously  depressed. 
In  some  instances,  after  lasting  for  some  months  or  even  a  few  years, 
it  disappears  spontaneously;  as  a  rule,  however,  when  once  established, 
it  is  more  or  less  persistent.  Constipation,  digestive  disturbance,  men- 
strual irregularity,  various  nervous  symptoms,  headache,  hyperesthesia, 

1  Foot,  Dublin  Quarterly  Jour.  Med.  Sci.,  Aug.,  1869,  and  Dec.,  1873   (a  good 
paper  with  particulars  of  38  cases);  see  also  paper  by  Pooley,  loc.  tit.,  who  has  col- 
lected a  number  of  reported  cases;  and  Heidingsfeld,  "The  Pathology  of  Chromidrosis," 
Jour.  Amer.  Med.  Assoc.,  Dec.  13,  1902  (brief  review,  histologic  study,  and  bibli- 
ography). 

2  Dubreuilh,  Arch.  Clin.  de  Bordeaux,  Jan.,  1894. 

3  J.  K.  Mitchell,  "Seborrhoea  Nigricans,"  Philada.  Med.  Jour.,  Jan.   15,   1899, 
reports  a  remarkable  case  involving  both  eyelids  and  adjacent  parts,  and  reviews  similar 
cases  recorded;  Colcott  Fox,  London  Clin.  Soc'y  Trans..  1881,  vol.  xiv,  p.  211,  reports 
2  somewhat  similar  cases,  the  exudation  being  of  a  bluish-black  color;  Putnam,  New 

York  Med.  Jour.,  July  4,  1903,  also  reports  a  case  of  "inky-black"  chromidrosis  of  eye- 
lids, malar  regions,  upper  portion  of  the  nose,  and  the  edge  of  the  mucous  membrane 
of  the  lips,  in  a  young  woman  aged  nineteen,  associated  with  hysteric  paralysis  and 
amenorrhea;  final  recovery  was  made,  the  chromidrosis  lasting  nine  months  (case 
also  seen  in  consultation  by  Dr.  G.  W.  Wende).  See  also,  for  unusual  cases,  interesting 
paper  by  Osier,  "Ochronosis,  the  Pigmentation  of  Cartilages,  Sclerotics,  and  Skin  in 
Alkaptonuria,"  Lancet,  Jan.  2,  1904. 

4  J.  C.  White,  Jour.  Cuian.  Dis.,  1884,  p.  293.  5  Crocker,  Diseases  of  the  Skin. 


CHROMIDROSIS  1 079 

neuralgic  pains,  and  distinct  hysteric  symptoms  are  associated  in  many 
cases. 

Etiology. — While  in  some  instances  it  may  be  attributed  to 
malingering  and  is  of  artificial  production,  it  is  now  well  established 
that  this  is  not  the  fact  in  most  cases.  The  disease  is,  it  is  true,  ex- 
tremely rare.  Its  subjects  are  mostly  women  between  the  ages  of 
sixteen  and  fifty,  and  usually  of  the  nervous,  neurasthenic  class.  The 
immediate  exciting  cause  is  often  noted  to  be  mental  excitement,  fright, 
anxiety,  etc.  Uterine  disturbance1  and  pronounced  constipation  are 
also  seemingly  factors,  especially  the  latter.  Mitchell  states  that  in 
almost  all  cases  in  the  report  of  which  the  habitat  was  mentioned,  the 
place  of  residence  was  near  the  sea.  De  Mericourt  thought  that  possibly 
there  was  some  causal  relationship  in  this  fact,  to  which  he  also  called 
attention. 

It  is  known,  too,  that  the  ingestion  or  absorption  of  certain  chem- 
icals or  drugs  has  been  responsible  in  rare  instances  for  the  production 
of  colored  sweat.  Thus  green  sweat  has  been  caused  by  copper,  as  noted 
by  Clapton,2  Halford,3  and  others.  Temple4  noted  pink  perspiration, 
which  also  stained  the  hair,  in  a  patient  taking  potassium  iodid.  In 
the  Kollmann-Scherer5  case  of  blue  chromidrosis  the  color  was  presumed 
to  be  due  to  the  iron  the  patient  had  been  taking,  iron  protosulphate 
being  found  in  the  sweat. 

Pathology. — The  pathology  of  chromidrosis  is  still  involved  in 
obscurity.  According  to  our  present  knowledge,  it  must  be  considered 
a  functional  disorder  of  the  sweat-glands,  although  it  is  not  improbable 
that  the  secretion  from  sebaceous  glands  may,  in  some  cases  at  least, 
be  partly  responsible.  In  many  instances  the  disease  doubtless  belongs 
among  the  hysteric  neuroses  (Besnier  and  Doyon,  Crocker,  and  others). 
Indican  has  been  found  by  various  observers  (Hoffmann,  Bizzio,  and 
others)  in  the  secretion,  to  the  chemical  transformation  of  which  in  con- 
tact with  the  air  the  color  is  supposed  to  be  due.  Others,  however,  have 
not  succeeded  in  finding  this,  so  that  as  yet  the  subject  needs  further 
investigation.  In  Mitchell's  case  microscopic  and  bacteriologic  exami- 
nations of  the  exudate  failed  to  throw  any  light  on  the  condition;  the 
material  was  found  to  be  insoluble  in  ether  and  soluble  in  acids,  which 
seemed  to  show  that  it  was  not  a  fatty  exudate,  as  Neligan  had  believed. 
On  the  other  hand,  in  White's  patient  the  coloring-matter  was  soluble 
in  ether,  and  the  exudate  was  of  an  oily  nature;  careful  examinations 
failed  to  explain  its  origin.  Heidingsfeld's  histologic  examination  of  a 
single  case  showed  it  to  be  an  anomaly  of  pigmentation,  entirely  inde- 
pendent of  the  glandular  secretions. 

Prognosis  and  Treatment. — The  condition  is  usually  per- 
sistent, lasting  several  years  or  longer,  though  it  is  often  variable  as 

1  Barie,  Annales,  1889,  p.  937  (with  review  and  literature  references),  records  a  case 
of  brownish-yellow  chromidrosis  of  the  palm  and  dorsal  surface  of  the  hand,  recurring 
alternately  on  each  hand,  at  several  consecutive  menstrual  periods. 

2  Clapton,  Med.  Times  and  Gaz.,  1868,  p.  658  (a  number  of  cases  referred  to). 

3  Halford,  London  Med.  Gaz.,  1833,  p.  211. 

4  Temple,  Brit.  Med.  Jour.,  Aug.  29,  1891,  p.  477. 

6  Quoted  by  Hoffmann,  Wiener  med.  Wochenschr.,  1873,  No.  13,  p.  292. 


I080  DISEASES   OF   THE   APPENDAGES 

to  degree.  In  some  cases  it  has  disappeared  for  a  time,  to  reappear 
subsequently.  Final  recovery  is,  however,  to  be  expected.  The  un- 
derlying condition — most  frequently  nervous  disorders,  uterine  disturb- 
ances, and  protracted  constipation— is  to  be  treated  by  appropriate 
methods.  Ordinarily  external  treatment  is  of  no  avail.  In  White's 
case,  however,  the  use  of  an  ointment  containing  boric  and  salicylic 
acids  brought  about  a  disappearance  of  the  blemish. 

Red  Chromidrosis — Pseudochromidrosis. — As  already  stated,  the 
effused  sweat  in  these  cases  is  free  from  color,  but  it  subsequently  becomes 
stained  by  extraneous  micro-organisms.  The  axilla  is  the  most  common 
site  for  it,  although  it  is  also  seen  in  the  genitocrural  region;  in  fact, 
any  warm,  moist,  hairy  region  may  be  its  seat.  The  color  is  usually 
orange  or  red.  The  investigations  of  Hoffmann,1  Babes,2  Balzer.and 
Barthelemy,3  and  Hartzell4  go  to  show  that  this  condition  is  due  to 
chromatogenous  bacteria,  which  are  found  attached  to  the  hairs  in  agglu- 
tinated masses — zooglea — and  also,  according  to  Balzer  and  Barthelemy, 
in  scrapings  of  the  epidermis  and  in  the  discolored  linen.  These  latter 
observers  found,  both  in  the  cleanly  and  uncleanly,  parasitism  of  the  axilla 
quite  common,  but  it  is  not  always  accompanied  by  color  formation. 
Other  hairy  regions  were  also  noted  to  be  the  seat  of  the  same  zooglea, 
but  rarely  accompanied  by  red  coloration.  Balzer  and  Barthelemy 
concluded,  from  their  valuable  studies,  that  there  is  a  form  of  parasitism 
which  occurs  as  a  transitory  or  permanent  condition  in  a  large  number 
of  individuals  subject  to  profuse  perspiration,  and  in  whom  masses  of 
microbes,  generally  non-chromatogenous,  sometimes  chromatogenous, 
may  develop.  It  is  probable,  as  Van  Harlingen5  states,  a  change  in  the 
character  of  the  secretions  from  some  unknown  cause  affords  an  oppor- 
tunity for  development,  and  the  germs  of  the  disease  assume  unwonted 
vitality;  apparently,  too,  abundant  perspiration  favors  the  multiplica- 
tion of  the  chromatogenous  organisms.  According  to  Crocker,  red 
sweat  is  always  associated  with  lepothrix. 

Treatment  consists  of  the  frequent  use  of  soap  and  water  and  appli- 
cations of  boric  acid  and  resorcin  lotions,  as  prescribed  in  Eczema.  Cor- 
rosive sublimate  solution,  i  or  2 :  1000,  washings  with  chloroform,  aro- 
matic vinegar,  and  ether  are  commended  by  Balzer  and  Barthelemy. 
Any  faulty  condition  of  the  general  health  should  be  corrected. 

HEMATIDROSIS 

Synonyms. — Bloody  sweat;  Hemidrosis;  Ephidrosis  cruenta;  Sudor  sanguineosa; 
Hysteric  stigmata;  Bleeding  stigmata;  Fr.,  Hematidrose. 

Hematidrosis,  or  bloody  sweat,  is  an  extremely  rare  condition,  and 
its  occurrence  has  very  often  been  seriously  doubted.  The  valuable 
contributions  and  analytic  review  by  Parrot,6  who  collected  the  records 

1  Hoffmann,  loc.  cit.  2  Babes,  Centralblatt  fur  Wisxensch.,  1882,  p.  146. 

3  Balzer  and  Barthelemy,  Annale.s,  1884,  p.  317. 

4  Hartzell,   University  Med.  Mag.,  July,  1893. 

5  Van  Harlingen,  "Chapter  on  Chromidrosis,"  Twentieth  Century  Practice,  vol.  v. 
("Diseases  of  the  Skin")  (an  excellent  review  of  the  subject). 

8  Parrot,  Gazette  Hebdom.  de  Med.  de  Paris,  1859;  Bouveret  (loc.  cit.)  has  given  a 
good  condensed  resume  of  Parrot's  writings. 


URIDROSIS  I O8  I 

of  a  large  number  of  cases,  have,  however,  placed  the  existence  of  such 
an  affection  beyond  question.  Since  then  instances  have  been  reported 
by  McCall  Anderson,  W.  T.  Mitchell,  Hart,  Hyde,1  and  others.  Almost 
any  part  of  the  body  can  be  the  seat  of  the  manifestation,  and  it 
may  occur  at  several  points  simultaneously.  The  skin  may  be  per- 
fectly normal  in  appearance,  or  the  "bleeding"  may  be  momentarily 
preceded  by  slight  elevation  of  the  integument.  Somewhat  allied  cases 
have  also  been  described  in  which  the  bleeding  was  preceded  by  vesicle 
or  bleb  formation  and  also  by  erythematous  areas,  sometimes  becoming 
superficially  abraded  or  gangrenous ;  some  of  these  latter  probably  belong 
among  the  cases  of  "neurotic  excoriations"  of  Erasmus  Wilson,  and 
which  may  be  open  to  the  suspicion  of  artificial  production. 

Hematidrosis  is  chiefly  observed  in  highly  nervous,  hysteric  women, 
and  an  attack  usually  appears  during  some  intense  emotional  excite- 
ment, and  in  some  instances  has  been  noted  to  be  preceded  by  neuralgic 
pain  or  hyperesthesia  of  the  part.  It  has  in  a  few  cases  been  attributed 
to  faulty  or  vicarious  menstruation.  In  Huss'  case,  a  highly  nervous 
woman,  quoted  by  Parrot,  the  patient  could  bring  on  the  bleeding  by 
purposely  working  herself  into  a  state  of  excitement.  In  a  few  instances, 
too,  the  condition  might  be  considered  as  a  part  or  symptom  of  hemo- 
philia. The  quantity  of  blood  discharged  is  usually  small.  The  affec- 
tion is,  in  reality,  scarcely  hematidrosis ;  it  is  presumed,  and  probably 
correctly,  that  an  extravasation  of  blood  takes  place  into  and  around 
the  sweat-coils,  a  purpura  of  the  sweat-glands,  as  Crocker  aptly  states, 
and  this  mixes  and  is  discharged  with  the  sweat  secretion;  or  it  may  exude 
into  the  sweat-glands  by  the  process  of  diapedesis.  It  finds  its  exit 
from  the  sweat-pores,  and  it  is  barely  possible  that  there  may  be  at  the 
time  coincident  increase  in  the  sweat  secretion  itself. 

Treatment  is  to  be  based  purely  upon  indications  in  the  individual 
case. 

URIDROSIS 

Synonyms. — Urinidrosis;  Sudor  urinosus;  Urinous  sweat;  Sandy  sweat;  Fr., 
Uridrose;  Ger.,  Harnschweiss. 

This  term,  as  the  word  itself  conveys,  signifies  sweat  secretion  con- 
taining the  elements  of  the  urine,  more  particularly,  however,  urea. 

The  normal  sweat2  contains  a  minute  quantity  of  this  latter  sub- 
stance, but  exceptionally  cases  have  been  observed  in  which  the  amount 
was  sufficiently  large  to  be  noticeable  upon  the  skin.  It  is,  however, 
usually  observed  in  connection  with  renal  disease  (Kaup  and  Jiirgensen, 
Leube,  Deininger,  and  Taylor),  generally  preceded  by  partial  or  com- 
plete suppression  of  the  urine.  It  has  also  been  noted  in  cholera  (Schottin 
and  Drasche).  According  to  Djoritch,3  it  is  always  a  grave  prognostic 

1  Hyde,  "A  Contribution  to  the  Study  of  Bleeding  Stigmata,"  Jour.  Cutan.  Dis., 
1897,  p.  557,  reports  an  interesting  case  and  briefly  reviews  the  subject  and  gives  a 
complete  bibliography. 

2  See  interesting  paper  by  Easterbrook,  "The  Excretion  of  Urea  by  the  Skin  in 
Health,"  Scottish  Med.  and  Surg.  Jour.,  Feb.,  1900,  p.  120. 

3  Djoritch,  "Sueurs  d'  uree  en  general  et  dans  la  maladie  de  Bright  en  partictilier," 
These  de  Paris,  1895. 


IO82  DISEASES   OF   THE  APPENDAGES 

sign.  The  administration  of  jaborandi  has  also  favored  the  excretion 
of  large  quantities,  as  in  the  experiments  conducted  by  Hardy  and  Ball.1 
It  is  to  be  seen  upon  the  skin  as  a  whitish  coating,  bearing  a  rough  re- 
semblance to  hoar-frost  or  a  sprinkling  of  flour.  Under  the  microscope 
is  is  noted  to  be  made  up  of  crystalline  or  irregular  powdery  masses. 
The  deposit  is  generally  most  abundant  upon  exposed  parts — hands  and 
face;  probably  because  these  parts,  being  uncovered,  permit  freer  and 
quicker  evaporation  of  the  sweat  excretion.  Djoritch  believes  the 
exudation  of  urea  comes  chiefly  from  the  sebaceous  glands.  The  skin 
usually  gives  off  a  urinous  odor. 

Phosphoridrosis. — Instances  of  phosphoridrosis,  or  phosphorescent 
sweat,  are  extremely  rare.  It  has  been  observed  in  the  later  stages 
of  phthisis,  in  miliaria,  and  in  those  who  have  eaten  of  putrid  fish.  As 
an  example  of  the  last  cause  may  be  mentioned  the  case  recorded  by 
Panceri,2  in  which,  after  the  eating  of  phosphorescent  fish  (putrid?), 
which  sickened  the  patient,  the  sweat  was  noted  to  be  luminous  in  the 
dark.  Koster3  refers  to  a  case  in  which  the  body  linen  became  luminous 
after  violent  sweating.  Marsh4  refers  to  several  instances  of  its  occur- 
rence in  the  last  stages  of  phthisis,  and  to  a  case  of  a  luminous  extensive 
ulcerating  cancer  of  the  breast.  In  all  probability  the  phosphorescence 
is  due  to  photogenic  bacilli;  Beyerinck5  has  discovered  a  number  of 
varieties,  chiefly  derived  from  fish. 

SUDAMEN 

Synonyms. — Miliaria  crystallina;  Fr.,  Miliare  crystalline;  Ger.,  Schweissfriese- 
lausschlag. 

Definition. — A  non-inflammatory  ephemeral  disorder  of  the 
sweat-glands,  characterized  by  pin-point-  to  pin-head-sized,  discrete 
but  usually  thickly  set,  superficial,  translucent,  whitish  vesicles. 

Symptoms. — The  eruption  makes  its  appearance  suddenly,  the 
lesions  developing  irregularly  or  in  crops,  and  is  seen  most  frequently 
and  most  abundantly  on  the  trunk,  especially  anteriorly;  it  may,  how- 
ever, be  seen  over  other  parts,  and  occasionally  over  the  entire  surface. 
Its  appearance  seems  to  be  most  frequent  and  most  abundant  where 
the  epidermis  is  thin.  The  lesions  are  discrete,  although  often  closely 
crowded,  but  with  no  tendency  to  coalescence,  and  appear  as  whitish 
or  pearl-colored,  translucent,  very  minute  elevations,  which  bear  re- 
semblance to  small  dewdrops.  They  are  non-inflammatory,  without 
hyperemia  or  areola,  and  never  assume  such  characters.  The  contents 
remain  clear,  never  becoming  purulent,  and  quickly  or  gradually  disap- 
pear by  absorption  or  evaporation,  the  epidermal  covering  disappearing 
by  desquamation,  which,  however,  is  necessarily  extremely  slight.  There 

1  The  several  observations  here  quoted  are  from  Duhring,  Diseases  of  the  Skin, 
third  ed.,  p.  144,  where  literature  references  can  be  found. 

2  Panceri,  La  France  Med.,  March  31,  1877;  Cincinnati  Lancet  and  Observer,  May, 
1877,  p.  504. 

3  Quoted  in  Carpenter's  Physiology,  1876,  p.  550. 

4  Marsh,  Provincial  Med.  and  Surg.  Jour.,  1842,  vol.  iv,  p.  170. 

5  Supplement  to  Brit.  Med.  Jour.,  Jan.  i,  1891  (quoted  by  Crocker). 


SUDAMEN 


1083 


is  rarely  exhibited  any  tendency  to  spontaneous  rupture.  While  the 
whole  process  may  come  to  an  end  in  several  days  to  a  week,  the  disease 
may  be  more  prolonged  by  the  appearance  of  new  lesions.  There  are  no 
subjective  symptoms. 

Etiology  and  Pathology.— The  eruption  is  seen  in  those 
gravely  debilitated,  and  especially  when  associated  with  high  fever. 
It  therefore  often  occurs  in  the  course  of  typhus,  typhoid,  rheumatic, 
puerperal,  and  hectic  fevers;  and  is  probably  due  indirectly  to  nerve 
disturbance.  The  investigations  of  Robinson,  Haight,  and  Torok  show 
the  lesion  to  be  formed  between  the  lamellae  of  the  corneous  layers, 
usually  the  upper  layers. 
The  formation  of  the  lesion 
is  thought  to  be  due  to 
some  change  in  the  char- 
acter of  the  epithelial  cells 
of  the  corneous  layer,  prob- 
ably from  high  tempera- 
ture, causing  a  blocking  of 
the  surface  outlet  and  the 
escape  of  the  sweat  from 
the  sweat-duct  into  the  sur- 
rounding tissue  of  the  cor- 
neous layer;  the  contents  of 
the  lesion  consist  of  pure 
sweat  (Robinson). 

Diagnosis. — The 
characters  of  the  eruption, 
with  the  associated  general 
condition,  are  sufficiently 
distinct  and  pronounced  as 
to  make  the  diagnosis  a 
matter  of  no  difficulty. 
The  absence  of  all  hyper- 
emia  and  other  signs  of  in- 
flammation serves  to  dis- 
tinguish it  from  miliaria 

and  from  vesicular  eczema.  The  lesions  of  hydrocystoma  are  somewhat 
similar,  but  much  larger,  deeper  seated,  upon  the  face,  and  there  is  no 
associated  febrile  or  cachectic  factor. 

Prognosis  and  Treatment.— The  condition  is  usually  evanes- 
cent, rarely  lasting  for  more  than  several  days,  but  there  may  be  recurrent 
crops.  The  eruption  has  no  prognostic  value  as  to  the  disease  in  the 
course  of  which  it  appears.  Treatment  is  often  scarcely  necessary,  but 
the  parts  may  be  sponged  with  diluted  alcohol,  one  part  alcohol  to  several 
parts  water,  and  a  simple  dusting-powder,  such  as  powdered  starch, 
lycopodium,  or  zinc  oxid,  or  a  mixture  of  these,  applied;  or  the  dusting- 
powder  may  be  used  alone. 


Fig.  266. — Sudamen,  showing  vesicle  (/)  con- 
taining pure  sweat,  with  wall  of  upper  lamellae  of 
corneous  layer  (e)  and  sweat  orifice,  or  pore,  at  b; 
at  lower  part  of  vesicle  the  sweat-duct  leading  into 
the  corium  to  the  sweat-gland  (a);  d,  rete;  c,  hair- 
follicle.  The  rete  and  corium  are  normal  (courtesy 
of  Dr.  A.  R.  Robinson). 


1084 


DISEASES    OF   THE   APPENDAGES 


HYDROCYSTOMA1 

Synonyms. — Hidrocystoma;  Cysts  of  the  coil-ducts. 

Definition. — A  name  applied  to  a  non-inflammatory  affection 
characterized  by  discrete  pin-head-  to  pea-sized,  shining,  translucent, 
somewhat  deep-seated,  persistent  vesicles  appearing  on  the  face. 

Symptoms. — When  a  case  comes  under  observation  there  are 
ordinarily  a  number  of  lesions  to  be  seen,  of  various  sizes,  discrete, 


Fig.  267. — Hydrocystoma,  showing  the  yellowish-white  or  pearly,  deep-seated  cysts  or 
vesicles  (courtesy  of  Dr.  G.  T.  Jackson). 

occasionally  here  and  there  a  few  crowded  closely  together.     They 
are  rounded  or  ovoid,  translucent,  solid-looking,  tense,  shining,  whitish 

1  Literature:  Under  the  name  dysidrosis  of  the  face:  Jackson,  Jour.  Cutan.  Dis., 
1886,  p.  i  (with  colored  plate);  Rosenthal,  Deutsche  med.  Wochenschr.,  1887,  No.  20 — 
abs.  in  Monatshefte,  1887,  p.  615;  Jamieson,  Brit.  Jour.  Derm.,  1893,  p.  134;  Hallo- 
peau,  "Sur  un  case  de  dysidrose  du  nez,"  Annales,  1892,  p.  728.  Under  the  name  of 
hidrocystoma:  Robinson,  Jour.  Cutan.  Dis.,  1893,  p.  293  (with  colored  plate  and  histo- 
logic  examination  and  cuts),  and  in  Trans.  Amer.  Derm.  Assoc.for  1884,  and  in  Manual 
of  Dermatology,  New  York,  1884,  under  "Sudamen  of  the  Face";  Jarisch,  Verhandl. 
der  Deutsch.  dcrmatolog.  Gesell.,  V  Congress,  1895;  Adam,  Brit.  Jour.  Derm.,  1895, 
p.  169  (refers  to  9  cases;  histologic  examination,  with  7  histologic  cuts);  Hutchinson, 
ibid.,  p.  137  (with  colored  plate);  Morton,  ibid.,  p.  245  (daughter  of  one  of  Adam's 
cases);  Thibie'rge,  Annales,  1895,  p.  978  (4  cases,  histologic  examination,  general  review 
of  the  subject,  and  a  bibliography);  Bassaget,  "De  L'hidrocystoma,"  These  de  Paris, 
July  24, 1896  (gives  one  new  case  with  histologic  study,  and  reviews  previously  published 
cases);  Crocker,  Diseases  of  Skin,  second  ed.,  p.  731,  briefly  mentions  3  cases,  but  the 
blotchy  redness,  pustular  lesions,  and,  in  i  case,  atrophic  streaks  and  pits  noted  do  not 
accord  with  the  conditions  usually  observed;  Schidachi,  "Experimentelle  Erzeugung  von 
Hidrocystooiia,"  Arcliiv,  1907,  vol.  Ixxxiii,  p.  3  (with  histologic  cut). 


HYDROCYSTOMA 


1085 


or  light-yellowish,  projecting  vesicles,  with,  in  some  of  the  largest,  a 
bluish  tinge  peripherally ;  they  have  a  somewhat  thick  covering,  and  show 
no  tendency  to  spontaneous  rupture.  The  deepest  seated,  usually  the 
beginning,  lesions,  as  well  as  those  tending  to  disappear,  in  which  the 
contents  have  been  partly  absorbed,  look  not  unlike  boiled  sago-grains. 
Upon  the  whole,  the  same  appearances  are  maintained  throughout. 
There  are  no  inflammatory  symptoms.  Most  of  the  lesions  are  of  the 
size  of  a  small  pea,  but  many  are  smaller  and  some  larger.  Exceptionally 
around  the  border  of  the  large  vesicles  there  may  be  a  scarcely  noticeable 
hyperemic  areola.  The  face  is  the  seat  of  the  disease.  While  in  occa- 
sional cases  the  manifestation  consists  of  but  several  lesions,  which  are 
scattered  or  confined  to  limited  area,  as  the  nose  only  in  Hallopeau's 
case,  in  most  instances  there 
are  30  to  100  or  more  scattered 
over  this  entire  region.  Ex- 
ceptionally the  lesions  are 
found  on  one  side  of  the  face 
only,  as  in  Jamieson's  patient, 
and  associated  with  unilateral 
sweating.  They  are  persist- 
ent, and  often  last  for  weeks 
or  months,  the  contents  re- 
maining clear  and  never  be- 
coming purulent,  and  dis- 
appearing by  absorption  or 
desiccation,  leaving  no  trace 
or  a  slight  transitory  pigmenta- 
tion. There  is  a  complete  or 
partial  disappearance  during 
the  cold  season,  and,  as  a  rule, 
especially  if  subjected  to  the 
causative  factors,  a  reappear- 
ance as  soon  as  the  warm 
weather  sets  in.  Increased 


Fig.  268. — Hydrocystoma,  showing  small 
and  large  cysts  (a)  in  the  lower  part  of  the 
corium,  an  excretory  sweat-duct  at  b,  and  a 
sweat-coil  at  c.  As  the  vesicle  or  cyst  enlarges 
it  may  extend  to  near  the  epidermis  (courtesy 
of  Dr.  A.  R.  Robinson). 


sweating  of  the  face  is  often 

noticed.      The   eruption  gives 

rise  to  no  trouble  except  the  disfigurement;  occasionally  a  tense  feeling 

or  slight  smarting  is  felt.     Jackson  noted  in  his  case  that  the  skin  upon 

light  rubbing  became  easily  hyperemic. 

Etiology  and  Pathology.— With  rare  exceptions  the  disease 
has  been  observed  in  middle-aged  or  older  women,  and  especially  in 
those  whose  faces  are  subjected  to  a  warm,  moist  atmosphere,  as  washer- 
women, and  more  particularly  in  those  who  perspire  freely.  Of  the  30 
to  40  patients  observed  by  Robinson,  all  were  women  except  i ;  in  Adam's 
9  cases  were  3  men,  and  in  Thibierge's  4,  i  man.  Exacerbation  has 
been  noted  at  the  menstrual  period,  and  following  emotional  or  nervous 
excitement  (Hallopeau) .  The  causative  factor  in  the  reported  cases  would 
seem  to  be  heat  and  steam  moisture,  as  over  the  washtub  and  fire.  My 
own  observations  of  9  or  10  patients  are  in  accord  with  these  previously 


1086  DISEASES   OF   THE  APPENDAGES 

observed  facts.  Inasmuch  as  out  of  the  thousands  of  women  so  exposed 
but  few  show  the  affection,  there  remains  an  essential  factor  other  than 
the  above  as  yet  unrecognized.  The  unilateral  sweating  noted  in  a  few 
instances,  and  the  long-continued  hemicrania  in  Hutchinson's  case, 
indicated  possible  neurotic  element.  Thibierge  has  observed  joint 
pains  and  a  disposition  to  obesity  in  such  patients,  as  well  as  a  marked 
neurotic  tendency.  Adams,  on  the  other  hand,  contrary  to  general 
experience,  stated  that  his  9  patients,  except  i,  were  of  the  thin,  active, 
wiry  type. 

The  lesion  is  a  cyst-like  formation  of  the  duct  of  the  sweat-gland, 
and  has  its  seat  within  some  part  of  the  corium;  beginning  in  the  deeper 
part,  and,  as  it  increases  in  size,  encroaching  upon  the  epidermis.  The 
epidermis  is  normal;  nor  does  the  process  involve  the  sebaceous  glands 
or  hair-follicles.  The  cyst- wall  is  lined  with  two  or  more  layers  of 
epithelial  cells,  taking  their  origin  from  the  normal  epithelium  of 
the  duct;  the  contents  consist  of  retained  sweat,  and  are  always  acid 
(Robinson) . 

Diagnosis. — The  persistent,  pearly-looking,  translucent,  non- 
inflammatory projecting  vesicles,  with  their  limitation  to  the  face, 
their  occurrence  usually  in  middle-aged  women,  and  the  history  of 
some  duration,  give  a  picture  that  can  scarcely  be  mistaken  for  any 
other  affection.  It  should  not  be  confounded  with  sudamen,  pom- 
pholyx,  vesicular  eczema,  or  adenoma  of  the  sweat-glands.  Sudamen 
bears  some  resemblance,  but  the  superficial  nature  and  minute  size 
of  the  lesions,  the  distribution,  generally  most  abundant  on  the  trunk, 
and,  as  a  rule,  scanty  or  entirely  absent  on  the  face,  together  with  the 
associated  febrile  or  cachectic  state  and  the  short  duration,  are  entirely 
different  from  the  symptoms  of  hydrocystoma. 

Pompholyx,  or  dysidrosis,  is  a  disease  of  the  hands,  or  hands  and 
feet,  and  is  acute  in  character,  inflammatory,  and  runs  a  short  course. 
Vesicular  eczema  can  scarcely  be  confounded  with  it,  with  its  numerous 
aggregated  or  confluent  minute  vesicles,  usually  rupturing  spontaneously, 
and  the  gummy  oozing,  with  the  presence  of  inflammatory  symptoms, 
an  entirely  different  history,  and  the  intense  itching — symptoms  strik- 
ingly different.  Adenoma  of  the  sweat-glands  bears  some  similarity 
on  casual  inspection,  but  the  history  of  this  formation  and  the  character 
of  the  contents  are  not  like  those  of  hydrocystoma.  Milium  could 
scarcely  be  confused  with  it. 

Prognosis  and  Treatment.— The  disease  is  a  mild  disorder, 
and  beyond  the  disfigurement  need  not  be  the  source  of  any  anxiety. 
It  is,  however,  as  a  rule,  persistent,  with  partial  or  complete  abeyance 
during  the  winter.  With  treatment  and  the  avoidance  of  the  exciting 
causes — moist  heat  and  work  or  exercise  which  provokes  undue  per- 
spiratory action — the  condition  can  be  removed.  The  measures  re- 
quired are  purely  external  and  of  a  simple  character,  consisting  in  punc- 
turing of  the  lesions,  through  which  the  contained  liquid  can  escape  or 
be  pressed  out,  and  the  application  of  a  bland  dusting-powder.  Rosen- 
thai  saw  favorable  influence  from  the  use  of  a  i  to  2  per  cent,  alcoholic 
solution  of  naphthol. 


HYDROCYSTOMA  1087 

Granulosis  Rubra  Nasi.1 — While  the  first  case  of  this  malady  was 
recorded  by  Luithlen  (1900,  i  case),  it  is  especially  by  Jadassohn  (1901, 
7  cases),  Hermann  (1902,  10  cases),  and,  later,  by  Macleod  (  903), 
that  attention  has  been  particularly  called  to  this  peculiar  affection. 
The  present  accepted  name  we  owe  to  Jadassohn.  The  malady  is 
usually  limited  to  the  nose,  to  the  front  and  sides;  exceptionally,  in  addi- 
tion to  involving  this  part,  it  has  been  observed  to  affect  also  the  upper 
lip  (Macleod),  cheek  (Jadassohn,  Herrmann),  and  eyebrow  (Pringle). 
Examined  casually  and  not  too  closely,  it  bears  resemblance  in  its  gen- 
eral aspects  to  an  ill-defined  lupus  erythematosus  or  lupus  vulgaris. 
The  part  is  of  a  bright  red  color,  diminishing  in  intensity  toward  the 
sides  of  the  nose,  and  fading  gradually,  without  any  demarcation,  into 
the  adjacent  normal  skin.  Over  the  area,  irregularly  distributed,  are 
to  be  seen  pin-point-  to  pin-head-sized,  deep-red  or  brownish-red  specks 
and  papules,  the  color  wholly  disappearing  upon  pressure.  There  is  no 
disposition  to  coalescence.  The  papules  gradually  develop  into  pustules 
and  some  undergo  desiccation.  There  is  in  all  cases  an  associated  hy- 
peridrosis .  of  the  affected 'area,  and  sometimes  of  other  parts;  the  sweat 
often  being  seen  on  the  involved  region  in  scattered  droplets,  giving  it  a 
damp,  glistening  appearance.  The  course  of  the  malady  is  exceedingly 
chronic,  but  inasmuch  as  it  has  never  been  seen  in  adults,  it  apparently 
disappears  as  the  age  of  youth  is  passed,  and  without  leaving  scar  or 
trace.  Its  subjects  are  all  delicate  children,  and  more  commonly  males 
(in  Jadassohn's  7  cases,  between  seven  and  sixteen;  6  of  his  patients  were 
boys).  Pinkus  has,  however,  recently  reported  what  seems  to  be  a  case 
of  this  malady  in  a  man  aged  fifty-nine,  existing  since  childhood,  asso- 
ciated with  both  hyperidrosis  and  hydrocystoma.  Lebet  also  cites  a 
combination  of  hydrocystoma  with  the  disease;  and  in  one  of  Jadassohn's 
cases  there  were  a  few  hydrocystoma  lesions,  which  he  considered  purely 
accidental.  Both  Lebet  and  Pinkus  believe  there  is  a  relationship. 
Season  usually  has  no  influence,  but  aggravation  was  noted  in  Mac- 
leod's  case  in  hot  weather.  Hyperidrosis  seems  to  be  a  predisposing 
factor.  There  is  no  reaction  after  tuberculin  injections  (Jadassohn). 

1  Literature:  Luithlen,  Kaposi's  Festschrift,  1900,  p.  709;  Jadassohn,  Archiv,  1902, 
vol.  Iviii,  p.  145;  Hermann,  ibid.,  1902,  vol.  Ix,  p.  77;  W.  Pick,  ibid.,  1902,  vol.  Ixii, 
p.  105;  Macleod,  Brit.  Jour.  Derm.,  1903,  p.  131  (case  demonstration),  and  ibid.,  p. 
197  (full  report  of  same  case,  with  review  of  the  literature  and  references — I  am 
indebted  to  this  paper).  Pringle  (case  records  given  by  Macleod)  demonstrated  2 
cases  before  Derm.  Soc'y  of  London,  1894,  under  provisional  diagnosis  of  "hydrocys- 
toma." Case  reported  by  Meachen,  Brit.  Med.  Jour.,  1903,  xv,  p.  104  (also  cited  by 
Macleod),  is  also  suggestive  of  this  disease.  Saalfeld  (Soc'y  Trans.),  Monatshefte,  1903, 
vol.  xxxvi,  p.  28  (case  demonstration — nose  and  upper  lip);  Malherbe,  Jour.  mal. 
cutan.,  Feb.,  1905;  Audry,  Jour.  mal.  cutan.,  Nov.,  i903;-Ormsby  (Soc'y  Trans.), 
Jour.  Cutan.  Dis.,  1905,  p.  183  (case  demonstration);  Baumer,  Dermatolog.  Zeitschr., 
1904,  vol.  xi,  H.  9;  Pinkus,  "Ueber  die  Beziehungen  des  Hidrocystoms  zur  Granulosis 
rubra  nasi,"  ibid.;  Lebet,  "Constitution  a  1'etude  de  1'hidrocystome  (avec  une  note  sur 
la  granulosis  rubra  nasi),"  Annales,  1903,  p.  273;  Marcel  See,  Annales,  1904,  p.  1037 
(case  demonstration);  Baumer,  Dermatolog.  Zeitschr.,  1904,  vol.  xi,  p.  646  (histology); 
Colcott  Fox,  Brit.  Jour.  Derm.,  1906,  p.  320  (case  report);  Macleod,  ibid.,  p.  342 
(second  case,  further  history  of  first  case,  and  resume,  with  references  of  other  published 
cases,  with  a  general  consideration  of  clinical  characters,  etiology,  anatomy,  pathogene- 
sis,  and  treatment);  Hallopeau,  Jour.  mal.  cutan.,  April,  1906  (4  cases,  in  i  instance 
showing  heredity,  and  in  other  circulatory  disturbance  (asphyxia)  of  the  fingers  and 
ears);  Adamson,  Brit.  Jour.  Derm.,  1907,  p.  71  (case  demonstration). 


1088  DISEASES   OF   THE   APPENDAGES 

The  principal  pathologic  changes  are  to  be  found  in  the  corium,  and 
especially  about  the  sweat  apparatus;  according  to  Jadassohn  and 
others  the  histologic  findings  give  the  impression  that  it  is  a  chronic 
inflammation  originating  in  the  vessels  around  the  sweat  apparatus. 
The  epidermis,  with  the  exception  of  a  slight  parakeratosis  in  the  neigh- 
borhood of  the  sweat  pores,  is  not  involved.  Herrmann  was  not  able  to 
confirm  Jadassohn's  histologic  conclusions,  as  to  a  particular  predomi- 
nance of  the  process  in  and  about  the  sweat  apparatus,  but  regarded  the 
condition  as  purely  a  perivascular  disturbance  of  an  inflammatory  type. 
Treatment  seems  without  positive  influence,  the  malady  being  resistant 
to  all  therapeutic  measures  so  far  tried.  Malherbe  commends  linear 
scarification. 

MILIARIA 

Synonyms. — Lichen  tropicus;  Heat-rash;  Prickly  heat;  Red  gum;  Strophulus;  Fr.. 
Miliare;  Ger.,  Schweissflechte. 

Definition. — An  acute,  mildly  inflamfnatory  disorder  of  the 
sweat-glands,  characterized  by  numerous  pin-point-  to  pin-head-sized, 
discrete  but  closely  crowded  papules,  vesicopapules,  and  vesicles,  or  an 
admixture  of  these  several  lesions,  and  accompanied  by  more  or  less 
pricking,  burning,  or  itching. 

Symptoms. — There  are  two  clinical  varieties  of  this  affection, 
one  composed  wholly  or  almost  entirely  of  papular  lesions,  and  the  other 
of  vesicular  lesions.  In  the  majority  of  cases,  however,  while  there 
is  a  preponderance  of  one  type  of  lesion  there  is  a  distinct  admixture 
of  the  two.  Some  lesions,  too,  are  neither  pure  papules  or  pure  vesicles, 
but  midway  between  these — vesicopapules.  It  is  especially  to  the 
papular  type — miliaria  papulosa — that  the  names  lichen  tropicus  and 
prickly  heat  are  given,  although  these  terms,  more  especially  the  latter, 
are  often  used  synonymously  with  the  disease  name  miliaria,  whatever 
may  be  the  type.  It  makes  its  appearance  suddenly,  occurring  upon  a 
limited  portion  of  the  body,  or,  as  commonly  observed,  involving  a  greater 
part  of  the  entire  integument.  The  lesions  are  minute,  for  the  most 
part  pin-head-sized,  and  rarely  exceed  the  size  of  millet-seeds.  In  color 
they  are  pinkish  or  bright  red,  and  closely  crowded,  although  they  re- 
main discrete,  so  that  the  entire  region  affected  is  more  or  less  uniformly 
hyperemic.  While  in  this  type  the  whole  eruption  may  be  entirely 
made  up  of  papules,  it  is  usual  to  see  an  intermingling  of  vesicopapules 
and  vesicles. 

The  vesicular  variety — miliaria  vesiculosa — is  that  variety  of  miliaria 
in  which  the  eruption  is  distinctly  vesicular.  The  lesions  are  small — 
for  the  most  part  the  size  of  pin-points  or  pin-heads.  They  are  present 
in  great  numbers,  are  acuminate  or  conic  in  shape,  never  tend  to  coal- 
esce, and  show  no  disposition  to  rupture.  The  lesions  have  a  slight  pink- 
ish or  red  areola,  and  being  so  closely  crowded,  this  gives  the  whole  field 
of  eruption  its  red  and  inflammatory  aspect — miliaria  rubra.  Later 
the  areolae  fade,  the  transparent  contents  of  the  vesicles  become  some- 
what opaque  and  yellowish-white,  and  the  eruption  has  a  whitish  or 


MILIARIA 


1089 


yellowish  cast — miliaria  alba.     Occasionally  the  contents  of  some  become 
seropurulent  or  even  purulent. 

In  all  cases  of  miliaria  there  is  usually  a  feeling  of  burning,  prick- 
ing, or  itching,  which  may  be  slight,  moderate,  or  intense  in  character. 
Sweating  generally  is  noted  to  precede  and  accompany  the  eruption. 
The  lesions  tend  to  disappear  in  the  course  of  some  days  or  one  or  two 
weeks,  the  papules  gradually  fading  away;  the  vesicles  disappear  by 
absorption  or  desiccation,  the  epidermal  covering,  which  is  always  ex- 
tremely thin,  disappearing  by  slight,  at  times  scarcely  perceptible, 
desquamation.  When  the  closely  crowded  vesicular  lesions  are  broken 
open  by  rubbing  or  accidentally,  the  liberated  contents,  minute  in  quan- 
tity, dry  to  insignificant  thin  crusting.  In  cases  in  which  the  cause 
continues  there  are  fresh  outcroppings,  and  the  disease  is  thus  prolonged, 


^^^^^:^^^^ 


Fig.  269. — Miliaria,  vesicopapule,  showing  vesicle  (a)  with  the  excretory  sweat-duct 
in  the  lower  central  part,  and  inflammatory  changes  in  the  rete  (b),  and  also  in  the 
upper  part  of  the  corium  and  deeper  down  along  the  blood-vessels  (courtesy  of  Dr.  A. 
R.  Robinson). 

or  in  such  instances  it  may  be  transformed  into  a  veritable  eczema, 
although  such  termination  is  not  common.  Not  infrequently  in  these 
prolonged  cases,  and  more  especially  in  infants  and  young  children, 
boils  and  small  cutaneous  abscesses  are  seen  in  association  with  it. 

Btiology  and  Pathology.— Extreme  heat  is  the  essential  causa- 
tive factor;  this  may  be  due  to  the  weather  temperature  or  to  working 
in  an  overheated  room,  from  vapor  baths,  or  from  being  overclad.  Those 
who  perspire  freely  are  its  most  common  subjects,  more  particularly 
infants  and  young  children,  and  middle-aged  adults  who  are  overfleshy. 
In  the  latter  free  drinking  of  beer  or  other  alcoholic  drinks  is  sometimes 
a  factor.  In  some  instances  debility  seems  to  be  of  predisposing  in- 
fluence. 

The  affection  is  due  to  sweat  obstruction,  with  mildly  inflammatory 
symptoms  as  a  cause  or  consequence;  with  congestion  and  exudation, 

(59 


1090  DISEASES   OF  THE  APPENDAGES 

with,  at  times,  sweat  effusion  about  the  ducts,  leading  to  the  formation, 
according  to  the  intensity  of  the  process,  of  papules  or  vesicles.  But 
there  is  still  some  difference  of  opinion,  however,  as  shown  in  the  follow- 
ing briefly  stated  views:  (i)  that  it  is  an  inflammatory  disease  of  the 
epidermis  and  not  an  affection  of  the  sweat-glands  alone;  the  lesion 
occurring  around  a  sweat-duct  in  the  rete  and  upper  part  of  the  corium, 
with  slight  inflammatory  effusion  and  usually  transudation  or  retention 
of  sweat,  the  vesicular  lesions  all  being  connected  with  the  sweat-glands 
(Robinson);1  (2)  that  the  vesicles  are  due  to  dilated  sweat-ducts,  the 
papules  to  the  occurrence  of  cysts  filled  with  cellular  elements,  and  of 
cysts  in  the  lower  region  of  the  rete,  and  to  circumscribed  swelling  in  the 
immediate  neighborhood  of  a  sweat-pore  (Pollitzer2) ;  (3)  that  no  con- 
nection between  the  sweat-gland  and  vesicle  can  be  found,  and  that  the 
lesions  are  purely  of  inflammatory  origin,  or  eczematous,  probably  due 
to  irritation  produced  by  the  sweat  on  the  surface  (Torok3).  As  all  are 
good  observers,  it  is  probable  that  the  lesions  vary  somewhat  in  origin 
and  formation. 

Diagnosis. — The  rapidity  of  the  outbreak,  the  closely  crowded 
lesions,  the  mild  inflammatory  aspect,  the  preceding  and  often  accom- 
panying sweating,  absence  of  tendency  in  the  vesicles  to  spontaneous 
rupture,  the  external  high  temperature  factor,  and  absence  of  consti- 
tutional symptoms,  are  usually  sufficiently  distinctive.  Papular  eczema 
is  in  most  cases  rather  limited  in  extent,  the  lesions  are  larger  and  mark- 
edly inflammatory,  come  out  more  slowly  and  are  persistent,  and,  where 
close  together,  there  is  a  good  deal  of  inflammatory  swelling  and  infiltra- 
tion. The  same  features  serve  to  distinguish  vesicular  eczema;  moreover, 
in  this  latter  there  is  distinct  tendency  to  spontaneous  rupture  of  the 
lesions  and  characteristic  gummy  oozing  and  crusting.  There  is  a  re- 
semblance to  sudamen,  but  in  this  latter  there  are  no  inflammatory  signs, 
the  vesicles  being  transparent,  whitish,  resembling  minute  dewdrops, 
and  seen  in  association  with  some  febrile  or  cachectic  state.  Miliaria 
or  similar  lesions  occur  sometimes  in  the  exanthemata,  but  the  consti- 
tutional symptoms  and  the  accompanying  or  quickly  following  charac- 
teristic eruption  of  the  latter  serve  as  differential  points. 

Prognosis  and  Treatment.— Under  favorable  conditions  at  the 
end  of  several  days  or  a  week  or  two  the  disease  has  come  to  an  end. 
In  some  cases  the  cause  persisting,  there  may  be  rapidly  recurrent  at- 
tacks, so  that  the  eruption  may  almost  be  continuous  over  several  weeks 
or  longer,  with  or  without  occasional  furuncles,  or  eventually  developing, 
especially  in  the  folds,  into  an  intertrigo  or  an  eczema. 

In  the  management  of  the  affection  its  common  cause — excessive 
heat  from  high  temperature  or  from  too  much  clothing — should  be  kept 
in  mind.  The  disorder  is  thought  to  be  more  frequent  in  those  of  de- 
bilitated constitution,  and  for  this  reason  treatment  of  a  tonic  character 
is  sometimes  appropriate.  In  those  of  full  habit  and  stout,  refrigerant 

1  Robinson,  Jour.  Cutan.  Dis.,  1884,  p.  362,  and  in  Bangs-Hardaway's  Amer.  Text- 
book, p.  1096. 

2  Pollitzer,  Jour.  Cutan.  Dis.,  1893,  p.  50  (with  several  cuts),  and  New  York  Med. 
Jour.,  1894,  vol.  lix,  p.  12. 

3  Torok,  abs.  in  Monatshefte,  1891,  vol.  xiii,  p.  437. 


MI  LI  ARIA  1091 

and  acid  drinks  are  apparently  of  service.  Saline  laxatives  should  be 
administered  in  the  beginning,  and  repeated  from  time  to  time  in  the 
more  persistent  cases. 

As  a  rule,  however,  removal  or  modification  of  the  cause,  and  the 
application  of  a  dusting-powder  or  cooling  and  astringent  lotions  are 
all  that  are  required  in  the  average  case.  The  dusting-powder  may  con- 
sist of  zinc  oxid,  boric  acid,  talc,  and  starch,  singly  or  of  equal  parts. 
The  simple  household  remedy  of  one  part  vinegar  or  alcohol  to  several 
parts  water  will  also  often  be  sufficient  in  such  instances.  In  rather 
extensive  cases,  in  which  itching  or  burning  is  a  prominent  symptom, 
the  following  lotion  may  be  prescribed: 

1$.    Ac.  carbolic.,  5ss  (2.); 

Ac.  boric.,  3ij  (8.); 

Alcoholis,  f5j  (32.); 

Aquae,  q.  s.  ad  Oss  (256.). 

Or  one  of  thymol,  5  to  10  grains  (0.35-0.7),  sodium  borate,  8  grains 
(0.55),  alcohol,  i  ounce  (32.),  and  water  enough  to  make  \  pint  (256.), 
may  be  employed.  In  infants  or  others  in  whom  there  is  a  distinct 
tendency  to  furuncular  complication,  a  plain  saturated  solution  of  boric 
acid,  with  i  or  2  grains  (0.065-0.13)  of  resorcin  to  the  ounce  (32.),  is 
especially  to  be  commended.  In  some  instances  one  of  these  lotions, 
followed  immediately  by  a  dusting-powder,  is  more  grateful.  In  those 
persons  of  rather  stout  condition,  who  are  frequently  subject  to  the  affec- 
tion, and  who  perspire  somewhat  freely,  the  daily  use  of  a  dusting- 
powder  of  i  part  salicylic  acid  to  30  to  50  parts  boric  acid  will,  if  the  pa- 
tient avoid  active  exercise  and  overclothing,  often  prove  a  preventive. 

Miliary  fever1  (sweating  sickness;  miliary  sweat  rash;  sudor  anglicus; 
English  sickness;  Fr.,  suette  miliare)  is  an  epidemic  disease  of  rare  and 
scarcely  known  occurrence  in  recent  years,  in  which  profuse  sweating 
and  miliaria  are  conspicuous  symptoms.  The  last  epidemic  occurred  in 
France.  The  earliest  symptoms  are  ill-defined  prodromata,  such  as 
feverishness,  weakness  of  the  legs,  and  general  malaise  and  nervous 
symptoms,  the  last  consisting  of  feelings  of  epigastric  constriction,  of 
suffocation,  sometimes  paroxysmal,  and  agitation,  delirium,  etc.,  and 
accompanied  by  copious  sweating.  Cramps  and  constriction  of  the 
muscles  are  also  observed.  The  tongue  is  coated  and  the  bowels  con- 
stipated, and  in  the  early  stage  cough  is  habitual  and  epistaxis  generally 
abundant.  The  eruption  soon  presents,  characterized  by  two  chief 
features:  first,  a  miliary  papule,  transformed  later  into  a  vesicle,  and, 
second,  a  polymorphous  erythema.  This  latter  is  of  three  forms — 
a  morbilliform  eruption,  a  scarlatinoid  rash,  and  purpura.  The  morbil- 
liform  rash  first  presents,  followed  by  the  scarlatinal  and  purpuric  char- 
acters. In  some  instances  the  eruption  remains  morbilliform,  and  in 
some  cases  the  earliest  rash  is  the  scarlatinal. 

The  eruption  appears  first  on  the  face,  and  then  spreads  to  the 

1  This  description  is  abbreviated  from  an  editorial  review,  Lancet,  Oct.  i,  1887,  p. 
671,  of  Brouardel  s  report  of  "L'epidemie  de  suette  miliare  du  Poiton,"  Bull.  Acad.  Med., 
1887. 


DISEASES   OF   THE   APPENDAGES 

neck,  trunk,  and  upper  limbs,  and  finally  to  the  legs — the  last  often 
being  much  less  involved  than  the  other  parts.  The  veil  of  the  palate 
is  often  dotted  over  with  red  spots.  The  eruption  frequently  shows  itself 
in  two  or  three  successive  crops,  the  previous  crop  disappearing  com- 
pletely and  rapidly,  to  be  followed  by  another.  The  purpuric  spots, 
however,  are  apt  to  remain  a  long  time.  As  soon  as  the  eruptive  stage 
is  pronounced,  the  general  symptoms  gradually  abate.  The  so-called 
"suette  blanche"  variety  is  composed  of  papules,  which  remain  hard  and 
opaque,  with  but  little,  if  any,  tendency  to  vesicular  transformation. 
The  final  disappearance  of  the  eruption  is  followed  by  desquamation. 
The  malady  is  fraught  with  danger,  the  mortality  varying  from  12  to  33 
per  cent. 


CLASS  IX— PARASITIC  AFFECTIONS 

A.  DISEASES    DUE    TO    VEGETABLE    PARASITES 
FAVUS 

Synonyms. — Tinea  favosa;  Tinea  ficosa;  Tinea  lupinosa;  Tinea  maligna;  Tinea 
vera;  Porrigo  favosa;  Porrigo  lavalis;  Porrigo  lupinosa;  Porrigo  scutulata;  Derma- 
tomycosis  favosa;  Porrigophyta;  Trichomykosis  favosa;  Crusted  ringworm;  Honey- 
comb ringworm;  Fr.,  Teigne  faveuse;  Teigne  du  pauvre;  Teigne  rural;  Ger.,  Erbgrind. 

Definition. — Favus  is  a  contagious,  vegetable-parasitic  disease 
of  the  skin,  characterized  by  pin-head-  to  pea-sized,  friable,  cup-shaped 


Fig.  270.— Favus,  in  a  woman  aged  twenty-three,  of  some  years'  duration;  showing  hair 
loss,  atrophic  thinning  of  the  skin,  and  the  cup-shaped  crusts  at  peripheral  portion. 

yellow  crusts,  tending  sooner  or  later  to  form  coalescent,  mortar-like 
masses. 

Symptoms. — The  common  and  usual  site  of  favus  is  the  scalp, 
but  it  may  occur  upon  any  portion  of  the  integument,  and  occasion- 
ally attacks  the  nails  (see  Onychomycosis) .  To  the  latter  regions  it 
is  usually  conveyed  from  the  disease  on  the  scalp,  although  it  does  occur 

1093 


IO94  PARASITIC  AFFECTIONS 

sometimes  primarily  upon  the  non-hairy  surface,  and  to  which  it  may 
indeed  be  limited.  The  nails  are  rarely  the  primary  seat  of  the  malady. 

In  favus  of  the  scalp,  sometimes  designated  tinea  favosa  capitis, 
favus  pilaris,  the  affection  develops,  as  a  rule,  insidiously  and  slowly, 
beginning  as  an  insignificant  superficial  inflammation  or  merely  as  a 
hyperemic  spot;  in  the  earliest  stage  or  period  this  is  more  or  less  cir- 
cumscribed and  slightly  scaly,  the  scaliness  being  usually  of  a  thin, 
branny  character.  There  is  soon  noticed  the  appearance  of  yellowish 
points  at  the  hair-follicle  outlets,  surrounding  the  hair-shaft.  These 
yellowish  points  or  crusts  increase  in  size,  growing  slowly,  becoming  ordi- 
narily the  area  of  small  peas;  they  are  cup-shaped,  with  the  convex 
side  pressing  down  upon  the  papillary  layer  of  the  skin,  and  the  concave 
side  facing  externally,  constituting  the  so-called  favus  scutulum.  They 
are  raised  several  lines  above  the  surface  level,  are  friable,  sulphur- 
colored,  and  usually,  in  the  beginning  at  least,  each  cup  or  disc  is  pierced 
by  a  hair.  Some  show  distinct  concentrically  disposed  furrows.  Upon 
removing  the  crust  the  underlying  surface  is  found  to  be  somewhat 
excavated,  reddened,  and  if  the  malady  has  existed  for  some  time,  also 
atrophied;  exceptionally  it  is  suppurating.  In  detaching  the  disks,  more 
especially  those  of  some  duration,  slight  serous  exudation  or  even  bleeding 
is  sometimes  noticed.  As  the  disease  continues  and  progresses,  the 
crusted  points  or  spots  extend  somewhat,  new  ones  arise  in  the  inter- 
spaces, and,  as  a  result,  the  crusts  become  more  or  less  confluent  over 
the  involved  area,  and  form  irregular  masses  of  thick,  yellow  or  yellowish, 
mortar-like  accumulations.  While  the  crusts  are  yellowish,  and  at  first 
a  clear  yellow,  later,  from  the  admixture  of  extraneous  matter,  they  often 
have  a  brownish  tinge.  They  have,  when  present  in  any  quantity,  a 
peculiar,  characteristic  odor,  which  has  been  likened  to  that  of  stale, 
musty  straw,  to  that  of  mice,  and  the  urine  of  cats. 

The  progress  of  the  malady  is  exceedingly  slow,  so  that  months 
often  elapse  before  there  is  much  involvement,  the  disease  sometimes 
limiting  itself  to  an  irregular  area  of  one  or  two  inches  in  diameter. 
Not  infrequently,  while  the  first  patch  increases  gradually,  new  foci 
show  themselves  in  one  or  more  near-by  or  remote  parts  of  the  scalp. 
In  some  instances,  especially  near  the  border  of  the  crusts,  are  seen 
pustules  or  suppurating  points,  and  exceptionally  the  whole  involved 
area  may  exhibit  slight  or  moderate  suppurative  action,  by  which  the 
accumulated  masses  are  in  places  loosened  and  cast  off;  this  latter 
usually  occurring  after  the  malady  has  been  of  some  duration,  during 
which  time  the  hair  of  the  affected  surface,  or  most  of  the  hairs,  have 
loosened  and  fallen  out. 

The  hairs,  in  fact,  are  involved  early  in  the  disease;  they  become 
brittle,  lusterless,  break  off,  some  splitting  up,  and  many  falling  out. 
After  a  time  the  crusts  may  disappear  here  and  there  over  the  oldest 
part,  leaving  an  atrophic,  thinned-looking,  more  or  less  hairless  sur- 
face, with  scanty  or  numerous,  scattered,  yellowish  point,  cup-shaped 
disks  or  small  confluent  crusted  spots;  at  the  border  of  the  area  the  dis- 
ease is  still  noted  to  be  active,  and  presenting  the  ordinary  symptoms 
already  described.  The  disease  may  thus  gradually  invade  more  or 


FAVUS 


1095 


less  of  the  entire  scalp,  and  may  remain  active  over  the  entire  involved 
surface,  which  is  covered  with  the  yellowish,  mortar-like  masses.  In 
sluggish,  long-continued  cases,  in  which,  in  most  parts,  the  malady  has 
ceased  to  exist  or  to  be  active,  there  is  a  more  or  less  general  scurfmess, 
with  irregularly  dispersed,  small,  flattened,  yellowish,  scaly  spots;  the 
skin  is  atrophic,  dry,  harsh,  and  relatively  or  completely  hairless,  usually, 
however,  with  small  or  large  dry  tufts  here  and  there. 

Favus  of  the  general  surface  or  non-hairy  parts,  or  tinea  favosa 
epidermidis,  exhibits  symptoms  essentially  similar  to  those  upon  the 


Fig.  271. — Favus,  in  a  Russian  boy  aged  fourteen,  of  eight  years'  duration,  showing 
the  extensive  atrophic,  cicatricial,  hairless  areas  left.  Disease  only  active  now  pos- 
teriorly, and  to  a  slight  extent  to  the  right  anteriorly,  from  which  the  crusts  have  been 
removed. 

scalp,  beginning  at  the  lanugo  hair-follicles.  In  some  instances,  how- 
ever, there  is  tendency  to  the  circinate  patch  (favus  circinatus),  with 
the  outer  part  more  or  less  inflammatory,  sometimes  papulovesicular 
(favus  herpeticus),  and  studded  with  small  yellow  points  and  favus 
scutula;  the  central  portion  tending  to  clear  up,  presenting  a  resemblance, 
barring  the  yellowish  points  and  .disks,  to  ringworm.  There  may  be  one 
or  more  of  such  areas.  Exceptionally  a  patch  consists  of  several  concen- 
tric rings.  In  most  cases,  however,  the  disposition  to  massing  similar 
to  that  observed  on  the  scalp  is  exhibited,  although  the  masses  are  more 


1096 


PARASITIC  AFFECTIONS 


apt  to  have  a  rough  and  irregular  surface.     In  most  instances,  especially 
if  neglected,  the  malady  spreads  rather  rapidly,  and  often  involves  large 

areas  and  is  somewhat  widely 
distributed.1  The  rapidity  of 
its  extension  is  apparently  in- 
creased by  conditions  of  ill 
health.2  While  usually  per- 
sistent, especially  when  more  or 
less  extensive,  it  is  very  much 
less  so  than  the  disease  on  the 
scalp;  and  in  extremely  limited 
body  cases  often  tends  to  spon- 
taneous cure.  In  some  in- 
stances marked  atrophy  of  the 
underlying  skin  results,  and 
occasionally  distinct  ulcera- 
tion.3 

While  favus  is  a  disease  of 
the  cutaneous  surface,  it  is  pos- 
sible in  rare  instances  that  the 
mucous  membranes  may  be- 
come implicated.4  It  has  in  a 
few  cases  been  observed  on  the 
glans  penis.5 

The  subjective  symptoms  in 
favus  are  rarely  pronounced  and 
sometimes  entirely  absent;  itch- 
ing, varying  in  degree,  is  occa- 


1  See  paper  by  Cantrell  and  Stout, 
"A   case   of   Favus  of   the  Head  and 
Body,"  Jour.  Cutan.   Dis.,  1894,  pp. 
375  and  419   (with  review  of  similar 
cases  and  bibliography). 

2  Malcolm     Morris,     Brit.    Jour. 
Derm.,  1891,  p.  101  (with  illustration), 
and  Montseret,  La  presse  med.,  No.  40, 
1898,  p.  254,  both  report  a  case  involv- 
ing the  general  surface  in  phthisical 
subjects,  in  whom,  during  the  last  stage 
of  the  constitutional  malady,  there  was 
rapid  spread  of  the  favus. 


Fig.  272. — Favus — generalized — in  an 
Italian  boy  aged  ten;  on  scalp  of 'several 
years'  duration,  on  general  surface  some 
months.6 


3  In  an  instance  observed  by  Hallopeau,  and  one  by  Vidal,  referred  to  in  Wick- 
ham's  Paris  letter  to  Brit.  Jour.  Derm.,  1890,  p.  149,  the  ulcerative  action  was  quite 
marked. 

_ 4  Kaposi,  Wien.  med.  Presse,  1884,  p.  1375,  reports  a  case  of  generalized  favus  in 
which,  the  patient  dying  subsequently  from  gastro-intestinal  disease,  Kundrat  ("gastro- 
enteritis favosa,"  Wien.  med.  Blatter,  1884,  p.  1538),  found  at  the  necropsy  the  favus 
fungus  in  the  esophagus,  stomach,  and  intestine,  some  of  which  in  the  last  had  under- 
gone putrefactive  change. 

5  Gliick,  Arc.hiv,  1899,  vol.  xlvii,  p.  339  (with  colored  plate),  noted  an  instance  in 
which,  in  addition  to  several  patches  on  the  outer  surface  of  the  prepuce,  there  were  some 
typical  crusts  on  the  corona  and  glans. 

6  This  is  the  case  reported  by  Cantrell  and  Stout,  entering  the  Philadelphia  Hospital 
just  at  the  end  of  Dr.  Cantrell's  term,  coming  subsequently  under  my  care. 


FAVUS  1097 

sionally  somewhat  troublesome;  there  may  also  be  in  the  suppurative 
conditions  some  soreness. 

Etiology. — Favus  is  due  solely  to  the  invasion  of  the  cutaneous 
structures,  especially  the  epidermal  portion,  by  the  vegetable  para- 
site, the  achorion  Schonleinii.  It  is  seen  in  both  sexes,  but  much  more 
frequently  in  males;  it  may  occur  at  almost  any  age,  but  it  is  rare  for 
the  scalp  disease  to  begin  after  the  age  of  fifteen.  Hutchinson1  found 
in  44  cases  the  latest  age  at  which  it  began  was  seventeen;  this  patient, 
when  coming  under  notice,  was  aged  twenty-nine,  the  oldest  of  the  44, 
having  had  the  disease  twelve  years.  It  is  a  contagious  malady,  but 
relatively  much  less  so  than  ringworm.  It  is  conveyed  from  one  person 
to  another,  or  to  man  from  the  lower  animals,  such  as  cats,  dogs,  rabbits, 
fowl,  mice,  and  sometimes  cattle2  and  the  horse.  It  is  probably  communi- 
cated occasionally  by  cats,  the  latter  contracting  it  from  rats  and  mice, 
especially  the  latter;3  but  Sabouraud's  observations,  as  well  as  those  of 
other  investigators,  throw  doubt  upon  such  communication — at  all 
events  think  that  such  transmission  is  exceedingly  rare.  Its  conta- 
giousness seems,  however,  somewhat  variable,  single  cases  often  existing 
in  a  family  for  years,  without  any  other  member  becoming  involved, 
although  striking  exceptions  are  sometimes  noted.4  The  malady  is  much 
more  common  among  certain  nationalities  than  others;  it  is  compara- 
tively frequent  in  Northern  Italy,  Southern  France,  Russia,  Poland, 
Austria,  Germany,  Hungary,  and  in  Scotland.5  In  England  and  in  the 

1  Hutchinson,  "Clinical  Report  on  Favus,"  Med.  Times  and  Gas.,  1859,  vol.  xix, 
P-  553  (with  analytic  table  of  44  cases). 

2  Gigard,  "Sur  urie  epidemic  de  teigne  faveuse  sivissant  a  Nantoin  chez  les  betes 
cornes  et  chez  les  enfants,"  Lyon  medicate,  1880,  vol.  xxxiv,  p.  457,  recorded  its  occur- 
rence at  about  the  same  time  in  16  cows  and  4  children  in  a  French  village. 

3  See  interesting  paper  by  Sherwell,  American  Veterinary  Review,  Nov.,  1892,  de- 
tailing the  contraction  of  the  disease  by  4  members  of  a  family  through  the  intermediary 
of  the  dog,  the  latter  contracting  it  from  affected  mice;  Hutchins,  Jour.  Cutan.  Dis., 
1895,  p.  377,  records  a  case  in  a  negro,  who  apparently  caught  it  from  pet  white  rats; 
Adamson,  Brit.  Jour.  Derm.,  1911,  p.  49,  met  with  3  cases  of  mouse  favus  (achorion 
Quinckeanum)  in  human  beings,  and  is  inclined  to  believe  that  it  is  not  so  rare  as  com- 
monly believed. 

4  Crocker,  Diseases  of  the  Skin,  third  ed.,  p.  1272,  noted  its  occurrence  in  3  chil- 
dren of  a  family,  one  after  another,  the  disease  being  primarily  contracted  from  a  cat; 
Robinson  (discussion),  Jour.  Cutan.  Dis.,  1895,  p.  217,  had  under  observation  3  cases 
in  the  same  family,  and  Allen,  ibid.,  a  case  in  an  Irish  woman,  whose  3  children  con- 
tracted the  disease;  Duhring,  Diseases  of  the  Skin,  third   ed.,  p.  596,  refers   to  an 
instance  where  13  members  of  one  family  were  in  the  course  of  years  affected,  and 
another  of   mother  and  2  children,  constituting  the  whole  family;   in  17  cases  ob- 
served by  J.  C.  White  ("Analysis  of  5000  Cases  of  Skin  Diseases"),  Boston  M.ed.  and 
Siirg.  Jour.,  1876,  vol.  xciv,  p.  565,  more  than  half  were  instances  where  2  or  3  mem- 
bers of  the  same  family  were  affected;  in  50  cases  observed  by  Bodin,  Annales,  1894, 
p.  1220,  more  than  half  the  patients  alleged  that  they  had  caught  it  from  others,  and 
10  had  been  in  contact  with  affected  animals;  in  10  cases  its  origin  could  not  be  traced; 
I  have  met  with  several  instances  of  its  occurrence  in  2  of  a  family;  Crary,  Bull.  Lying- 
in- Hospital,  New  York,  May,  1904,  vol.  i,  No.  6,  reports  a  case  in  a  child  fourteen  days 
after  birth,  appearing  on  face,  scalp,  and  elbow;  the  mother  having  the  disease  upon  the 
scalp. 

5  In  France  its  frequency  is  shown  by  Feulard,  Trans.  II  Internal.  Derm.  Cong., 
Vienna,  1892,  p.  393,  and  Annales,  1892,  p.  1118,  from  statistics  taken  from  the  French 
Army  Department;  between  1876-80,  of  those  examined  for  army  service  (at  the  age 
of  twenty),  1541  had  favus;  1881-85,  J399;  1887-91,  964,  the  malady  showing  a  some- 
what rapid  decrease,  but  it  is  much  more  common  than  these  figures  indicate,  inasmuch 
as  the  disease  is  chiefly  seen  in  children  and  adolescents. 

In  Belgium,  Thomson  (Clinique,  Brussels,  1894,  vol.  viii,  p.  52 — abs.  in  Brit.  Jour. 


1098  PARASITIC  AFFECTIONS 

United  States  it  is  relatively  uncommon,  and  with  us  is  seen  chiefly 
among  immigrants  from  the  countries  named;1  generalized  favus  is  espe- 
cially rare  in  native-born  Americans.2 

Favus  of  the  non-hairy  or  general  surface,  except  the  instances 
of  slight,  limited  patches  sometimes  seen,  is  usually  consecutive  to 
the  disease  on  the  scalp,  and  in  extensive  types  almost  invariably  so, 
although  Lustgarten3  has  reported  a  case  of  the  latter,  the  eruption 
covering  a  large  portion  of  both  legs,  in  which  the  scalp  was  wholly  free. 
The  nails  (see  Onychomycosis)  are  only  rarely  invaded  by  the  favus 
fungus,  and  then  almost  always  secondarily,  from  scratching  the  affected 
scalp. 

While  favus  is  met  with  over  the  entire  world,  its  prevalence  is 
apparently  greatly  influenced  by  nationality,  lack  of  personal  cleanli- 
ness, neglect  of  the  scalp,  and  probably  some  inherent  peculiarity  of 
the  skin.  It  is  commonly  believed  that  a  damp,  moist  climate  favors 
its  occurrence,  but  this  does  not  seem  borne  out  by  the  facts.  It  is 
essentially  a  disease  of  the  poor,  ill-fed,  and  uncared  for,  although 
occasionally  seen  in  those  of  fair  or  good  circumstances  and  surroundings. 
There  is  scarcely  doubt  but  what  an  integument  whose  resisting  power 
has  been  impaired  by  ill  health,  improper  and  insufficient  food,  etc., 
becomes  a  readier  soil  for  the  successful  inoculation  and  growth  of  the 
fungus.  Its  much  more  rapid  spread  in  the  body  cases  during  the  last 
stages  of  phthisis  in  the  instances  named  points  to  this  conclusion. 

Pathology. — The  achorion  Schonleinii  is  a  vegetable  parasite 
first  discovered  by  Schb'nlein  in  1839,  and  later  by  Gruby  and  Wedl, 
although  Remak  was  the  first  to  confirm  its  pathogenic  character  by 
successful  inoculation,  and  who  gave  it  the  name  in  honor  of  its  dis- 
coverer. It  consists  of  mycelium  and  spores,  existing  in  such  profusion 
that  it  is  readily  detected.  The  spores  are  usually  rounded  or  ovalish, 
often  somewhat  elongated,  and  vary  from  0.0023  to  0.0052  mm.  in 
diameter  (Duhring).  The  mycelium  is  composed  of  narrow,  appar- 
ently flattened  tubes  or  threads,  which  ramify  in  all  directions  without 
definite  arrangement;  they  average  from  0.0023  to  0.003  mm-  m  di- 
ameter, and  vary  greatly  in  length,  and  are  straight,  curved,  bent  or 
crooked,  or  inclined  to  branch  in  a  forked  manner;  and  sometimes  they 
are  divided  or  broken  up  in  such  a  way  as  to  have  the  appearance  of  the 

Derm.,  1894,  p.  156)  shows  its  great  frequency  in  that  country;  between  1888-92  there 
were  exempted  from  military  service,  owing  to  the  disease,  3.03  per  1000,  and  even  with 
rigid  examination  of  the  recruits  it  exists  in  the  service  to  the  extent  of  0.15  per  1000. 

In  Scotland,  McCall  Anderson  gives  (Lancet,  1871,  ii,  pp.  672  and  742)  156  cases 
in  10,000  consecutive  dispensary  skin  cases,  or  15.6  per  1000. 

In  England,  according  to  Crocker,  it  is  observed  in  only  i  of  2000  consecutive  skin 
cases. 

1  In  the  United  States  the  statistics  of  the  American  Dermatological  Association 
show  3.43  per  1000,  most  of  the  patients,  however,  being  foreign  born.     In  36  cases 
under  my  care  (20  at  the  Philadelphia  Dispensary  for  Skin  Diseases  in  a  period  of  ten 
years,  and  16  in  the  Philadelphia  Hospital  in  a  period  of  five  years,  Philadelphia  Hos- 
pital Reports,  1896,  vol.  iii,  p.  176)    the  patients  were  of  the  following  nationalities: 
American  born,  5;  Russian,  10;  Austrian  and  German,  10;  Italian,  3;  Irish,  3;  Rou- 
manian, 2;  Hungarian,  i;  English,  i;  and  Canadian,  i. 

2  Stout,  Neiv  York  Med.  Jour.,  June  20,  1908,  p.  1182,  reports  a  case,  scalp,  nails, 
arms,  and  legs  being  invaded. 

3  Lustgarten,  Jour.  Cutan.  Dis.,  1895,  p.  217  (with  illustration). 


FAVUS 


1099 


links  of  a  chain  (Duhring).  As  the  disk-like  scutulum  and  the  mortar- 
like  mass  are  composed  almost  wholly  of  the  fungus,  there  is  no  difficulty 
in  demonstrating  its  presence.  For  the  examination  a  portion  of  the  crust 
is  placed  on  a  slide  in  a  few  drops  of  liquor  potassae,  the  cover-glass  placed 
over  it,  and  allowed  to  stand  for  several  minutes  or  longer;  the  cover- 
glass  is  then  pressed  down,  and  an  examination  made  with  a  power  of 
300  to  500  diameters.  If  an  affected  hair  is  examined,  the  same  steps  are 
taken,  except  that  a  longer  time  should  be  allowed  for  the  action  of  the 
liquor  potassae,  and  sometimes  a  stronger  potash  solution  could  be  used 
with  advantage. 

According  to  Robinson,1  as  well  as  to  the  investigations  of  others, 
"the  parasite  first  obtains  a  lodgment  in   the  funnel-shaped  depression 


Fig.  273. — Favus  fungus — achorion  Schonleinii  (X  about  700;  partly  diagrammatic). 

in  the  epidermis  through  which  the  hair-shaft  emerges  upon  the  surface. 
It  grows  luxuriantly  in  the  upper  part  of  the  hair-sac,  and  insinuates 
itself  on  all  sides  between  the  superficial  layers  of  the  epidermis.  When 
it  reaches  a  short  distance  on  all  sides  of  the  follicle-mouth,  it  breaks  the 
looser  layers  and  appears  on  the  surface,  giving  us  the  familiar  cup- 
shaped  bodies.  It  also  invades  the  hair-shaft  itself,  though  not  to  the 
extent  that  the  ringworm  parasite  does.  It  penetrates  between  the 
cellular  layers  of  the  root-sheath,  and  multiplies  in  the  cortical  substance 
of  the  hair.  The  nutrition  of  the  hair  is  interfered  with  by  the  mechan- 
ical pressure  of  the  growth  upon  the  papillae.  The  hair  falls  out,  and 
eventually  in  many  cases  the  papilla  atrophies  and  a  new  growth  becomes 
impossible.  In  cases  of  any  standing  the  parasite  may  be  demonstrated, 
not  only  in  the  cortical  but  in  the  medullary  substance  of  the  hair. 
1  Robinson,  Manual  of  Dermatology,  p.  605. 


I  100 


PARASITIC  AFFECTIONS 


Splitting  of  the  hair  may  occur,  as  in  ringworm,  but  as  a  usual  thing  the 
hair  falls  out  before  that  occurs."  "In  the  skin  itself  the  parasite  usually 
confines  itself  to  the  upper  corneous  cells,  and  does  not  extend  to  the  liv- 
ing tissues.1  In  cases  where  the  surface  is  covered  by  irregular,  mortar- 
like  masses  of  the  parasite,  the  entire  upper  layer  of  the  epidermis  will  be 
found  infiltrated  with  the  achorion.  The  corium  itself  is  usually  in  a 
state  of  chronic  inflammation,  and  suppuration,  which  may  be  quite 
abundant,  often  occurs  under  the  crusts.  Even  where  no  pus  is  found, 
the  presence  of  the  parasite  causes  atrophy  of  the  skin,  and  at  last  pit- 
like  depressions  or  more  extensive  reddened  scars  are  left.  When  the 
glandular  structures  are  entirely  destroyed,  the  achorion  no  longer  finds 
a  suitable  nidus,  and  the  disease,  at  that  spot,  is  at  an  end." 


Fig.  274. — Section  through  a  favus  scutulum,  showing  the  thinning  and  atrophy  of 
the  underlying  surface,  presumably  as  the  result  of  pressure  (courtesy  of  Dr.  M.  B. 
Hartzell). 

While  the  malady  is  generally  considered  to  be  due  to  the  one  variety 
of  fungus,  there  is  a  growing  belief  that  future  investigations  may  show, 
as  now  accepted  in  ringworm,  that  there  may  be  several  species.  On 
this  basis  the  variable  contagiousness  shown  and  the  slight  variations  in 
the  clinical  features  might  find  satisfactory  explanation.  Several  ob- 
servers (Quincke,  Frank,  Unna,  Sabrazes,  Bodin)2  have  found  several 
varieties.  Both  Frank  and  Unna,  from  experimental  inoculations  and 

1  Darier  and  Halle,  "Sur  un  casde  granulome  favique,"  Annales,  1910,  p.  127,  state 
that  the  achorion  can  get  down  into  the  living  tissue,  and  rarely  may  produce  kerion- 
like  lesions  and  lesions  with  histopathologic  resemblance  to  tuberculid. 

2  Quincke,  Monalshefte,  1887,  p.  981;  Frank,  ibid.,  1891,  vol.  xii,  p.  255  (with 
review);  Unna,  ibid.,  1892,  vol.  xiv,  p.  i;  and  also  in  Brit.  Jour.  Derm.,  1892,  p.  139 
(with  colored  plate);  Sabrazes,  "Sur  le  favus  de  l'homme,  de  la  poule  et  du  chien," 
Annales,  1893,  p.  340;  Bodin,  loc.  cit.  (with  complete  review  and  references);  and  "Sur 
un  nouveau  champignon  du  favus  (achorion  gypseum),"  Annales,  1907,  p.  585  (with 
review  and  references). 


FAVUS  IIOI 

cultures,  conclude  that  there  are  three  distinct  species  which  give  rise 
to  slightly  different  clinical  pictures.  Sabraze's  experiments  and  observa- 
tions indicate  that  there  is  one  variety  peculiar  to  fowls,  one  to  the  dog, 
and  the  other  to  man,  the  three  being  intercommunicable.  On  the  other 
hand,  other  investigators  (Elsenberg,  Krai,  Dubreuilh,  Danielssen, 
Busquet,  Mibelli)1  have  either  failed  to  confirm  such  findings  or  ascribe 
the  alleged  differences  to  the  character  of  the  "soil,"  culture  methods, 
and  other  accidental  or  accessory  conditions.2  In  200  cases  of  scalp 
favus  Sabouraud  found  them  all  due  to  the  achorion  Schonleinii.  The 
conclusion  seems  to  be  that  only  exceptionally  is  the  disease  due  to  any 
other  fungus  variety.3 

Diagnosis. — The  characters  of  favus — the  yellow,  and  usually 
cup-shaped  crusts,  brittleness  and  loss  of  hair,  the  underlying  atrophy, 
together  with  the  history — are  generally  so  distinctive  that  it  is,  as  a 
rule,  readily  recognized.  In  cases  in  which  the  scalp  has  been  thor- 
oughly washed  just  before  seeking  advice  the  peculiar  crusts  will  be 
lacking,  but  the  other  features,  especially  the  atrophic  or  cicatricial 
condition  of  the  involved  surface,  will  commonly  be  sufficient.  In  such 
instances  hairs  from  the  affected  area  can  be  examined  with  the  micro- 
scope, or  the  patient  permitted  to  go  and  return  in  a  week  or  ten  days, 
with  instructions  that  in  the  meantime  no  application  is  to  be  made  or 
the  parts  washed;  by  the  end  of  this  period  there  is  usually  a  reappearance 
of  the  yellowish  points  and  cup-shaped  disks,  although  the  latter  may  not 
have  acquired  any  size.  But  such  beginning  crusts  can  be  microscop- 
ically examined  and  the  matter  readily  determined.  In  cases  in  which 
the  disease  has  been  long  continued  the  cup-shaped  crusts  are  commonly 
wanting,  the  scalp  being  more  or  less  covered  with  irregular,  mortar- 
like,  yellowish,  or  brownish-yellow  accumulations;  but  the  color  and 
odor  of  the  latter,  together  with  the  other  characters  named,  especially 
the  atrophy  and  hair  loss,  afford  means  for  diagnosis.  In  some  in- 
stances— in  those  in  which,  from  extraneous  matter  and  the  coexistence 
of  a  seborrhea,  the  crusts  are  of  a  less  granular  character  and  brownish 
in  color — there  is,  on  first  glance,  a  possible  doubt,  but  a  consideration  of 
the  essential  features  named  suffices  to  clear  the  difficulty.  In  doubtful 
cases  the  microscope  is  to  be  resorted  to. 

The  diseases  with  which  it  is  most  likely  to  be  confounded  are  eczema, 
ringworm,  seborrhea,  and  psoriasis.  The  atrophic  and  scar-like  charac- 

1  Elsenberg,  Archiv,  1889,  p.  179;  Krai  (Pick  and  Krai),  ibid.,  1891,  Erganzungs- 
heft  (the  fungus  described  is,  however,  somewhat  different  from  that  commonly  found; 
gives  review  and  references);  Danielssen,  Atlas  of  Vegetable  Parasite  Diseases,  Bergen, 
1892;  Busquet,  Annales,  1892,  p.  916;  Mibelli,  Giorn,  ital.,  1892,  fasc.  ii,  iii — abs.  in 
Monatshefte,  1893,  vol.  cvi,  p.  47. 

2  Of  great  interest  in  this  connection  also  is  the  observation  by  Mewborn,  Jour. 
Cutan.  Dis.,  1903,  p.  n  (with  culture  illustrations,  and  resume  of  pertinent  literature, 
with  bibliography),  of  "A  Case  of  Favus  of  the  Scrotum,  Coexisting  with  Ringworm  of 
the  Thigh,  Giving  Identical  Trichophyton-like  Cultures"  (a  megalosporon  ectothrix  of 
probable  animal  origin). 

Winfield,  Jour.  Cutan.  Dis.,  1897,  p.  13  (with  illustration  of  case  and  fungus),  met 
with  an  instance  of  a  favus-like  eruption  on  the  oral  mucous  membrane  (roof  of  the 
mouth),  with  many  points  of  resemblance  in  color  and  crusting  to  favus,  but  which  was 
found  due  to  the  aspergillus  nigrescens. 

3  Four  animal  species  of  the  fungus  are  usually  acknowledged :  achorion  Quincke- 
anum;  achorion  gallinae,  oospora  canina,  and  achorion  gypseum. 


1 102  PARASITIC  AFFECTIONS 

ter,  the  condition  of  the  affected  hair,  the  hair  loss,  the  odor  and  history, 
as  well  as  the  other  features,  will  serve  to  distinguish  it  from  eczema, 
seborrhea,  and  psoriasis.  In  none  of  these  is  there  a  tendency  to  patchy 
hair  loss.  Ringworm  lacks  the  crusting  and  atrophic  changes  of  favus, 
and  ordinarily  shows  but  slight  scaliness  and  a  distinct  tendency  for  the 
hair  to  break  off,  especially  near  the  follicular  outlets;  moreover,  ring- 
worm patches  are  likely  to  be  fairly  well  rounded,  while  the  favus  areas 
are  commonly  somewhat  irregular  (see  Ringworm  for  other  differential 
points).  The  atrophic,  cicatricial  areas  of  lupus  erythematosus  occurring 
on  the  scalp  show  some  resemblance,  but  they  lack  the  crusting  and  other 
features,  and  the  disease  is  usually  seen  here  in  association  with  charac- 
teristic patches  on  the  face.  Alopecia  areata  can  scarcely  be  considered, 
inasmuch  as  it  has  only  one  feature  in  common, — the  hair  loss, — showing 
no  scaling,  crusting,  or  cicatricial  formation. 

The  diagnosis  of  favus  of  the  non-hairy  or  general  surface  rarely, 
if  ever,  gives  rise  to  difficulty.  The  ring-shaped  patches  sometimes 
present  a  similarity  to  ringworm,  but  the  yellowish  points  and  cup- 
shaped  crusts  of  the  former  are  not  seen  in  the  latter  disease.  The 
features  of  favus  of  the  nails  are  elsewhere  considered  (see  Onycho- 
mycosis). 

Prognosis. — Favus  of  the  scalp,  if  at  all  advanced  and  of  some 
duration,  is  a  most  intractable  disease.  In  some  instances  it  may,  in- 
deed, be  almost  said  to  be  incurable;  that  is,  the  time  required  to  bring 
about  permanently  favorable  results  is  so  long,  varying  at  least  from 
six  months  to  one  or  two  years,  and  the  measures  of  treatment  so  irksome 
and  tedious  that  very  few  patients  among  the  class  in  which  the  disease 
prevails  will  be  found  to  be  sufficiently  persevering.  It  is  true  the  malady 
after  years  tends  gradually  to  wear  itself  out,  and  patients  will  occa- 
sionally be  seen  with  the  evidences  of  its  ravages,  such  as  atrophic  scar- 
ring and  baldness,  in  whom,  after  a  duration  of  five,  ten,  or  fifteen  years 
or  more,  spontaneous  cure  has  resulted,  helped,  doubtless,  by  treatment 
pursued  irregularly  from  time  to  time.  In  my  earlier  experience  in 
dispensary  practice  I  often  thought  I  saw  cures  resulting  after  several 
months'  treatment,  but  a  larger  observation  and  returning  patients  have 
taught  me  that  while  the  disease  was  apparently  cured,  it  was  only  bene- 
fited and  somewhat  diminished  in  area;  and  that  a  permanent  and  com- 
plete cure  requires  a  much  longer  period  and  the  employment  of  actively 
energetic  measures  of  treatment.  Under  the  latter  circumstances  the 
malady  in  every  instance  can  finally  be  removed — some  cases  in  five  or 
six  months,  but  most  of  them  in  not  less  than  a  year.  Efficient  depila- 
tion,  if  it  can  be  carried  out,  has  a  material  influence  in  shortening  the 
duration  of  treatment.  Recent  and  limited  cases  are,  of  course,  much 
more  readily  responsive,  and  require  less  time  for  their  cure;  and,  more- 
over, it  is  true  that  x-ray  treatment  (see  Ringworm)  in  skilled  hands 
has,  in  some  cases,  considerably  changed  the  unfavorable  outlook. 

Favus  of  the  general  surface  is  comparatively  easy  to  cure,  and,  as 
a  rule,  responds  to  proper  measures  in  the  course  of  one  or  two  weeks 
in  the  slight  limited  cases,  to  one  or  two  months  in  those  of  extensive 
distribution. 


FA  VUS  1 103 

Treatment. — A  necessary  preliminary  in  the  management  of 
favus  of  the  scalp  is  the  removal  of  the  crusts,  which  can  be  accom- 
plished by  oily  applications  and  soap-and-water  washings,  the  washings 
alone  often  sufficing.  An  essential  part  of  the  treatment  is  the  extrac- 
tion of  the  hairs  from  the  diseased  areas;  the  hair  of  the  unaffected 
parts  should  be  kept  closely  cropped,  so  as  to  permit  of  the  detection 
of  any  new  foci  of  disease.  The  most  efficient  plan  of  depilation  is 
by  means  of  the  forceps,  going  over  the  whole  diseased  region,  taking 
a  small  part  each  day;  it  is  slow  and  somewhat  painful,  and  must,  more- 
over, be  repeated  in  many  cases  two  or  three  times  before  a  cure  results. 
It  is  found,  however,  that  the  second  or  third  time,  if  it  is  required,  need 
not  be  so  general  as  the  first.  The  application  of  a  strong  carbolic  acid 
wash  just  before  depilation  is  practised  will  lessen  the  pain  of  this  pro- 
cedure. If  this  tedious  plan  is  not  feasible,  then  the  hair  should  be 
seized,  near  the  scalp,  between  the  thumb  and  a  spatula  or  similar  flat 
instrument  and  a  moderate  amount  of  tractive  force  used;  the  diseased 
hairs  can  be  thus  pulled  out,  while  those  sound  and  firmly  seated  slip 
through.  It  is  not  so  effective  as  depilation  by  the  forceps.  The  use 
of  a  depilatory,  as  in  ringworm  of  the  scalp,  from  time  to  time  will  be  found 
an  efficient  substitute  for  these  harsher  methods.  The  x-ray  treatment 
has  some  advocates,  both  for  its  depilating  and  curative  action,  but 
should  be  employed  with  extreme  caution,  in  the  same  manner  as  ring- 
worm (q.  v.};  and  unless  one  is  experienced  in  its  use,  it  is  much  wiser 
to  hold  to  the  usual  plans  of  treatment. 

The  whole  scalp  is  to  be  washed  every  day  with  sapo  viridis  and 
hot  water,  the  lather  permitted  to  remain  for  from  five  to  thirty  minutes, 
according  to  the  irritability  of  the  skin,  and  then  rinsed  off;  after  the 
scalp  has  been  rubbed  dry  the  remedial  application  is  made.  These  are 
essentially  the  same  as  employed  in  the  treatment  of  ringworm  of  the 
scalp.  The  most  valuable  are  mercuric  chlorid,  from  i  to  4  grains 
(0.065-0.26)  to  the  ounce  (32.)  of  water;  sulphurous  acid,  pure  or  slightly 
diluted;  ointments  of  tar,  sulphur,  and  mercury;  pyrogallol  ointment, 
from  \  to  i  dram  (2.~4.)  to  the  ounce  (32.);  chrysarobin  ointment,  from 
30  to  60  grains  (2. -4.)  to  the  ounce  (32.).  A  good  compound  ointment 
is  the  following: 

1$.     Ac.  carbolici,  5j  (4-); 

Ungt.  picis  liq., 

Ungt.  hydrargyri  nitrat.,  aa  3ij  (8.); 
Ungt.  sulphuris,  3iv  (16.). 

As  a  certain  amount  of  chemical  change  takes  place  in  this,  it  should 
be  made  up  fresh  about  once  weekly. 

Crocker  cured  i  case  of  twelve  years'  duration  with  an  ointment 
consisting  of  i  dram  (4.)  of  resorcin  to  the  ounce  (32.)  of  lanolin  and 
oil.  If  a  lotion  is  selected,  it  should  be  rubbed  in  gently  for  a  few 
minutes  and  then  dabbed  on  for  four  or  five  minutes  and  allowed 
to  dry  in;  caution  should  be  exercised  in  the  use  of  strong  lotions 
of  mercuric  chlorid.  If  an  ointment  is  prescribed,  it  should  be  thor- 
oughly worked  into  the  cutaneous  structures  by  more  or  less  vigorous 


1 104  PARASITIC  AFFECTIONS 

rubbing;  and,  better  still,  if  at  bed- time  this  rubbing  in  of  the  ointment  is 
followed  by  its  application  as  a  plaster  spread  upon  lint  or  any  suitable 
material.  After  a  few  months'  treatment  the  remedies  should  be  dis- 
continued for  a  time  in  order  that  the  effect  may  be  properly  observed. 
In  all  cases  after  several  months'  active  management  the  malady  will 
be  found  to  be  much  less  extensive  in  area,  and  in  resuming  therapeutic 
measures  this  should  be  taken  into  account,  depilation  being  practised 
upon  and  about  the  diseased  areas  only,  the  hair  on  other  parts  of  the 
scalp  being  kept  short  for  easy  inspection.  In  this  manner,  if  the  treat- 
ment is  energetically  pursued  and  faithfully  carried  out  by  the  patient 
or  attendant,  the  surface  involved  becomes  less  and  less,  and  a  cure  will 
sooner  or  later  result.  The  new-growing  hairs  in  the  affected  areas 
should  be  examined  microscopically  from  time  to  time  for  any  evidence 
of  fungus.  If  there  are  no  signs  of  a  return  of  scaliness,  yellowish  points, 
or  dulled,  lusterless  hair  in  five  or  six  weeks  after  cessation  of  treatment, 
the  case  may  be  considered  as  cured. 

In  favus  of  the  general  or  non-hairy  surface  the  crusts  are  to  be 
washed  off  with  soap  and  water,  or  by  the  conjoint  application  of  soften- 
ing ointments  or  oils  and  frequent  washings  or  alkaline  baths.  This  is 
usually  effected  in  one  or  several  days.  The  remedial  applications  are 
ointments  of  sulphur,  i  or  2  drams  (4-8.)  to  the  ounce  (32.);  of  white 
precipitate,  from  \  to  i  dram  (2. -4.)  to  the  ounce  (32.) ;  of  mercury  oleate 
ointment,  from  10  to  20  per  cent,  in  strength;  of  tar,  i  or  2  drams  (4--8.) 
to  the  ounce  (32.);  of  pyrogallic  acid,  from  20  to  60  grains  (1.3-4.)  to  the 
ounce  (32.);  of  chrysarobin,  from  10  to  60  grains  (0.65-4.)  to  the  ounce 
(32.) ;  of  resorcin,  from  \  to  i  dram  (2. -4.)  to  the  ounce  (32.) ;  and,  in  fact, 
any  of  the  so-called  parasiticidal  remedies.  Sulphurous  acid,  diluted 
with  i  or  2  parts  of  water;  a  2  to  5  per  cent,  lotion  of  carbolic  acid,  and 
painting  with  tincture  of  iodin,  \vill  also  have  usually  a  promptly  curative 
action.  The  ointments  of  mercury  oleate  and  pyrogallol  are  applicable 
only  when  the  disease  is  of  limited  extent. 

Constitutional  treatment  is  generally  considered  uncalled  for  in 
this  malady,  but  I  am  convinced  that  improvement  in  the  general 
health  and  nutrition  is  of  contributory  service,  although  it  may  be  slight. 
Cod-liver  oil,  in  doses  of  \  to  i  dram  (2. -4.),  along  with  3  to  10  grains 
(0.2-0.65)  °f  sulphur  three  times  daily,  have,  I  believe,  some  influence; 
the  former  by  improving  the  nutrition,  the  latter  by  the  resulting  cuta- 
neous sulphurous  exhalation,  making  the  skin  a  less  favorable  habitat 
for  the  fungus. 

RINGWORM 

Synonyms. — Tinea  trichophytina;  Trichophytosis;  Microsporosis;  Dermatomycosis 
trichophytina;  Fr.,  Trichophytie;  Ger.,  Herpes  tonsurans;  Scherende  Flechte. 

Until  somewhat  recently  ringworm  in  all  its  types  and  in  all  situa- 
tions was  thought  to  be  due  to  one  fungus — the  trichophyton.  And 
yet  the  admirable  work  of  Sabouraud,  independently  pursued  but  a 
few  years  back,  and  by  which  the  plurality  of  the  fungi  causing  this 
malady  was  established,  was,  as  this  distinguished  investigator  sub- 
sequently ascertained  and  generously  pointed  out,  practically  an  elab- 


RINGWORM  IIO5 

oration  of  what  Gruby  had  indicated  fifty  years  previously,  and  the 
significance  and  brilliancy  of  whose  discovery  during  all  this  interim 
had  remained  not  only  unappreciated,  but  unrecognized.1  The  term 
"porrigo  decalvans"  which  he  applied  to  the  scalp  disease  caused  by 
the  small-spored  fungus — the  microsporon  Audouini — previously  em- 
ployed by  Bateman  to  designate  the  malady  now  known  as  alopecia 
areata,  led  to  the  erroneous  belief  that  Gruby  had  this  latter  affection 
in  view,  and  hence  his  supposed  fungus,  always  looked  for  in  vain  by 
others  in  alopecia  areata,  was  soon  considered  purely  mythic.  Sa- 
bouraud's  brilliant  investigations,  however,  have  placed  Gruby's  work 
in  an  entirely  different  light.  One  of  Gruby's  fungi  was  independently 
discovered  by  Malmsten  in  1844,  and  denominated  by  him  trichophyton 
tonsurans.  The  common  belief  was  that  this  fungus  was  one  of  the  com- 
mon molds,  but  Thin  and,  since,  others  have  shown  that  it  is  a  specific 
fungus.  The  trichophyton  was  gradually  accepted  by  most  dermatolo- 
gists as  the  etiologic  factor  in  all  ringworm  cases,  and  this  view  continued 
to  be  held  until  the  result  of  Sabouraud's  studies  was  announced.  Sa- 
bouraud,  who  has  done  so  much  in  the  investigations  of  the  fungi,  based 
his  earlier  classification  upon  the  size  of  the  fungus  elements,  their  rela- 
tions to  the  hair-shaft  and  root,  and  their  resistance  to  potassium  hydrate 
solution.  His  classification  then  consisted  of  two  main  divisions:  (i) 
the  small-spore  fungus,  or  microsporon;  (2)  the  large-spore  fungus,  or 
megalosporon,  or  trichophyton.  He  further  divided  the  trichophyton 
or  megalosporon  class  into  two  varieties:  (i)  megalosporon  endothrix, 
or  trichophyton  endothrix,  commonly  referred  to  as  "endothrix,"  in 
which  the  fungus  is  found  inside  of  the  hair-shaft;  (2)  megalosporon  ecto- 
thrix,  or  trichophyton  ectothrix,  commonly  referred  to  as  "ectothrix," 
in  which  the  fungus  is  found  outside  and  chiefly  on  the  surface  of  the 
hair-shaft;  as  not  infrequently  in  this  latter  variety  the  fungus  is  found 
also  in  the  hair,  especially  in  the  cortical  portion,  it  is  more  recently 
spoken  of  as  "endo-ectothrix."  The  megalosporon  endothrix,  or  tricho- 
phyton endothrix,  was  further  divided  into  two  subspecies:  (a)  resistant 
variety  and  (6)  fragile  variety;  the  former  practically  unaffected  by 
potassium  hydrate  solution,  and  the  latter  more  or  less  disintegrated  by 
it.  The  megalosporon  ectothrix,  or  trichophyton  ectothrix,  had  several 
or  more  subvarieties.  In  the  endothrix  variety  the  stage  of  invasion 
of  the  hair  by  the  fungus  is  short,  so  short  that  it  may  be  easily 
missed,  but  there  are  certain  exceptions,  as  sometimes  this  invasion 
stage  is  noted  to  be  prolonged,  so  that  at  first  this  fungus  may  be  mis- 
taken for  an  endo-ectothrix.  Sabouraud,  therefore,  divided  the  endo- 
thrix into  two  subvarieties,  the  true  endothrix  and  the  neo-endothrix, 
the  latter  comprising  those  with  the  long  invasion  stage.  For  all  practical 
purposes  the  classification  distinctions  as  just  outlined  seem  sufficient 
for  text-book  and  teaching. 

Later   investigations    by    Sabouraud   disclosed   the   fact   that   the 

1  Bazin,  Recherches  sur  la  nature  et  le  traitement  des  teignes,  Paris,  1853,  confirmed 
Gruby's  observations;  and  in  1891  Furthmann  and  Neebe,  "Vier  Trichophytonarten," 
Monalshefte,  1891,  vol.  xiii,  p.  477,  advocated  the  plurality  of  the  causative  fungi,  and 
described  four  varieties. 

70 


II06  PARASITIC  AFFECTIONS 

etiologic  fungi  were  in  reality  in  much  larger  number  than  had  been 
originally  supposed,  and  that  it  was  not  possible  to  identify  them  all  by 
the  differences  referred  to;  moreover,  he  found  that  some  of  the  tricho- 
phyton  ectothrix  had  small  round  spores  that  might  be  mistaken  for  the 
microsporon  variety.  These  reasons  led  to  the  necessity  of  establishing 
other  more  certain  means  of  individual  identification;  and  the  most 
convenient  for  the  purpose  was  the  culture,  designating  each  variety  of 
the  fungi  by  the  most  striking  character  or  feature  of  its  growth  in  culture- 
flasks;  the  division  into  the  two  main  classes  remaining,  however,  the 
same.  According  to  these  later  studies  by  Sabouraud,  more  than  forty 
varieties  of  these  two  classes  of  fungi  have  been  found  associated  with 
ringworm,  eleven  of  the  microsporon,  and  over  thirty  of  the  trichophy- 
ton;  of  these,  twenty-eight  are  rarely  seen,  and  of  those  remaining, 
there  are  only  about  eleven  which  occur  with  sufficient  frequency  to 
be  mentioned  here;  most  of  the  cases,  in  fact,  being  found  due  to 
five  or  six  varieties— two  of  the  microsporons  and  about  four  of  the 
trichophytons.1 

The  Microsporons. — Ringworm  when  due  to  the  microsporons 
is  sometimes  designated  microsporosis.  The  microsporon  Audouini, 
of  human  origin,  is  chief  of  the  microsporon  or  small- spore  group,  and 
is  the  important  etiologic  fungus  in  children;  most  institutional  scalp 
epidemics  of  ringworm  are  due  to  this  fungus;  on  the  other  hand,  the 
family  epidemic  is  probably  more  commonly  due  to  the  microsporons  of 
animal  origin.  The  microsporon  Audouini  is  well-known  in  England, 
in  our  own  country,  and  in  France,  becoming  less  so  hi  France  as  the 
neighboring  borders  of  Italy,  Spain,  and  Germany  are  approached; 
scarcely  being  found  at  all  in  these  latter  countries,  nor  in  Sweden, 
Denmark  and  Austria,  and  elsewhere.  The  other  three  somewhat 
important  ones  of  this  group  are  the  microsporon  fdineum  and  its  closely 
related  species,  microsporon  lanosum  (microsporon  canis  of  Bodin),  both 
of  animal  origin,  and  the  microsporon  tardum,  of  human  origin;  these 
three  are  found  to  be  etiologic  in  a  small  proportion  of  cases  in  England 
and  France.  In  our  own  and  other  countries,  so  far  as  I  am  aware,  no 
investigations  bearing  upon  any  of  the  microsporons  except  the  micro- 
sporon Audouini  are  on  record.  The  microsporons,  especially  the  micro- 
sporon lanosum,  according  to  Darier,  are  occasionally  responsible  for  tinea 
circinata.  The  scalp  patches  due  to  the  microsporon  Audouini  (and  it  is 
almost  wholly  a  scalp  parasite)  are  usually  of  the  sluggish,  well-defined, 
round  or  oval,  scarcely  visibly  inflammatory  type,  with  fine  scales  of 
a  gray  slate  or  ashen  color,  and  with  many  short  hair-stumps.  The  mi- 
crosporons of  animal  origin  present  similar  sluggish  lesions  on  the  scalp 
in  children,  sometimes  with  slightly  perceptible  inflammatory  signs, 
and  the  patches  may  extend  on  to  the  adjacent  non-hairy  surface;  they 
usually  show  an  erythematous  areola.  In  children  and  adults  they  are 
the  cause  of  some  cases  of  tinea  circinata  and  occasional  cases  of  tinea  of 

1  See  Sabouraud's  classic  work,  Les  Teignes,  the  most  complete  and  exhaustive 
yet  published  on  the  subjects  of  ringworm  and  favus,  and  rich  in  illustrations.  Jack- 
son and  McMurtry's  book  on  Diseases  of  the  Hair,  1912,  presents  Sabouraud's  views 
on  the  subject  somewhat  at  length. 


RINGWORM  HO/ 

the  bearded  parts,  although  in  this  last  region  it  is  now  generally  thought 
that  the  microid  variety  of  trichophyton  ectothrix  may  have  been  mis- 
taken for  the  microsporon. 

The  Trichophytons. — Ringworm  when  due  to  these  fungi  is  some- 
times designated  trichophytosis.  The  most  important  endothrix  tricho- 
phytons,  designated  according  to  Sabouraud's  new  naming  by  a  culture 
characteristic,  are:  the  trichophyton  crateriforme  (endothrix,  resistant), 
trichophyton  acuminatum  (endothrix,  fragile),  trichophyton  molaceum 
(endothrix,  resistant),  and  the  trichophyton  cerebriforme  (endothrix  (neo- 
endothrix),  resistant).  These  endothrix  trichophytons  are  believed  to 
be  of  human  origin;  they  seldom  provoke  active  inflammatory  symptoms; 
they,  especially  the  first  three  named,  are  responsible  for  almost  all  the 
cases  of  trichophytosis  of  the  scalp,  the  lesions,  as  a  rule,  being  small; 
they  are  usually  the  etiologic  fungi  in  the  disseminated  and  black-dot 
varieties;  to  this  group  also,  especially  the  last  three,  are  due  some  cases 
of  ringworm  of  the  glabrous  skin  and  of  the  beard,  and  to  the  trichophy- 
ton acuminatum  and  trichophyton  violaceum,  almost  all  nail  cases.  Beard 
cases  are,  however,  doubtless  due  most  frequently  to  the  trichophyton 
cerebriforme,  this  variety  also  attacking  the  glabrous  skin  and  scalp; 
on  the  glabrous  skin  it  frequently  gives  rise  to  erythematous  patches, 
sometimes  beset  with  vesicopustular  lesions,  and  often  impetiginous 
crusts;  on  the  bearded  regions  it  may  present  similar  conditions,  with 
small  follicular  abscesses  also;  on  the  scalp  patches  due  to  this  fungus 
are  usually  rounded,  faintly  erythematous,  also  slightly  elevated,  cov- 
ered with  yellowish-gray  scales,  beneath  which  broken,  bent,  and  twisted 
hairs  and  sometimes  stumps  are  seen.  In  many  cases  of  trichophyton 
ringworm  of  the  scalp  the  hairs  of  the  patch  are  not  affected  so  generally 
as  in  microsporon  cases,  so  that  in  children  with  long  hair  the  disease 
is  often  overlooked  or  mistaken  for  a  seborrheic  condition.  The  ecto- 
thrix (endo-ectothrix)  trichophytons  are  divided  into  two  classes,  those 
with  small  spores  and  those  with  large  spores — the  microid  class  and  the 
megaspore  class.  The  ectothrix  trichophytons  are  believed  to  be,  either 
directly  or  indirectly,  of  animal  origin.  They  almost  always  provoke 
considerable  inflammatory  reaction,  and  are  usually  responsible  for  many 
cases  of  kerion  and  for  kerion-like  lesions  on  the  scalp  and  bearded 
regions;  the  neighboring  cervical  lymphatic  glands  may  become  swollen. 
Of  the  microid  trichophytons  the  trichophyton  asteroides  is  the  most  im- 
portant, the  lesions  from  which,  usually  first  erythematous,  develop  into 
follicular,  pustular,  and  kerion  formations.  Of  the  megaspore  ectothrix 
trichophytons  those  most  frequently  encountered,  although  rather  rare, 
are  the  trichophyton  rosaceum  and  the  trichophyton  ochraceum.  The 
former  is  usually  responsible  on  the  glabrous  skin  for  the  segmental 
and  incomplete  circled  reddish  lesions ;  on  the  bearded  regions  the  lesions 
due  to  this  fungus  are  generally  small  and  somewhat  disseminated,  the 
hair  is  apt  to  be  broken  off  short  and  each  hair  or  hair- stump  surrounded 
at  and  slightly  within  the  follicular  mouth  by  a  minute  keratotic  dry 
scaly  cone,  presenting  a  rough  resemblance  to  keratosis  pilaris.  The 
other  of  this  group,  the  trichophyton  ochraceum,  may  provoke  on  the 
glabrous  skin  or  bearded  parts  erythematous  scaly  circles  or  round 


H08  PARASITIC  AFFECTIONS 

patches,  which  may  become  vesicular,  pustular,  nodular,  or  kerion-like; 
it  is  met  with  most  frequently  in  those  who  have  to  do  with  cattle. 

It  has  been  found  (Castellani,  Fernet,  Sabouraud,  Whitfield)  that 
the  fungus,  epidermophyton  inguinale,1  of  eczema  marginatum  (tinea 
cruris)  is  in  many  ways  distinct  from  the  ordinary  ringworm  fungi.  It 
had  always  been  supposed  to  be  one  of  the  usual  ringworm  trichophytons, 
but  unlike  any  other  species  of  this  class — in  which,  however,  Sabouraud 
places  it — it  never  attacks  the  hair.  It  is  also  the  pathogenic  fungus  in 
some  cases  of  eczematoid  and  vesicular  and  vesicobullous  eruptions  on 
the  hands  and  feet;  this  fungus  is  thought  to  be  of  human  origin.  Other 
investigators,  among  whom  are  Jamieson,  Adamson,  Colcott  Fox  and 
Blaxall,  Unrai,  C.  J.  White,  Malcolm  Morris,  Castellani,  Whitefield,  and 
others,  have  all  added  to  our  knowledge  of  these  pathogenic  fungi, 
and  practically  accept  Sabouraud's  conclusions.  Rosenbach,  Krosing, 
Ullman,  Waelsch,  Leslie  Roberts,  Pelegatti,  Ducrey  and  Reale,  and  others, 
whose  studies  and  observations  have  also  contributed  to  our  knowledge, 
did  not  wholly  agree  with  Sabouraud's  original  divisions  of  the  fungi,  or 
with  his  views  that  each  fungus  tends  to  produce  always  a  special  clinical 
type  of  disease,  but  one  can,  I  think,  say  that  to-day  Sabouraud's  bril- 
liant work  and  conclusions  rightly  hold  sway.2 

The  features,  character,  and  behavior  of  ringworm  vary  consider- 

1  Castellani,  Brit.  Jour.  Derm.,  1910,  p.  149,  believes  that  so  far  three  varieties  of  the 
epidermophyton  have  been  identified:  (i)  Epidermophyton  cruris  (Castellani,  1905), 
synonymous  with  epidermophyton  inguinale  (Sabouraud,  1907),  trichophyton  cruris 
(Castellani,  1905),  and  trichophyton  Castellani  (Brooke,  1908);  (2)  epidermophyton 
Perneti  (Castellani,  1907);  (3)  epidermophyton  rubrum  (Castellani,  1910),  synony- 
mous with  trichophyton  rubrum  (Castellani),  and  epidermophyton  purpureum  (Bang, 
1910). 

2  The  reader  desiring  to  pursue  further  the  investigations  and  mycology  of  the  ring- 
worm fungi  is  referred  to  the  following  valuable  publications  and  papers:  Sabouraud, 
"Contribution  a  1'etude  de  la  trichophytie  humaine,"  Annales,  1892,  p.  1061;  and  his 
later  and  more  complete  publication,  Les  tricho  phyties  humaines,  Paris,  1894;  Rosen- 
bach,  "Ueber  die  tieferen  eiternden  Schimmel-erkrankungen  der  Haut  und  deren 
Ursache,"  Wiesbaden,  1894;  Leslie  Roberts,  "The  Present  Position  of  the  Question  of 
the  Vegetable  Hair  Parasites,"  Brit.  Med.  Jour.,  1894,  ii,  p.  685;  and  "The  Physiology 
of  the  Tricophytons,"  Jour.  Pathol.  and  Bacterial.,  1895-96,  vol.  iii,  p.  300;  Adamson, 
"Observations  on  the  Parasites  of  Ringworm,"  Brit.  Jour.  Derm.,  1895,  pp.  201  and  237; 
Colcott  Fox  and  Blaxall,  "An  Inquiry  into  the  Plurality  of  Fungi  Causing  Ringworm  in 
Human  Beings  as  Met  with  in  London,"  ibid.,  1896,  pp.  242,  291,  337,  and  377;  and 
"Some  Remarks  on  Ringworm,"  Brit.  Med.  Jour.,  1899,  ii,  p.  1529;  Bodin,  "Des  teignes 
tondantes  du  cheval  et  leur  inoculations  humaines,"  These  de  Paris,  1896;  Aldersmith, 
Ringworm  and  Alopecia  Areata,  fourth  ed.,  London,  1897;  Malcolm  Morris,  Ring- 
worm in  the  Light  of  Recent  Research,  London,  1898;  Chas.  J.  White,  "Ringworm  as 
it  Exists  in  Boston,"  Jour.  Cutan.  Dis.,  1899,  p.  i;  Bodin  and  Almy,  "Le  microsporum 
du  chien,"  Receuil  de  med.  •veterinaire,  1897,  p.  161;  Suis  and  Suffran,  "Note  prelimi- 
naire  sur  le  microsporum  lanosum  du  chien,"  Annales,  1908,  p.  151;  Sabouraud,  "Iden- 
tification du  microsporum  lanosum  (Sabouraud.  1907)  au  microsporum  caninum  (Bodin 
and  Almy,  1897"),  Annales,  1908,  p.  153;  Sabouraud,  "Nouvelles  recherches  sur  les 
microsporums,"  Annales,  1907,  pp.  163,  225,  236,  and  369  (with  review,  references,  nu- 
merous text  cuts,  and  2  plates — cultures);  Sabouraud,  Suis,  and  Suffran,  "Frequence du 
microsporum  caninum  ou  lanosum  chez  le  chien  et  chez  rhomme,"  Annales,  1908,  p.  32*1 
(3  case  illustrations  (dogs) ,  1 5  case  recitals  (dogs) ,  and  cultures  with  review  of  the  sub- 
ject and  references);  and  Sabouraud,  "Les  trichophytons  faviformes,"  ibid.,  1908,  p.  609 
(with  plate  showing  cultures,  several  illustrations,  and  pertinent  references);  Colcott 
Fox,  "A  Further  Contribution  to  the  Study  of  the  Endothrix  Trichophyta  Flora  in 
London,  Illustrated  by  a  Collection  of  Cultures  and  Photographs,"  Brit.  Jour.  Derm., 
1909,  p.  271;  Favera,  "Sur  1'etat  des  trichophyties  de  la  Province  de  Parme  (Italic)," 
Annales,  1909,  p.  433  (with  review  and  references);  and  Sabouraud's  Les  Teignes. 


RING  WORM 


IIO9 


ably  according  to  the  part  involved,  whether  it  be  the  general,  non- 
hairy  surface,  the  genitocrural  region,  the  scalp,  or  the  bearded  region. 
In  a  measure  the  anatomic  conditions  and  physical  peculiarities  of  these 
various  regions  are  responsible  for  the  difference  in  the  clinical  pictures, 
although  in  the  light  of  recent  research  it  is  not  unlikely  that  they  are 
also  to  some  extent  to  be  attributed  to  the  special  fungus  which  may  be 
etiologically  involved.  The  symptoms  and  diagnostic  characters  can 
best  be  described  under  the  several  regional  headings. 

I.  RINGWORM  OF  THE  GENERAL  SURFACE 

Synonyms. — Tinea  circinata;  Tinea  trichophytina  corporis;  Trichophytosis  corporis; 
Ringworm  of  the  body;  Ringworm  of  the  non-hairy  surface;  Ringworm  of  the  glabrous 
skin;  Fr.,  Herpes  circine;  Herpes  circine  parasitaire;  Herpes  parasitaire;  Tricophytie 
circinee;  Trichophytie  des  parties  glabres;  Ger.,  Herpes  tonsurans;  Herpes  tonsurans 
circumscriptus;  Scherende  Flechte;  Tricophytie  der  unbehaarten  Hautstellen. 

Symptoms. — Ringworm  of  the  general  or  non-hairy  surface,  or 
tinea  circinata,  as  it  is  quite  commonly  called,  may  exhibit,  as  more 
especially  regards  its  inflammatory  characters,  some  variations.  In 


Fig.  275. — Ringworm  (tinea  circinata)  (courtesy  of  Dr.  M.  B.  Hartzell). 

its  typical  and  most  common  expression  the  malady  presents  as  one, 
several,  or  more  small,  slightly  elevated,  sharply  limited,  somewhat 
scaly,  hyperemic  spots.  They  spread  in  a  uniform  manner  peripher- 
ally, and  as  they  extend  tend  to  clear  up  more  or  less  completely  in 
the  central  portion,  assuming  a  ring-like  aspect.  Usually,  when  coming 
under  observation,  on  the  average  several  days  to  one  or  two  weeks  after 
their  first  appearance,  the  patch  or  patches  are  from  \  to  i  inch  in  di- 


1 1  10 


PARASITIC  AFFECTIONS 


ameter,  the  innermost  or  central  part  pale  red,  or  of  apparently  normal 
color,  with  or  without  a  trifling,  often  scarcely  perceptible,  furfuraceous 
scaliness;  and  the  outer  portion  somewhat  elevated,  but  rarely  to  a 
conspicuous  degree,  hyperemic  or  mildly  inflammatory,  and  somewhat 
scaly.  The  hyperemia,  inflammatory  character,  and  scaliness  are  sharply 
contoured  externally,  while  gradually  diminishing  on  the  inner  side. 
The  scaliness  is  seldom  more  than  moderate  in  amount;  usually  it  is  slight. 
After  reaching  a  variable  size,  from  a  part  of  an  inch  to  several  inches  in 
diameter,  they  remain  practically  stationary,  or  in  most  instances  after 
a  time  tend  to  spontaneous  disappearance.  After  the  first  several  days 
or  a  week,  more  especially  when  the  spreading  tendency  has  about  ceased, 
the  color  often  becomes  paler,  and  even  goes  into  a  pale,  brownish  red. 
At  times,  when  close  together,  several  may  merge  and  form  a  large,  irreg- 
ular, gyrate  patch.  As  commonly  noted  there  are  rarely  more  than 


Fig.  276. — Ringworm,  showing  the  rather  uncommon  occurrence  of  a  double  ring. 
Illustration  also  shows  a  marked  example  of  freckles. 

several  patches  present;  in  some  instances  only  one,  in  others  five  to  ten 
or  more.1  In  some  cases  the  patches  remain  small  and  insignificant, 
and  with  but  little,  sometimes  no,  tendency  to  clearing;  in  such  they 
appear  to  be  more  of  the  nature  of  rounded,  brownish-red  or  brownish- 
yellow,  scurfy  spots,  with  practically  no  distinct  inflammatory  signs, 
and  lacking  the  sharply  defined  border.  In  others  the  areas  consist  of 
ill-defined  rings,  some  segments,  and  some  scurfy  spots.  Very  excep- 
tionally a  patch  may  consist  of  two  or  three  concentric  rings. 

The  most  frequent  sites  for  ringworm  are  the  face,  neck,  hands,  and 
forearms,  although  they  are  quite  frequently  seen  elsewhere.  In  rare 
instances  the  palm  is  the  seat  of  one  or  two  patches,  usually  quite  inflam- 

1  Colcott  Fox  and  Blaxall,  Brit.  Jour.  Derm.,  1898,  p.  37,  report  two  instances  in 
brothers,  aged  five  and  seven,  in  whom,  especially  in  one  (illustration  given),  the  patches 
were  quite  numerous  and  of  somewhat  general  distribution,  but  none  on  the  scalp;  in- 
fection probably  from  a  "mangy"  cat. 


RING  WORM  1 1 1 1 

matory,  the  ring-like  border  being  of  a  vesicopapular  or  papulosquamous 
character.  The  sole  of  the  foot  is  also  a  rare  site,  and  here  it  may  appear 
as  just  described,  or  of  its  ordinary  clinical  features;  or  it  may  simulate 
flattened,  callous-like  areas;  two  such  cases  have  come  under  my  observa- 
tion. In  rare  instances  a  patch  in  the  neighborhood  of  the  lips  or  vulva 
has  been  noted  to  extend  on  to  the  mucous  membrane  (tinea  of  the  mu- 
cous membrane).1  In  very  exceptional  examples  of  the  mildly  inflam- 
matory and  slightly  or  moderately  scaly  type  the  patches  are  somewhat 
generalized  and  quite  numerous,  sometimes  with  much  less  tendency  to 
central  clearing  than  commonly  seen,  and  exemplifying  the  cases  ob- 
served in  Vienna  and  described  under  the  name  of  herpes  tonsurans 
maculosus,2  although  most  of  such  cases  are,  it  is  believed,  examples  of 
pityriasis  rosea. 

Instead  of  the  malady  appearing  as  slightly  inflammatory  maculo- 
squamous  rings,  sometimes  the  process  is  of  a  severer  grade;  the  pe- 
ripheral portion  is  observed  to  be  markedly  elevated,  red,  showing  a  good 
deal  of  inflammatory  action,  and  not  infrequently  constituted  of  closely 
set  papules,  vesicopapules,  or  exceptionally  vesicles,  which  may  even 
become  pustular.  It  spreads  in  the  same  manner  and  in  other  .ways  is 
similar,  the  central  portion  clearing  up;  it  differs  from  the  common 
milder  type  chiefly  in  the  degree  of  inflammation.  In  some  of  these  cases 
as  the  patch  spreads  the  center  clears  somewhat,  but  becomes  studded 
with  papulopustules  or  pustules.  In  other,  rarer,  instances  the  condition, 
usually  consisting  of  one  or  several  patches,  is  over  the  entire  area  fairly 
uniform  in  the  character  of  the  inflammatory  process,  with  but  little, 
sometimes  scarcely  perceptible,  lessened  activity  centrally;  the  extreme 
border  is,  however,  rather  more  elevated.  Such  patches,  with  practically 
no  disposition  to  clear  centrally,  have  a  decidedly  eczematous  aspect, 
often  with  considerable  infiltration,  differing  from  the  latter  disease  only 
in  the  sharply  defined  character  of  the  border. 

In  other  rather  rare  cases  (Ojelaleddin-Moukhtar,  Whitfield,  Sa- 
bouraud)3  the  malady  may  show  itself  on  the  hands  and  fingers  and  also 

1  Robinson  (case  demonstration)  and  also  Cutler  (discussion),  Jour.  Cutan.  Dis., 
1893,  p.  366,  record  such  instances,  extending  to  the  lip  and  mucous  membrane  of  the 
mouth;  Giletti  (cited  by  Malcolm  Morris,  loc.  cit.,  p.  78)  has  reported  a  case  of  pri- 
mary ringworm  of  the  mucous  membrane  of  this  region. 

2  I  recall  clearly  an  instance  of  extensive  distribution  involving  the  trunk  chiefly,  in 
Professor  Neumann's  clinic,  when  a  student  of  this  distinguished  teacher,  in  which  the 
diagnosis  was  confirmed  by  the  microscope.     Jarisch  (Die  Hautkrankheiten,  Vienna, 
1900,  p.  580)  is  right,  I  believe,  in  his  opinion  that  there  are  two  maladies  which  clinic- 
ally are  often  indistinguishable — the  one,  pityriasis  rosea,  the  other,  a  type  of  exten- 
sively distributed  ringworm,  the  latter  being  rare. 

3  We  owe  our  knowledge  of  these  vesicobullous  and  eczematoid  types  of  the  hand, 
foot,  and  toe  regions  especially  to  Whitfield,  Lancet,  July  25,  1908;  and  Brit.  Jour. 
Derm.,  1911,  p.  36,  and  to  Sabouraud,  Annales,  1910,  p.  289,  and  Archiv,  1912,  cxiii, 
p.   923,   although   in   a   contribution    curiously   overlooked,   Ojelaleddin-Moukhtar, 
Annales,  1892,  p.  885,  had  several  years  previously  directed  attention  to  it.     The 
etiologic  fungus  is  (with  possibly  some  exceptions)  the  epidermophyton  inguinale;  the 
same  fungus  has  been  found  recently  to  be  the  usual  etiologic  one  in  tinea  cruris — 
entirely  distinct  from  the  ordinary  ringworm  fungi.     The  several  conditions  are  fur- 
ther presented  by  Whitfield  and  Sabouraud,  and  fully  discussed  by  Pringle,  Fernet, 
Colcott  Fox,  Adamson,  Bunch,  Dore,  Sequeira,  Graham  Little,  Bolam,  Gray,  and 
Malcolm  Morris,  in  Brit.  Jour.  Derm.,  1911,  pp.  375-402.     See  also  paper  by  Bang, 
Annales,  1910,  p.  229  (epidermophyton  purpureum). 


1 1 1 2  PARASITIC  AFFECTIONS 

about  the  feet,  especially  the  toes  and  interdigital  spaces,  as  a  chronic 
scaly  condition  generally  diagnosed  as  "gouty  eczema";  or  as  an  acute 
vesicular  or  vesicobullous  dermatitis  scarcely  distinguishable  in  different 
cases  from  a  moderate  dermatitis  venenata,  an  acute  eczema,  or  from 
pompholyx.  In  some  instances,  especially  about  the  fingers,  it  may  pre- 
sent as  ill-defined,  somewhat  scanty,  scattered  small  vesicles,  suggestive 
of  a  mild  eczema  or  extremely  mild  pompholyx.  The  vesicular  and  vesico- 
bullous types  are  rather  rare  about  the  feet  and  toes;  in  the  latter  region 
it  shows  itself  most  frequently  about  the  interspaces  and  on  contiguous 
parts,  and,  as  a  rule,  as  an  eczematoid  eruption,  similar  to  and  doubtless 
often  looked  upon  as  a  veritable  eczema  of  these  parts.  Occasionally  it 
is  more  or  less  strictly  limited  to  one  or  two  interdigital  spaces  of  the 
fingers  or  toes,  simulating  an  inflamed  or  overtreated  moist  intertrigo. 
Exceptionally  in  the  sole  it  presents  itself  in  calloused  or  thickened 
epidermic  patches  or  areas.  In  some  instances  there  will  be  found 
an  associated  tinea  cruris  or  tinea  axillaris,  the  same  fungus  (epider- 
mophyton  inguinale)  being  etiologic. 

Another  form  only  rarely  noted  is  that  presenting  itself  as  a 
somewhat  raised,  inflammatory  patch,  beset  with  crowded  follicular 
papules  or  papulopustules,  sometimes  pustules,  and  sometimes  small 
nodular  growths.  Usually  but  one  or  two  areas  are  present,  of  \  to 
2  inches  in  diameter,  and  fairly  rounded,  or  irregularly  rounded  or 
ovalish  in  shape,  and  showing  variable,  but  generally  considerable, 
infiltration  and  depth.  It  occurs  most  commonly  on  the  forearm, 
back  of  the  hand,  and  the  buttocks,  although  it  may  occur  on  any 
part.  The  hairs  of  the  area  drop  out,  as  a  rule,  but  regrowth,  after  cure, 
takes  place.  In  other  exceptional  instances  a  similar  but  still  more 
advanced  inflammatory,  deep-seated  form  is  observed,  of  a  somewhat 
boggy,  pseudocarbuncular  aspect,  with  sometimes  considerable  elevation, 
and  a  follicular,  seropurulent,  or  mucopurulent  discharge;  this  is  a  rela- 
tively moderate  counterpart  of  kerion  of  the  scalp,  and  also  of  some  of 
the  boggy  tumors  of  ringworm  of  the  bearded  region.  This  condition 
(so-called  perifolliculitis  suppurative  conglomerate)  was  formerly  thought 
to  be  an  independent  affection  (first  described  by  Leloir,  Quinquaud 
and  Pallier,  and  Besnier  and  Doyon),1  but  is  now  known  to  belong  among 
the  manifestations  produced  by  the  trichophyton.  Very  rarely  the  deep 
type  extends  considerably,  the  central  portion  then  flattening  down, 
becoming  less  active  while  extension  is  taking  place  at  the  periphery, 
where  there  is  a  border  of  deep-seated  inflammatory  infiltration,  with 
follicular  papulopustules  or  pustules,  so  that  finally  a  large,  rounded, 
or  irregularly  outlined  patch  may  result  (agminate  folliculitis)  ?  Some 
tumor-like  lesions  of  a  granulomatous  character  and  aspect  (granuloma 

1  Leloir,  "Sur  une  variete  nouvelle  de  perifolliculites  suppurees  et  conglomerees  en 
placards,"  Annales,  1884,  p.  437;  Quinquaud  et  Pallier,  "Des  perifolliculites  suppurees 
agminees  en  plaques,"  These  de  Paris,  1888;  Besnier  et  Doyon's  French  translation  of 
Kaposi's  Treatise,  vol.  i,  p.  795. 

2  See  Hartzell's  paper,  "A  Unique  Case  of  Agminate  Folliculitis  of  Parasitic  Origin," 
Jour.  Cutan.  Dis.,  1895,  p.  456  (with  case  illustration  and  histologic  cuts  showing  the 
fungus);  Duhring  and  Hartzell,  "A  Case  of  Papulo-ulcerative  Follicular  Hyphomycetic 
Disease  of  the  Skin,"  Amer.  Jour.  Med.  Sci.,  1895,  vol.  cix,  p.  283. 


RINGWORM  III3 

trichophyticum) ,  first  described  by  Majocchi,  are  exceptionally  met  with, 
sometimes  showing  ulcerative  action.1 

One  more  form  remains  to  be  described  affecting  the  genitocrural 
^region,  and  known  as  tinea  cruris,  eczema  marginatum,  tinea  trichophy- 
tina  cruris,  tinea  circinata  cruris,  epidennophytie  inguinale,  dhobie  itch, 
which  is  more  common  than  the  rare  varieties  just  described.  It  may 
begin  here,  as  the  ordinary  superficial  ring  type,  usually  several  or  more 
areas  soon  presenting,  or  quite  frequently  as  an  intertrigo  or  a  super- 
ficial intertriginous  eczematoid  eruption.  It  may  remain  somewhat 
limited  and  of  a  mild  to  moderate  inflammatory  grade;  or,  favored  by  the 
heat  and  moisture  of  the  parts,  the  malady  develops  and  may  spread 
rapidly,  the  involved  areas  become  more  or  less  uniformly  inflammatory 
and  coalesce.  The  inflammatory  symptoms  become  predominant,  and 
the  whole  of  the  genitocrural  region  may  be  involved,  even,  in  extreme 
cases,  extending  some  distance  down  the  thighs,  upward  on  the  pubic 


Fig.  277. — Ringworm  (tinea  circinata)  of  inflammatory,  kerion-like  type,  consisting 
of  three  patches  on  forearm;  patient  a  hostler.  (The  conglomerate  pustular  folliculitis 
of  Leloir.) 

region,  and  backward  to  the  anus  and  immediate  neighborhood ;  in  women 
it  may  also  extend  on  to  the  mucous  membrane  of  the  vulva.  It  then 
presents  all  the  symptoms  of  a  moderately  or  markedly  infiltrated  true 
eczema;  the  border,  however,  is  somewhat  elevated,  sharply  defined, 
and  not  infrequently,  especially  in  its  earlier  existence,  one  or  more 
outlying  ordinary  clinical  ring-like  or  rounded  patches  of  the  malady 
may  be  seen.  Occasionally  this  type  is  also  observed  in  one  or  both 
axillae  (tinea  axillaris,  tinea  circinata  axillaris) ,  either  along  with  the  dis- 
ease in  the  genitocrural  region  or  independently.  It  is  not  uncommon 

1  Schamberg,  "A  Case  of  Hyphomycetic  Granuloma,"  Jour.  Cutan.  Dis.,  1902,  p. 
410,  with  case  and  histologic  cuts,  review  and  references;  Sequeira,  "A  Case  of  Tricho- 
phytic  Granulomata,"  Brit.  Jour.  Derm.,  1912,  p.  207,  previously  briefly  reported,  ibid., 
1906,  p.  269  (a  remarkable  case  of  extensive  ringworm,  especially  of  the  trunk,  of  years' 
duration,  with  the  development  of  trichophytic  granulomata  leaving  scars,  and  a  per- 
sistent ulcerative  condition  of  the  umbilicus;  with  brief  review  of  subject  (of  reports 
by  Majocchi,  Bang,  Campana,  Pini,  Mazza,  and  Vignolo-Lutati)  with  references). 
Sequeira's  paper  and  Vignolo-Lutati's  paper,  "Ueber  Granuloma  Trichophyticum  Ma- 
jocchi," Monatshefte,  1908,  Ixvii,  p.  184,  together  give  a  pretty  complete  bibliography. 


1 1 14 


PARASITIC  AFFECTIONS 


among  those  who  frequent  gymnasiums  and  those  engaged  in  athletic 
sports;  moderate  epidemics  occasionally  occur  among  this  class.  Tinea 
cruris  (the  eczema  marginatum  of  Hebra)  had  been  always  thought 
due  to  the  ordinary  trichophyton  fungus,  but  recent  investigations  show 
the  causative  fungus  to  be  epidermophyton  inguinale.1 

Dhobie  itch  is  a  name  given  to  this  affection  (tinea  cruris)  in  certain 
tropical  countries,  where  it  usually  involves  both  the  genitocrural  and  axil- 
lary regions ;  its  symptomatology  is  about  the  same,  except  the  process  is, 
as  a  rule,  much  more  intense  in  its  inflammatory  aspects.  In  the  hot 
and  moist  seasons  the  inflammation  from  the  active  proliferation  of  the 
organism  and  the  sweating,  heat,  and  friction  of  the  parts  is  often  so  severe 
that  the  patient  may  be  unable  to  go  about,  or  even  to  dress.  The  itch- 
ing often  leads  to  violent  scratching,  and  the  parts  may  become  raw; 
and,  as  a  result  of  secondary  bacterial  infection,  boils  and  abscesses  may 


Fig.  278. — Tinea  cruris.     Ringworm  of  the  genitocrural  region. 

be  added  to  the  ordinary  features.  On  the  approach  of  the  cool  season 
the  malady  partially  and  sometimes  completely  subsides.  While  it  is 
usually  due  to  the  same  organism  (Epidermophyton  inguinale)  as  ob- 
served in  the  cases  of  tinea  cruris  observed  here  and  elsewhere,  already 
referred  to,  other  parasites,  such  as  the  Microsporon  furfur,  the  Micro- 
sporon  minutissimum,  and  the  organism  of  impetigo  contagiosa  (Manson) 
have  been  variously  thought  to  have  a  bearing  in  some  instances.  The 
spread  of  the  disease  is  believed  to  be  by  means  of  the  laundry,  hence 
the  name  "dhobie  (laundrymen's)  itch." 

1  Sabouraud,  "Sur  1'eczema  marginatum  de  Hebra,"  Arch,  de  med.  Experiment/lie, 
1907,  Nos.  5  and  6;  Alexander,  "Beitrage  zur  Kenntnis  der  Eczema  marginatum," 
Archiv,  May,  1912,  cxii;  Nicolau,  "Contribution  a  1'etude  du  soi-disant  eczema  margina- 
tum de  Hebra,"  Annales,  Feb.  1913,  p.  65  (cases,  review  of  subject  with  references). 
See  also  references  of  the  eczematoid  and  vesicobulbous  eruptions  due  to  this  same 
fungus. 


RINGWORM  IH5 

Ringworm  of  the  general  surface,  as  commonly  encountered,  rarely 
gives  rise  to  any  troublesome  subjective  symptoms — occasionally  slight 
or  moderate  itching;  this,  in  the  more  inflammatory  types,  those  which 
show  an  eczematous  aspect,  and  especially  when  involving  the  genito- 
crural  or  axillary  region,  may  in  some  cases  be  at  times  quite  severe  and 
troublesome. 

Diagnosis. — There  is  little  difficulty  in  recognizing  the  ordinary 
cases  of  ringworm  of  the  general  surface,  as  the  growth  and  characters 
of  the  patch,  the  slight  scaliness,  the  tendency  to  disappear  in  the  central 
portion,  together  with  the  history,  and,  if  necessary,  by  microscopic 
examination  of  the  scrapings  from  the  border  of  the  patch.  The  ring- 
like  areas  of  psoriasis  bear  some  resemblance,  but  it  is  practically  only 
in  the  ring  appearance,  the  other  features  being  wholly  different  (see 
Psoriasis  for  differential  points).  The  circinate  tubercular  syphiloderm 
has  sometimes  been  confused  with  ringworm,  but  the  greater  infiltration 
of  the  former,  its  slow  course,  long  duration,  color,  and  often  pigmenta- 
tion, atrophy,  ulceration,  or  scarring  generally  serve  in  the  differentiation. 
Dermatitis  seborrhoica,  especially  as  it  commonly  occurs  in  the  sternal 
and  interscapular  regions,  with  the  segment-like  configuration,  is  some- 
what suggestive,  but  the  scales  of  this  latter  are  greasy,  and  often  have 
projections  into  the  glandular  openings;  moreover,  these  sites  are  common 
for  dermatitis  seborrhoica,  and  extremely  unusual  for  ringworm.  In 
the  deep-seated  types  the  markedly  inflammatory,  follicular,  and  cir- 
cumscribed character  should  always  suggest  ringworm  fungus  invasion 
and  lead  to  carefully  made  microscopic  examinations.  As  Hartzell's 
case  showed,  however,  sometimes  the  fungus  lies  deeply,  and  must  be 
looked  for  in  a  section  of  the  involved  tissue.  A  circumscribed  patch 
suggestive  of  an  exceedingly  flat,  superficial,  mild  carbuncular  formation 
should  always  awaken  the  suspicion  of  deep-seated  ringworm. 

Tinea  cruris,  and  also  its  counterpart  sometimes  occurring  in  the 
axillae,  is  to  be  differentiated  from  eczema  and  dermatitis  seborrhoica  of 
these  regions.  The  history  of  the  case,  its  frequent  beginning  with  rings, 
its  gradual  spread  and  sharply  defined  elevated  border,  frequently  with 
outlying  typical  ringworm  patches,  will  usually  suffice,  but  in  some  in- 
stances careful  microscopic  examinations  of  the  scrapings  from  the  border 
are  found  necessary  for  a  definite  conclusion. 

n.  RINGWORM  OF  THE  SCALP 

Synonyms. — Tinea  tonsurans;  Tinea  tondens;  Tinea  trichophytina  capitis;  Tri- 
chophytosis  capitis;  Microsporosis  capitis;  Trichophytia  capitis;  Trichonosis  furfuracea; 
Herpes  tonsurans;  Herpes  circinatus;  Porrigo  furfurans;  Fr.,  Herpes  tonsturant; 
Teigne  tondante;  Teigne  tonsurante;  Trichophytie  circin6e;  Trichophytie  du  cuir 
chevelu;  Ger.,  Scherende  Flechte;  Herpes  tonsurans;  Herpes  tonsurans  capillitii.- 

Symptoms. — Ringworm  of  the  scalp,  or  tinea  tonsurans,  as  it  is 
quite  frequently  called,  in  the  large  number  of  cases  varies  but  slightly 
in  its  characters,  except  as  to  the  extent  of  the  involvement.  In  relatively 
few  instances,  however,  the  features,  one  or  all,  show  a  material  de- 
parture from  the  ordinary.  It  begins  usually  in  the  same  manner  as 
that  upon  the  general  surface,  as  a  hyperemic,  scaly  spot,  with  practically 


IIl6  PARASITIC  AFFECTIONS 

no  tendency  to  central  clearing.  In  infants  or  very  young  children  with 
light,  scanty  hair,  however,  it  sometimes  presents  all  the  characters 
of  that  on  the  latter  region,  showing,  moreover,  but  little  disposition, 
in  the  beginning  at  least,  to  hair  or  follicular  involvement.  Its  devel- 
opment is,  as  a  rule,  much  more  insidious.  Sooner  or  later  the  hairs  and 
hair-follicles  are  invaded  by  the  fungus,  and  in  consequence  the  hairs 
fall  out  or  become  brittle  and  break  off,  either  a  little  distance  from  the 
skin  or  just  on  a  level  with  it.  The  hyperemia  or  inflammatory  action 
is  scarcely,  and  often  not  at  all,  recognizable.  The  surface  is  a  trifle 
scaly,  rarely  conspicuously  so.  The  follicular  openings,  except  in  long- 
standing cases,  are  slightly  elevated  and  prominent,  and  the  patch  may 
have  a  puffed  or  goose-flesh  or  plucked-fowl  appearance.  In  other  in- 
stances the  surface  is  somewhat  smooth  and  irregularly  scaly,  the  scali- 
ness  being  of  a  furfuraceous  character,  and  of  a  grayish  or  dirty-gray 
color.  There  may  or  may  not  be  at  times  slight  or  moderate  itching,  but 
it  is  seldom  sufficient  to  give  rise  to  complaint. 

A  typical  fully  developed  patch  of  ringworm  of  the  scalp  in  the  ma- 
jority of  cases  is,  therefore,  noted  to  be  rounded,  grayish,  somewhat 
scaly,  and  slightly,  but  often  scarcely  perceptibly,  elevated.  The  fol- 
licles, more  especially  those  from  which  the  hairs  have  fallen,  are  some- 
what projecting,  usually  stuffed  with  grayish  epidermic  debris;  there 
is  more  or  less  alopecia,  with  here  and  there  over  the  area  broken,  gnawed- 
off-looking  hairs,  some  of  which,  of  a  whitish  or  grayish  color,  may  be 
broken  off  above  and  just  at  the  outlet  of  the  follicles.  Many  of  the 
broken  hairs  and  stumps  are  surrounded  within  the  fojlicle  mouth  and 
somewhat  above  by  a  powdery  sheath,  flattening  out  slightly  at  the  level 
of  the  surface,  constituting  the  so-called  circumpilar  collarette,  which, 
when  numerous,  give  the  patch  a  powdery  appearance.  One,  several, 
or  more  such  areas,  of  different  sizes  from  a  fraction  of  an  inch  to  a  few 
inches  in  diameter,  may  be  present — in  the  average  case  usually  two  or 
three.  They  extend,  as  a  rule,  somewhat  slowly,  those  of  the  larger 
dimensions  named  requiring  several  weeks  to  a  few  months  or  longer. 
After  attaining  a  variable  size,  they  may  remain  more  or  less  stationary, 
and  the  malady  may  thus  sluggishly  continue  indefinitely  or  new  spots 
arise  here  and  there.  When  several  patches  are  in  close  proximity,  from 
gradual  enlargement  coalescence  takes  place,  and  a  large,  irregular  area 
results.  The  scaliness  rarely  consists  of  more  than  a  slight  branniness, 
although  exceptionally  it  is  of  moderate  amount.  In  some  children, 
after  an  indefinite  duration,  sometimes  partly  as  the  result  of  treatment 
and  sometimes  spontaneously,  the  hairs  begin  to  grow  in  again,  the  disease 
in  great  measure  disappears,  and  there  are  left  small  scattered  spots, 
each  often  scarcely  involving  more  than  several  follicles,  constituting 
the  disseminated  ringworm  of  Alder  Smith.  Occasionally  the  malady 
presents  itself  primarily  in  this  form. 

In  other  instances  the  inflammatory  character  is  relatively  more 
pronounced,  especially  at  the  periphery,  the  border  consisting  of  con- 
tiguous, ill-defined  papules  or  vesicopapules,  and  in  some  cases  a  tendency 
to  pustulation;  the  main  part  of  the  patch  being  as  already  described, 
or  distinctly  hyperemic  and  inflammatory.  In  others  the  whole  patch 


RINGWORM  III7 

may  show  a  scanty  or  abundant  number  of  papulopustules,  and  in  such 
very  often,  from  time  to  time,  considerable  crusting  may  be  seen. 

The  loss  of  hair  of  the  involved  areas  is  rarely  complete,  but  in  most 
instances  there  are  no  long  hairs,  those  remaining  usually  having  broken 
off  near  the  scalp ;  they  are  lusterless,  brittle,  some  of  them  often  twisted 
up  or  bent,  and  which  break  upon  the  slightest  attempt  at  traction.  In 
others  most  or  all  of  the  hairs  are  broken  off  just  at  the  follicle  mouth, 
and  give  the  patch  a  dotted  appearance — so-called  black-dot  ringworm. 
In  occasional  cases,  usually  in  those  of  decidedly  blonde  hair,  the  hairs 
are  only  moderately  lost,  not  sufficiently  so  to  attract  attention,  those 
remaining  being  dry,  lusterless,  often  bent  and  straggly,  and  easily  broken; 


Fig.  279. — Ringworm  (tinea  tonsurans)  of  somewhat  inflammatory  type. 

the  patch  is  recognizable  only  on  close  inspection,  the  skin  being  found 
slightly  scaly,  and  sometimes  with  scarcely  perceptible  hyperemia.  In 
exceptional  instances,  however,  the  hair  loss  is  not  only  complete,  but  it 
is  rapid,  the  hairs  not  breaking  off  at  the  surface  level,  but  falling  entirely 
out  of  the  follicles,  the  area  developing  and  extending  rapidly — consti- 
tuting the  so-called  bald  ringworm  or  bald  tinea  tonsurans  of  Liveing. 

Occasionally  a  type  of  ringworm  of  the  scalp,  of  a  markedly  inflam- 
matory nature,  known  as  kerion,  tinea  kerion,  kerion  ringworm,  de- 
velops either  from  a  pre-existing  patch  of  ordinary  characters  or  primarily 
as  such,  the  inflammation  involving  the  deeper  tissues.  It  presents  the 
appearance  of  a  more  or  less  bald,  rounded,  inflammatory,  edematous, 
boggy,  honey-combed,  somewhat  prominent,  carbuncle-like  tumor,  dis- 


1 1 1 8  PARASITIC  AFFECTIONS 

charging  from  the  follicular  openings  a  mucoid  or  mucopurulent  secre- 
tion. It  is  sometimes  painful.  If  neglected,  crusting  often  takes  place, 
and  the  pent-up  discharge  may  undergo  change  and  become  offensive. 
Those  hairs  which  have  not  fallen  out  come  away  with  practically  no 
traction.  If  pressure  is  made  laterally,  the  thick,  glairy,  mucoid  or 
mucopurulent  secretion  can  readily  be  ejected.  Very  often  the  intensity 
of  the  inflammatory  action  results  in  destruction  and  dislodgment  of 
the  fungus,  and  a  spontaneous  cure  results.  This  type  practically  cor- 
responds to  the  boggy  or  tumor-like  formation  frequently  seen  in  ring- 
worm of  the  bearded  region,  and  also  to  that  rarely  encountered  on  the 
general  surface.  To  a  prominently  elevated  kerion-like  type,  appearing 
as  variously  sized  nodular  elevations,  and  which,  instead  of  discharging 
through  the  follicles,  gradually  breaks  down  and  empties  like  an  abscess, 
Majocchi  has  given  the  name  of  granuloma  trichophyticum.1 

Diagnosis. — Ringworm  of  the  scalp,  as  commonly  encountered, 
presents  a  clear  and  decisive  symptomatology;  its  features — the  slight 
scaliness,  broken  hair,  hair-stumps,  the  black  dots,  often  prominent 
follicles,  with  more  or  less  baldness  of  the  involved  area,  together  with 
the  history — are  ordinarily  sufficiently  characteristic  to  prevent  error, 
and  will  serve  to  exclude  such  maladies  as  seborrhea,  psoriasis,  and 
eczema,  in  which  such  a  symptom-complex  is  lacking.  The  hair  loss 
and  nutritional  changes  in  the  hair  are  the  most  important  differential 
points.  Moreover,  the  scaliness  of  psoriasis  is  more  abundant,  and 
patches  are  usually  to  be  found  elsewhere.  Eczema  is  commonly  diffused, 
quite  itchy,  often  with  considerable  scaliness,  and  frequently  with  a 
history  of  gummy  oozing.  Seborrhea  is,  as  a  rule,  general  over  the  scalp, 
the  scales  are  greasy,  and  while  there  may  be  some  thinning  out  of  the 
hair,  this  does  not  occur  in  patches. 

Favus  and  alopecia  areata  are  the  two  diseases  with  which  con- 
fusion is  most  likely  to  be  experienced.  In  favus,  although  the  same 
tendency  to  hair  loss  and  the  same  lusterless  and  brittle  condition  of 
the  hairs  are  noted,  the  presence  of  the  yellowish,  cup-shaped  crusts  or 
mortar-like  accumulations,  and  the  atrophic  character  of  the  involved 
skin,  are  wholly  different  from  what  obtains  in  ringworm.  Nor  are  the 
patches  of  favus,  as  a  rule,  rounded  as  they  are  in  ringworm.  The 
incomplete  hair  loss,  the  scaliness,  the  brittle  and  broken  hairs,  and  the 
hair-stumps  will  serve  to  distinguish  the  malady  from  alopecia  areata, 
in  which  the  sole  symptom  is  loss  of  hair,  complete  in  character,  the  skin 
being  perfectly  smooth  and  with  a  shiny  and  highly  polished  appearance. 
As  between  the  rare  type,  bald  ringworm,  and  alopecia  areata,  micro- 
scopic examination  of  the  hairs  from  the  edge  of  the  patch  will  usually, 
if  the  former  disease,  disclose  fungus,  and  thus  serve  to  distinguish  it. 
In  fact,  in  all  cases  of  doubt  as  between  ringworm  and  the  several  mala- 
dies named,  the  microscope  should  be  resorted  to.  It  is  to  be  remem- 
bered that  ringworm  of  the  scalp,  with  extremely  rare  exceptions,  never 
occurs  in  the  adult. 

The  inflammatory  types  of  ringworm  are  rare,  and  while  such  in- 

1  Majocchi,  "Granuloma  tricofitico,"  Boll,  della.  Accad.  Med.  di  Roma,  1883,  and 
"Atti  dell  VII  riunione  della,"  Soc.  ltd.  di  Derm,  e  Sifil.,  Milan,  Sept.,  1906. 


RINGWORM  III9 

stances  resemble  some  of  the  inflammatory  diseases,  especially  eczema, 
the  hair  loss  and  involvement,  the  history  of  the  case,  its  limited  area, 
and,  if  necessary,  microscopic  examination,  will  suffice  to  differentiate. 
Kerion  should  not  be  confused  with  carbuncle;  a  mistake,  strange  to  say, 
that  has  been  occasionally  made  by  surgeons.  The  boggy,  circumscribed 
.character,  the  mucoid  or  mucopurulent  discharge  from  the  follicular 
openings,  and  frequently  a  history  of  its  having  begun  as  an  ordinary 
ringworm  patch  are  points  of  difference. 

EL  RINGWORM  OF  THE  BEARDED  REGION 

Synonyms. — Tinea  sycosis;  Tinea  barbae;  Tinea  trichophytina  barbae;  Tricho- 
phytosis  barbae;  Sycosis  parasitica;  Sycosis  parasitaria;  Sycosis  contagiosa;  Sycosis 
hyphomycotica;  Herpes  tonsurans  barbae;  Men tagra  parasitica;  Ringworm  of  the  beard; 
Barber's  itch;  Parasitic  sycosis;  Parasitic  men  tagra;  Hyphogenous  sycosis;  Fr.,  Sycosis 
parasitaire;  Sycosis  trichophytique;  Trichophytie  sycosique;  Trichophytie  de  la  barbe; 
Ger.,  Parasitare  Bartfinne;  Parasitische  Bartfinne. 

Symptoms. — Ringworm  of  the  bearded  region,  or  tinea  sycosis, 
as  it  is  commonly  termed,  is  met  with  infrequently  as  compared  to 
the  disease  on  the  scalp  or  general  surface.  There  are  two  distinct 


Fig.  280. — Ringworm  (tinea  sycosis,  superficial  type)  somewhat  suggestive  of  a  spread- 
ing circinate  syphiloderm  (fungus  demonstrated). 

types  observed,  one  which  remains  superficial,  and  the  other  a  deep- 
seated  or  nodular  form.  As  a  rule,  it  begins  in  the  same  manner  as 
ringworm  on  non-hairy  parts,  as  one  or  more  rounded,  slightly  scaly, 


II2O 


PARASITIC  AFFECTIONS 


hyperemic  patches,  with,  in  some  or  all,  the  tendency  in  their  earliest 
formation  to  be  more  pronounced  peripherally. 

In  the  superficial  variety  it  so  continues,  the  areas  enlarging  and 
clearing  up  somewhat  centrally,  the  border  being  usually  quite  distinctly 
elevated.  Several  near-by  patches  may  coalesce  and  give  rise  to  a 
large,  irregular  area.  There  may  or  may  not  be  slight  or  moderate, 
itchiness.  The  hairs  and  follicles  are  involved  to  a  slight  or  decided 
extent,  and  show  similar  changes  to  those  observed  in  the  scalp  disease; 
never,  however,  to  so  pronounced  a  degree.  They  are,  in  most  parts, 
readily  extracted,  with  but  little  traction;  in  fact,  in  some  cases  some 


Fig.  281. — Ringworm  (tinea  sycosis)  in  a  hostler,  of  ten  days'  duration.  Patches 
are  of  the  deep-seated,  kerion-like,  or  pustule-inflammatory  type,  the  hairs  loosening 
and  falling  out;  one  side  of  the  upper  lip  also  partly  involved. 

of  them  drop  out  spontaneously.  On  the  other  hand,  not  infrequently 
they,  or  the  most  of  them,  remain  firmly  implanted,  the  disease  limiting 
itself  to  the  epidermis  proper.  The  malady  may  thus  continue,  often 
after  a  time  remaining  stationary,  or  even  showing  a  tendency  to  disappear 
without  treatment.  There  is  in  this  form  rarely  any  disposition  to  pus- 
tulation.  In  other  instances  the  process  involves  the  tissue  somewhat 
more  deeply,  giving  rise  to  some  thickening  and  infiltration,  exhibiting 
a  midway  condition  between  the  superficial  variety  and  the  deep-seated 
form,  into  the  latter  of  which  it  may  finally  develop. 

Sabouraud  describes  a  superficial  form  (trichophytie  seche,  a  forme 
d'ichtyose  pilaire)  of  the  malady  in  which  the  skin  itself  remains  un- 


RINGWORM  1 1 21 

involved,  the  hairs  and  upper  part  of  the  follicles  suffering;  the  hairs 
are  broken  off  a  little  distance  from  the  skin,  and  the  base  is  surrounded 
by  dry  epidermic  scales  or  debris. 

The  deep-seated  -variety  begins,  as  a  rule,  in  the  same  manner  as 
described,  and  after  remaining  superficial  a  variable  time,  shows  a  de- 
cided, and  often  rapid,  tendency  to  extend  down  into  the  follicles  and 
tissues;  occasionally  it  begins  somewhat  similarly  to  sycosis  vulgaris. 
As  a  result  of  such  deep  involvement  more  or  less  subcutaneous  swelling 
ensues,  and  the  affected  parts  assume  a  distinctly  lumpy  and  nodular 
condition,  often  suggestive,  when  extensively  developed,  of  crowded, 


Fig.  282. — Ringworm  (tinea  sycosis)  of  the  deep-seated,  kerion-like,  and  nodular 
type.  The  whole  neck  and  chin  are  invaded,  the  hairs  loosening  and  falling  out. 
Three  months'  duration. 

sluggish,  somewhat  flattened,  furuncles  or  cutaneous  abscesses,  and  at 
times  having  a  carbuncular  aspect.  The  overlying  skin  is  usually  con- 
siderably reddened,  often  presenting  a  glossy  appearance,  and  studded 
with  few  or  numerous  follicular  pustules.  The  nodules  ordinarily,  after 
a  time,  tend  to  soften  and  break  down  and  discharge  at  one  or  more  of 
the  follicular  openings,  a  glairy,  glutinous,  mucopurulent  or  purulent 
material,  which  may  dry  to  thick,  adherent  crusts.  In  some  instances, 
instead  of  fairly  well-defined  lumpiness  or  nodulation,  it  presents  as 
patchy,  diffused,  sometimes  circumscribed,  firm,  later  boggy,  infiltra- 
tions. In  others  the  features  are  closely  similar  to  those  of  kerion  on 
the  scalp,  with  which,  in  fact,  the  process  is  in  many  respects  analogous. 
71 


1122 


PARASITIC  AFFECTIONS 


The  hairs  themselves  may  or  may  not  be  conspicuously  implicated,  but, 
as  a  rule,  as  soon  as  the  tumor-like  swellings  are  at  all  developed  they  fall 
out;  sometimes,  indeed,  earlier  in  the  disease.  The  extent  of  the  involve- 
ment varies;  it  may  take  in  the  whole  bearded  region,  being  especially 
well  marked  just  on  the  chin  and  under  the  jaw,  producing  a  good  deal 
of  disfigurement;  in  other  cases  it  may  remain  more  or  less  limited  to  the 
chin,  and  exceptionally  there  is  but  one  patch  of  carbuncular-looking 
aspect.  The  upper  lip  is  seldom  involved,  probably  never  independently, 
but  along  with  extensive  invasion  of  the  other  parts.  The  process  shows 
but  little  disposition  to  spontaneous  disappearance,  usually  continuing, 


Fig.  283. — Ringworm  (tinea  sycosis)  of  the  deep-seated,  kerion-like,  and  nodular 
type,  of  a  month's  duration,  consisting  in  this  instance — comparatively  rare — of  but  one 
area  made  up  of  several  confluent,  deep-seated,  suppurating  nodules,  with  loosening  and 
falling  out  of  the  hair.  Such  cases  are  occasionally  mistaken  for  carbuncles  and 
abscesses. 

in  an  irregular,  sluggish  manner,  more  or  less  indefinitely,  unless  relieved 
by  treatment.  As  to  subjective  symptoms,  there  may  be,  especially  in 
the  earlier  stages,  slight  itching;  later  possibly  burning,  and  variable  sore- 
ness and  tenderness. 

Diagnosis. — The  superficial  type  of  ringworm  of  the  bearded 
region  is,  as  a  rule,  readily  recognized  by  its  ring-like  configuration, 
its  method  of  beginning  and  extension,  and  quite  usually  also  by  evi- 
dences of  hair  involvement.  It  might  possibly,  if  consisting  of  but  few 
ring  patches,  be  mistaken  for  the  circinate  tubercular  syphiloderm.  In 
this  latter  the  border  is  more  infiltrated,  is  of  darker  color,  and  the  part 


RINGWORM  1123 

traversed  frequently  shows  atrophy  or  pigmentation,  or  both;  if  ulcera- 
tion  or  scarring  is  present,  as  often  noted,  it  would  furnish  conclusive 
proof  of  its  syphilitic  character,  as  these  are  not  seen  in  the  superficial 
form  of  ringworm.  Moreover,  in  ringworm  the  hairs  quite  commonly 
exhibit  the  effects  of  the  fungus  invasion,  and  in  doubtful  cases  can  be 
subjected  to  microscopic  examination.  The  ring-like  characters  of  the 
patches  and  the  hair  involvement,  as  well  as  the  history  and  course,  will 
serve  to  distinguish  it  from  eczema  and  seborrhea.  These  features  and 
the  absence  of  any  special  tendency  to  follicular  pustules  suffice  to  ex- 
clude sycosis  vulgaris. 

The  deep-seated,  nodular  form,  if  at  all  developed,  can  scarcely 
be  confounded  with  other  maladies — the  peculiar  lumpiness  of  the  parts, 
the  involvement  of  the  hair  and  hair  loss,  the  history,  and  finally,  in 
doubtful  cases,  microscopic  examination,  furnishing  conclusive  differ- 


Fig.  284.  Fig.  285. 

Figs.  284,  285. — Cultures  of  the  Microsporon  Audouini  on  maltose  proof  medium — 
at  fifteen  and  twenty  days.  Appears  first  as  a  white  feathery  disk,  with  a  minute 
central  acuminated  point,  and  shows  later  three  or  four  furrows,  and  later  still  these 
become  more  marked,  between  which  develop  shorter  furrows;  the  surface,  at  first  white 
and  feathery,  becomes  grayish  or  grayish  white,  appearing  not  unlike  a  short-nap 
woolen  cloth  (courtesy  of  Dr.  R.  Sabouraud;  from  his  work  Les  Teignes). 

ential  points.  Sycosis  vulgaris  is  relatively  superficial,  with  no  con- 
spicuous infiltration  or  lumpiness,  and  the  pustules  usually  small  and 
pierced  by  a  hair;  and  unless  the  suppurative  action  is  marked,  there 
is  but  little  tendency  for  the  hairs  to  fall  out.  There  could  scarcely  be 
confusion  with  the  tuberculogummatous  syphiloderm,  as  the  superficial 
or  deep  ulceration,  the  greenish,  purulent,  and  commonly  offensive  dis- 
charge, as  well  as  the  bulky  crusts  often  observed  in  syphilis,  are  not  to 
be  found  in  tinea  sycosis.  In  fact,  in  the  latter,  although  its  characters 
are  frequently  suggestive  of  possible  destructive  action,  most  cases 
after  recovery  show  but  little  marking,  often  not  any  at  all;  in  others 
several  or  more  small  insignificant  scars.  Special  care  should  be  exer- 
cised not  to  mistake  the  single  circumscribed  tumor-like  formation  to 
which  exceptionally  ringworm  limits  itself  for  a  carbuncle;  a  sluggish 
formation  of  this  kind  on  the  chin  region,  showing  generally  much  less 
inflammatory  activity  than  carbuncle,  with  relatively  slighter  swelling 
and  pain,  should  always  be,  first  of  all,  considered  as  probably  of  ringworm 


1 1 24  PARASITIC  AFFECTIONS 

fungus  origin,  and  the  hairs  accordingly  examined.  Three  or  four  in- 
stances have  come  to  my  notice  in  which  the  growth  was  opened  by 
surgeons  under  the  impression  that  it  was  carbuncular  or  of  the  nature 
of  an  abscess. 

Ktiology. — Ringworm  is  due,  as  stated  in  the  preliminary  remarks 
(q.  v.)  on  the  disease  and  its  fungi,  to  the  invasion  of  the  epidermic  tissue 
by  fungus  elements.  The  disease  is  contagious.  It  may  be  conveyed 
directly  by  contact  or  through  the  medium  of  toilet  articles  and  wearing 
apparel.  It  is  particularly  common  in  children's  schools  and  institutions 
where  there  are  so  many  opportunities,  direct  and  indirect,  for  commu- 
nication. Day  nurseries,  "homes,"  and  like  charitable  havens  for  in- 
fants and  children  are  often  quite  active  centers  for  its  spread.  Barber- 
shops and  hair-dressing  establishments,  "complexion  or  beauty  parlors," 
laundries,  etc.,  are  likewise  common  sources  of  the  disease.  It  is  also 


Fig.  286.  Fig.  287. 

Figs.  286,  287. — Cultures  of  the  Microsporon  lanosum  on  maltose  proof  medium — 
at  fifteen  and  thirty  days;  surface  downy,  with  a  smooth,  powdery  central  area,  around 
about  which  develops  a  ring  of  projecting  white  wooly  down;  this  results  in  a  relative 
depression  or  umbilication  centrally;  thread-like  lines  of  a  grayish  tint  radiate  from  the 
outer  border  of  the  ring  (courtesy  of  Dr.  R.  Sabouraud;  from  his  work  Les  Teignes). 

quite  frequently  transmitted  from  the  lower  animals,  especially  the 
cat,  dog,  horses,  cows,  rabbits,  etc.1  The  wearing  of  underwear  brought 
from  the  laundry  in  a  damp  condition,  subsequently  having  a  moldy 
odor,  has,  according  to  my  observations,  apparently  been  of  etiologic 

1  Examples  of  contagion  from  the  dog,  cat,  and  horse  are  found  quite  numerously 
referred  to  in  literature,  and  are  not  uncommon  in  the  experience  of  those  with  large 
clinical  opportunities.  Eddowes,  Brit.  Jour.  Derm.,  1898,  p.  149,  gives  an  instance  in 
a  girl  of  fifteen  of  its  contraction  from  a  pet  hedgehog,  the  fungus  being  found  in  the 
scrapings  from  the  patient,  and  also  in  the  prickles  of  the  animal;  Busch,  "On  Ring- 
worm Infection  in  Man  and  Animals,"  Brit.  Mcd.  Jour.,  Feb.  9.  1901,  records  several 
examples  of  animal  contagion,  among  which  one  from  a  pet  canary;  in  these  instances 
the  observations  were  confirmed  by  examihation  of  the  animals;  Kessler,  Jour.  Amer. 
Med.  Assoc.,  Oct.  25,  1902,  finds  that  in  stock-raising  districts  the  most  frequent  source 
of  contagion  is  from  cattle  and  especially  from  yearling  calves;  the  farmers  call  the  dis- 
ease "barn-itch";  and  Mewborn,  "A  Case  of  Ringworm  of  the  Face  and  Two  of  the  Scalp 
Contracted  from  a  Microsporon  of  the  Cat;  with  Some  Observations  on  the  Identifica- 
tion of  the  Sources  of  Infection  in  Ringworm  Cases  by  Means  of  Cultures."  New  York 
Med.  Jour.,  Nov.  15,  1902  (with  illustrations). 


PLATE  XXX. 


FIGS.  I  and  2  (x  about  300). — Microsporon  Audouini  in  the  hair;  Fig.  I  shows 
mosaic  of  spores  and  also  mycelium,  the  latter  seldom  seen  in  these  cases  ;  Fig.  2  is  a 
stained  specimen. 

FIG.  3  (x  about  400). — Trichophyton  of  the  endothrix  variety — stained  specimen. 

(Courtesy  of  Dr.  Charles  J.  White.) 

FlGS.  4  and  5   (x  about  400). — Trichophyton  of  the  variety  ectothrix  ;  hairs  from  a 
case  of  ringworm  of  the  bearded  region  involving  also  the  upper  lip — hairs  from  the 
latter  region.     Fig.  4  shows  fungus  on  surface  of  a  hair,  and  V'g.  5  fungus  in  the  hair. 
(Courtesy  of  Dr.  M.  B.  Hartzell.) 


RINGWORM  1125 

bearing  in  some  cases  of  body  ringworm.  Both  sexes  are  liable,  and  in 
about  equal  proportion;  and  age  in  a  general  way,  except  in  certain 
situations,  exercises  but  little  influence,  although  the  malady  is  seldom 
seen  in  those  past  fifty.  Those  of  fair  complexion  and  whose  general 
nutrition  is  impaired  are  thought  to  be  more  susceptible,  especially  as 


Fig.  288.  Fig.  289. 

Figs.  288,  289. — Cultures  of  the  Trichophyton  crateriforme  on  maltose  proof  medium 
— at  twenty  and  thirty-five  days;  central  crater-like  or  cup-shaped  cavity,  with  a  but- 
ton-like projection  in  the  middle;  surface  is  velvety  in  appearance,  the  central  part 
being  yellowish  in  color,  with  a  white  periphery,  becoming  later  cream  colored  (courtesy 
of  Dr.  R.  Sabouraud;  from  his  work  Les  Teignes). 

regards  the  scalp  affection,  but  while  seemingly  so  in  many  instances, 
Aldersmith,  Crocker,  and  many  others  hold  the  contrary.  My  own  ob- 
servations indicate  that  the  most  stubborn  types  are  more  commonly 
met  with  in  those  of  relatively  poor  general  health,  but  as  to  the  in- 


Fig.  290.  Fig.  291. 

Figs.  290,  291. — Cultures  of  the  Trichophyton  acuminatum  on  maltose  proof  me- 
dium— at  twenty  and  thirty-five  days;  powdery  surface  and  cream  colored,  becoming 
brownish  later,  with,  in  some  instances,  a  violet  tinge;  center  rather  sharply  acumi- 
nated, the  furrows  sometimes  opening  later  and  showing  small  holes  (courtesy  of  Dr.  R. 
Sabouraud;  from  his  work  Les  Teignes). 

fluence  of  complexion,  I  have  encountered  the  malady  in  all  its  situa- 
tions, but  especially  on  the  scalp,  quite  frequently  in  negro  children, 
probably  as  often  relatively  as  in  whites.  The  disease  prevails  to  a 
somewhat  greater  extent  in  some  countries  than  in  others,  although  it  is 
common  enough  everywhere.  Sabouraud's  experimental  investigations 


1 1 26  PARASITIC  AFFECTIONS 

indicate  that  susceptibility  may  measurably  depend  upon  the  acidity  or 
alkalinity  of  the  sweat  secretion,  the  latter  condition  largely  increasing 
the  proportion  of  successful  inoculations. 

Ringworm  of  the  general  surface  may  occur  at  any  age,  but  is  much 
more  frequent  in  children  and  young  adults;  less  so  in  the  middle  period 


Fig.  292.  Fig.  293. 

Figs.  292,  293. — Cultures  of  the  Trichophyton  violaceum  on  glucose  proof  medium 
— the  left  at  sixty  days;  the  right  shows  an  old,  thirty-day  culture,  having  been  more 
than  a  year  in  the  laboratory  and  taken  on  a  spongy  form.  Is  somewhat  rounded  in 
shape,  with  slightly  projecting  swellings,  and  with  small  button-like  projections  cen- 
trally; has  a  shining  surface  with  often  five  or  six  or  more  radiations;  and  is  of  a  beau- 
tiful violet  color  (courtesy  of  Dr.  R.  Sabouraud;  from  his  work  Les  Teignes). 

of  life,  and  rather  unusual  in  advancing  years.  As  typically  encountered, 
it  is  due  to  the  large-spored  fungus,  commonly  the  ectothrix  variety. 
This  is  also  etiologic  in  the  markedly  inflammatory  and  deep-seated 
types.  The  superficial  furfuraceous  macular  spots  or  patches  seen, 


Fig.  294.  Fig,  295. 

Figs.  294,  295. — Cultures  of  the  Trichophyton  cerebriforme  on  maltose  proof  me- 
dium— at  twenty-five  and  sixty  days;  surface,  which  is  powdery  and  at  first  white,  later 
cream  yellow,  is  suggestive  of  the  cerebral  convolutions;  at  the  central  part  a  break 
finally  occurs,  forming  a  cavity  with  irregular  periphery  (courtesy  of  Dr.  R.  Sabouraud; 
from  his  work  Les  Teignes). 

with  sometimes  but  little  tendency  to  clearing  centrally,  and  of  but 
slightly  hyperemic  character,  are  sometimes  due  to  the  small-spored 
fungus,  or  to  one  of  the  endothrix  varieties  of  the  large-spored  fungus; 
and  those  transitory  forms  of  lenticular  rosy  macules,  often  scarcely 
perceptibly  reddened,  are  also  caused,  for  the  most  part  at  least,  by  the 


RINGWORM 


1127 


endothrix  variety  of  the  large-spored  fungus,  although  this  latter  some- 
times, as  well  as  also  occasionally  the  microsporon,  are  productive  of 
typical  examples  of  the  malady.  Tinea  cruris,  as  well  as  some  of  the 
eczematoid,  vesicular,  and  vesicobullous  eruptions  about  the  hands  and 
feet,  are,  as  previously  stated,  due  to  a  special  fungus — Epidermophyton 
inguinale. 

Ringworm  of  the  scalp  is  a  common  affection,  but  it  is  one  which 
may  be  said  to  be  limited  to  children,  seldom  presenting  or  persisting 
after  the  fourteenth  or  fifteenth  year,  and  with  rare  exceptions  never 
occurring  in  the  adult.  I  have  met  with  but  one  such  instance  in  a 
woman  aged  thirty.  Professor  Duhring1  has  "never  seen  it  in  persons 
over  sixteen  or  seventeen  years  of  age."  Hyde  and  Montgomery2 
state  that  "ringworm  in  the  scalp  of  the  adult  and  the  aged  is,  indeed, 


Fig.  296.  Fig.  297. 

Figs.  296,  297. — Cultures  of  the  Trichophyton  asteroides  on  maltose  proof  medium 
— at  twenty  and  thirty  days;  central  prominence — which  later  shows  tendency  to  um- 
bilication — with  numerous  fine  star-like  radiations;  the  radiations  are  usually  more  dis- 
tinct and  pronounced  in  cultures  on  glucose  proof  medium;  the  color  is  a  pure  white, 
and  the  surface  powdery  like  plaster  of  Paris — representing  the  so-called  "gypsum" 
type  culture  (courtesy  of  Dr.  R.  Sabouraud;  from  his  work  Les  Teignes). 

among  the  rarest  of  cutaneous  accidents."  Crocker3  has  observed  it 
beginning  in  the  adult,  in  3  instances,  one  at  the  age  of  thirty-four,  one 
at  fifty-three,  and  another  at  fifty-five;  Jamieson4  in  2  women,  one  a 
nursemaid,  the  other  aged  thirty-eight;  Aldersmith,5  with  his  large  ex- 
perience, has  seen  it  in  but  5  cases  in  twenty  years.  Cases  have  been 
reported  recently  by  Colcott  Fox,6  Anderson,7  and  Abraham.8  These 

1  Duhring,  Diseases  of  the  Skin,  third  ed.,  p.  615. 

2  Hyde  and  Montgomery,  Diseases  of  the  Skin. 

3  Crocker,  Diseases  of  the  Skin,  third  ed.,  p.  1293. 

4  Jamieson,  Diseases  of  the  Skin. 

5  Aldersmith,  Ringworm  and  Alopecia  Areala;  also  an  additional  case  (male,  aged 
twenty-three),  reported  recently,  Brit.  Jour.  Derm.,  1898,  p.  5. 

6  Colcott  Fox,  ibid.,  1898,  p.  253  (in  a  man  aged  forty-two). 

7  Anderson,  ibid.,  p.  156  (resembling  alopecia  areata). 

8  Abraham,  ibid.,  p.  163  (4  cases  since  1885). 


1 1 28  PARASITIC  AFFECTIONS 

adult  scalp  cases — those  noted  by  the  last  four  observers  named  and  also 
the  last  one  of  Crocker's  cases — were  due  to  the  large-spored  fungus,  all 
except  Anderson's  to  the  endothrix  variety;  Anderson's  to  the  ectothrix. 
In  the  others  the  variety  of  fungus  was  not  known  or  not  stated. 

Ringworm  of  the  scalp,  however,  as  observed  in  children,  is  pre- 
ponderantly due  to  the  small-spored  fungus  (usually  the  microsporon 
Audouini),  although  in  a  fair  proportion  the  endothrix  (mostly  to  the 
trichophyton  crateriforme  and  trichophyton  acuminatum1)  of  the  large- 
spored  fungus  is  etiologic,  and  the  ectothrix  is  also  occasionally  causa- 
tive— the  last  being  commonly  responsible  for  the  inflammatory  pustular 
types.  In  hospital  and  dispensary  practice  C.  J.  White's  investigations 
show  the  microsporon  causative  in  Boston  in  88  per  cent,  of  the  cases; 
Corlett,2  90  per  cent,  in  Cleveland;  G.  W.  Wende  (cited  by  Corlett),  in 
89  out  oi  90  cases  in  Buffalo;  Colcott  Fox  and  Blaxall  give  80  to  90 
per  cent,  in  London,  where  Adamson's  observations  give  a  still  higher 
proportion — 178  out  of  183  cases,  and  Scott  (at  London  Hospital — 700 


Fig.  298.  Fig.  299. 

Figs.  298,  299. — Cultures  of  the  trichophyton  rosaceum  on  maltose  proof  medium — 
at  eighteen  and  forty-five  days;  at  first  it  presents  a  round  button-like  appearance  with 
a  central  knob-like  prominence;  later  five  or  six  large  rounded,  somewhat  deep,  radiating 
furrows  develop;  the  surface  is  velvety;  at  first  snow-white,  it  soon  changes  to  its  char- 
acteristic rose  color  (courtesy  of  Dr.  R.  Sabouraud;  from  his  work  Les  Teignes). 

cases)  89.8  per  cent.,  the  other  cases  (10.2  per  cent.)  being  due  to  the 
endothrix;  and,  according  to  Aldersmith,  78  per  cent,  in  private  prac- 
tice; Sabouraud,  60  per  cent,  in  Paris;  in  Scotland,  according  to  Norman 
Walker,3  the  enormous  bulk  of  the  cases,  and  in  18  out  of  20  of  Jamieson's4 
cases.  On  the  other  hand,  in  Italy,  Mibelli5  has  not  met  with  the  small- 
spored  fungus  in  a  single  instance,  the  malady  being  due  to  the  large- 
spored  variety.  The  trained  eye  can  in  many  instances  usually  recog- 
nize, by  the  clinical  appearances  in  a  given  case,  which  variety  of  fungus 

1  In  a  large  number  of  cases  of  trichophytosis  capitis  Colcott  Fox  found  38  per  cent, 
due  to  the  trichophyton  crateriforme,  26  per  cent,  to  trichophyton  acuminatum,  21 
per  cent,  to  trichophyton  sulfureum,  and  15  per  cent,  to  trichophyton  violaceum;  in 
211  Paris  cases  Sabouraud  found  53  per  cent,  due  to  trichophyton  crateriforme,  22  per 
cent,  to  trichophyton  acuminatum,  16  per  cent,  to  trichophyton  violaceum,  and  only  9 
per  cent,  to  all  the  other  species  of  trichophyton. 

2  Corlett,  "Recent  Researches  in  Ringworm,"  Jour.  Amer.  Med.  Assoc.,  March  18, 
1899. 

3  Norman  Walker,  An  Introduction  to  Dermatology. 

4  Jamieson,  Brit.  Med.  Jour.,  1893,  ii,  p.  470. 

5  Mibelli,  "Sur  la  pluralite  des  trichophytons,"  Annales,  1895,  p.  733. 


RINGWORM  1129 

is  likely  to  be  found,  but  this  knowledge  is  a  matter  of  no  import  in  the 
practical  management  of  the  case.1 

Pathology. — The  pathogenic  role  of  the  parasitic  vegetable  organ- 
ism in  provoking  the  conditions  described  is  at  the  present  day  unques- 
tioned. The  plurality  of  the  causative  fungi  is  also  generally  conceded, 
although  such  careful  observers  as  Leslie  Roberts  and  a  few  others  are  in- 
clined to  believe  that  the  variations,  or  many  of  them  at  least,  may  be 
due  to  the  cultural  methods  and  to  the  quality  of  the  "soil,"  etc.2  Thf- 
fungus  invades  the  epidermis  and  hair,  and  in  occasional  instances  the 
nails  (see  Onychomycosis),  and  the  phenomena  observed  are  due  to  its 


Fig.  300.  Fig.  301. 

Figs.  300,  301. — Cultures  of  the  epidermophyton  inguinale  on  maltose  proof 
medium — at  eighteen  and  thirty  days;  dry  and  powdery,  downy  in  appearance,  with 
wrinkle-like  radiating  furrows  and  slightly  elevated  folds,  and  a  small  central  depression; 
is  greenish  yellow  in  color  (courtesy  of  Dr.  R.  Sabouraud;  from  his  work  Les 
Teignes). 

mechanical,  irritative,  and  destructive  action.  In  some  instances,  more 
especially  in  the  markedly  inflammatory  types  of  the  malady,  fungus  ele- 
ments are  found  deep  in  the  follicles,  in  the  perifollicular  tissue,  as  well 

1  Those  cases  of  ringworm  of  the  scalp  presenting  the  well-defined  rounded  patch, 
with  follicular. prominences,  or  goose-flesh  appearance,  and  with  light  or  dirty-grayish 
colored  branny  or  lamellated  scales,  and  showing  a  powdery  sheath  or  sheath-like  cover- 
ing (so-called  circumpilar  collarette)  surrounding  the  whitish  or  grayish  stumps  and  hairs 
just  within  and  above  the  follicular  outlet  are  due  to  the  microsporon.     The  hairs  are 
grayish,  lusterless,  and  readily  broken,  and  as  most  have  been  broken  off,  the  patch  has 
a  nibbled  appearance.     Only  rarely  is  it  responsible  for  the  pustular  or  other  inflamma- 
tory forms.      In  that  due  to  the  trichophyton  of  the  endothrix  variety  (in  both  sub- 
species, resistant  and  fragile)  the  areas  are  smoother  than  those  due  to  the  microsporon, 
and  sometimes  the  surface  is  quite  clean  looking,  lacking  the  grayish,  frosted  look,  and 
only  exhibiting  broken  hairs  and  hair-stumps,  and  these  usually  without  the  circumpilar 
collarettes.     There  may  be  one  or  more  areas.     Sometimes  in  these  cases,  especially  due 
to  the  "resistant"  subspecies,  there  may  be  present  some  sebaceous  scaliness,  suggesting 
seborrhea.     Disseminated  ringworm  and  the  "black-dot"  ringworm  are  sometimes  due 
to  this  latter  subvariety,  although  the  "fragile"  subspecies  is  more  commonly  respon- 
sible for  these  forms,  and  also  for  many  of  the  cases  of  "bald  ringworm."     When  due  to 
the  endothrix,  more  especially  the  resistant  variety,  there  may  be  seen  very  often  one  or 
two  large  areas,  with  outlying  or  scattered  small  patches.     It  is  especially  ringworm 
of  the  scalp  caused  by  the  endothrix  that  often  has  associated  with  it  well-marked 
patches  of  tinea  circinata.     Kerion  and  other  markedly  inflammatory  and  pustular 
types  are  usually  due  to  the  ectothrix  variety;  Sabouraud  says  always,  but  Aldersmith, 
Colcott  Fox  and  Blaxall,  Adamson,  Malcolm  Morris,  and  others  have  found  the  kerion 
type  occasionally  produced  by  the  small-spored  fungus.      The  ectothrix  fungus  is 
also  held  responsible  for  the  cases  of  ringworm  of  the  bearded  region  observed  in  the 
male  adult,  and  contracted,  either  directly  or  indirectly,  from  animal  sources,  the  pus- 
producing  variety  from  the  horse.   It  is,  therefore,  much  more  common  in  hostlers  and 
those  who  have  to  do  with  these  animals  and  cattle.     For  further  information  on  these 
points  see  preliminary  remarks  on  this  disease. 

2  See  a  valuable  and  suggestive  publication  by  Leslie  Roberts,  An  Introduction  to 
the  Study  of  the  Mould  Fungi  Parasitic  on  Man,  1893 — a  good  critical  review  of  the 
same  by  Norman  Walker  in  Brit.  Jour.  Derm.,  1893,  p.  375. 


j  1 30  PARASITIC  AFFECTIONS 

as  in  the  derma  proper  (Robinson,  Pellizari,  Campana,  Rosenbach, 
Hartzell).  The  parasite  finds,  however,  its  most  suitable  habitat  and 
flourishes  most  luxuriantly  in  keratinized  epithelial  structures.  The 
exact  botanical  position  of  the  microsporon  and  the  trichophyton  are 
still  involved  in  some  doubt.  Sabouraud  contends  that  the  microsporon 
is  distinct  from  the  trichophytons,  but  is  not  able  as  yet  to  attach  it  to 
any  particular  family;  the  trichophyton,  owing  to  the  tendency  to  form 
masses  of  spores,  he  is  inclined  to  place  among  the  mucedinous  mold 
fungi,  varieties  of  the  family  botrytis,  or  the  sporotricha.  Other  in- 
vestigators, among  whom  are  Aldersmith  and  Colcott  Fox  and  Blaxall, 
believe  they  are  nearly  related  members  of  the  same  family,  and  that 
fructification  is  developed  practically  on  precisely  the  same  plan.  The 
source  of  the  fungi  is  also  as  yet  not  definitely  settled.  Sabouraud  be- 
lieves that  the  microsporon  is  essentially  a  human  parasite.  Malcolm 
Morris  states  the  matter  thus:  "The  origin  of  the  fungi  is  uncertain. 
Sabouraud  thinks  it  probable  that  the  trichophytes,  or  some  of  them, 
may  exist  independently  as  saprophytes,  and  this  suggests  the  possi- 
bility of  direct  contagion  from  moldy  vegetable  substances.  Ectothrix 
is  believed  to  be  exclusively  of  animal  origin  (Colcott  Fox) — more  par- 
ticularly the  horse  and  cat.  Some  trichophytes  also  infest  birds.  The 
small-spored  fungus  is  likewise  believed  to  be  occasionally  derived  from 
the  horse,  cat,  or  dog." 

In  extemporaneous  examination  for  fungus,  if  in  ringworm  of  the 
general  surface,  scrapings  are  taken  from  the  border  of  the  patch  and 
immediately  contiguous  skin,  and  put  in  some  liquor  potassae  on  a  glass 
slide,  with  the  cover-glass  lightly  placed  over  it;  this  is  permitted  to  soak 
for  five  or  ten  minutes  or  more,  and  then  the  cover-glass  pressed  down 
and  the  material  flattened  out.  If  in  ringworm  of  the  scalp  or  bearded 
region,  an  affected  hair-stump  or  broken  hair,  preferably  the  former, 
is  carefully  removed  or  picked  out  of  the  follicle,  and  similarly  treated, 
but,  as  a  rule,  a  much  longer  soaking  is  required,  and  in  stiff,  thick, 
and  dark  hairs  a  stronger  solution.  After  a  variable  time  the  cover- 
glass  is  firmly  pressed  down.  Occasionally  it  is  preferable  to  soak  the 
hair  in  a  shallow  vessel  containing  the  potash  solution.  The  specimen 
can  then  be  examined,  for  which  a  power  of  300  diameters  or  more  is 
required.  Jamieson  heats  the  potash  solution  containing  the  specimen 
somewhat  by  holding  the  slide  over  a  spirit-lamp  for  a  few  seconds,  and 
subsequently  washes  the  alkaline  solution  out,  and  examines  the 
specimens  in  glycerin.  They  can  be  mounted  in  this  latter,  although 
after  some  time  they  become  rather  thin,  washed-out-looking,  and  too 
transparent.1 

1  Malcolm  Morris  strongly  advises  the  adoption  of  staining  methods  for  the  careful 
morphologic  study  of  the  specimens.  His  plan,  as  modified  by  Norman  Walker,  is  as 
follows:  "The  hairs  and  scales  are  put  on  a  slide  and  a  drop  of  anilin-gentian  violet  or 
alum-gentian  violet  i  to  5:  100  added.  Here  it  must  remain  at  least  five  minutes.  It 
is  then  treated  with  Gram's  solution  for  three  minutes  or  longer,  and  then  dried  with 
blotting-paper.  Then  a  drop  of  anilin  oil  with  enough  iodin  in  it  to  make  a  dark  cherry 
color  is  added;  and  after  a  little  washing  to  and  fro  it  is  examined  under  a  low  power. 
In  most  cases  this  is  enough,  but  if  the  specimen  is  to  be  preserved,  it  must  be  washed 
in  pure  anilin  and  then  in  xylol  before  mounting."  The  small-spored  fungi,  according 
to  Morris,  stains  much  more  quickly  than  the  large  spored.  The  permanent  mounting 
can  be  made  in  Canada  balsam. 


RING  WORM  II3I 

The  characters  of  the  fungi  vary  somewhat.  The  spores  of  the 
microsporon  Audouini  are  usually  rounded,  occasionally  somewhat 
oval,  and,  as  the  result  of  pressure,  sometimes  polyhedral.  They  are 
often  double-contoured,  contain  granules  and  liquid,  and  are  from  2 
to  2.5  [i  in  diameter.  The  mycelium  consists  of  sharply  contoured, 
transparent,  pale-grayish,  branching  threads  or  tubes,  showing  frequently 
slight  bulging  at  irregular  intervals,  and  often  terminating  in  mycelial 
spores.  They  are  jointed  here  and  there  with  real  dissepiments,  the 
septa  containing  granules  and  cells.  Cultures  of  this  fungus  show  slight 
differences  in  some  instances,  indicating  possible  variations  in  the  plant, 
although  for  the  most  part  they  are  practically  identical.  These  dif- 
ferences are  slight  compared  to  those  observed  with  cultures  of  the  varie- 
ties of  the  trichophyton.  Some  trifling  variations  are  noted  also  in  cul- 
tures of  the  various  species  as  found  in  different  countries.  The  tricho- 
phyton, or  large-spored  fungus,  has  spores  and  mycelium  larger  than  those 
of  the  microsporon ;  the  spores  are  from  3  to  6  [i  in  diameter,  and'  are  ar- 
ranged in  a  ladder-like  or  bead-like  manner,  forming  band-like  mycelium. 
The  mycelium  does  not  branch  so  much  as  that  of  the  small-spored  fungus. 
The  mycelial  filaments,  whether  sporulated  or  not,  always  divide  dichot- 
omously  (Morris).  The  mycelium  of  the  ectothrix  is  large  and  very 
abundant  in  ringworm  of  the  body,  and  the  septa  are  long — much 
longer  than  the  septa  of  either  the  endothrix  and  the  microsporon. 
In  Sabouraud's  microid  class  of  the  ectothrix  the  spores  are  small,  and 
doubtless  often  taken  for  those  of  the  microsporons.  Culture  is  the 
only  certain  method  of  differentiating.  The  epidermophyton1  forms 
mycelial  network  exactly  like  a  trichophyton  (Sabouraud).  According  to 
the  variety  of  fungus,  its  position,  arrangement,  and  manner  of  the  hair 
invasion  are  to  a  variable  extent  somewhat  different,2  although,  according 

1  Whitfield  Brit.  Jour.  Derm.,  1911,  p.  380,  (hand  and  foot  cases)  advises,  when  ex- 
amination for  the  fungus  is  to  be  made  in  potash  solution,  "to  peel  off  the  scale  from 
the  most  suggestive  undermined  part  of  the  eruption,  and  to  lay  the  scale  with  its  deep 
surface  upward  on  the  slide;  by  attention  to  this  detail  it  is  commonly  easy  to  see  the 
fungus  immediately,  whereas  if  the  scale  is  laid  with  the  deep  side  downward  one  may 
have  to  wait  an  hour  or  more  before  one  can  see  sufficiently  clearly  to  identify  the  fun- 
gus." 

2  In  the  microsporon  ringworm  the  fungus  lies  around  the  hair,  forming  the  grayish 
sheath  or  collarette  described  by  Sabouraud.     This  observer  and  Malcolm  Morris  state 
that  the  cuticle  of  the  hair  is  first  attacked  and  eaten  away;  the  edges  thus  frayed  and 
the  interior  of  the  shaft  invaded  and  in  a  downward  direction,  toward  the  root.     Adam- 
son  and  Colcott  Fox,  on  the  contrary,  hold  that  the  epidermis  is  first  attacked.     The 
spores  are  often  arranged  in  a  mosaic-like  manner  around  the  hair,  with  little  tendency 
to  form  bands,  but  about  the  junction  of  the  shaft  with  the  bulbous  portion  is  a  terminal 
fringe  of  long,  plain,  narrow,  delicate,  sometimes  branched,  mycelial  threads,  which 
Colcott  Fox  regards  as  quite  characteristic.     The  hair  is  finally  often  completely  in- 
vaded, and  the  broken  ends  found  swarming  with  conidia. 

With  the  large-spored  fungus,  endothrix  variety,  the  hair-root  first  suffers,  and  the 
action  extends  upward,  the  spores  being  arranged  in  chains,  intermingled  with  short, 
irregularly  jointed  mycelium.  There  is  no  visible  circumpilary  sheath,  the  spores  lying 
sometimes  inside  and  sometimes  outside  of  the  hair.  The  mycelia  run  up  the  shaft 
parallel  to  its  long  axis.  This  variety  can  usually  be  recognized  microscopically  by  the 
large  spores  and  the  bead-  or  ladder-like  characters  of  the  chains  of  spores,  and  espe- 
cially by  their  intrapilar  position  (Aldersmith).  In  the  resistant  variety,  in  the  earliest 
stage,  strings  of  jointed,  ladder-like  mycelium  are  seen  outside  of  the  hair  and  also 
entering  its  substance;  in  the  latter  first  only  a  few  threads,  later  the  hair  is  more  or 
less  infiltrated  with  it.  Finally  all  parts  show  fungus  invasion — hair-shaft,  its  exterior, 
especially  between  the  hair  and  the  root-sheath,  and  the  bulb.  There  is  seen  dichoto- 


1132  PARASITIC  AFFECTIONS 

to  Colcott  Fox  and  Blaxall,  Malcolm  Morris,  Ravogli,  and  others,  the 
finer  distinctions  in  the  appearances  and  site  of  invasion  insisted  upon  by 
Sabouraud  are  not  to  be  taken  too  strictly. 

For  cultures  Sabouraud  advises  the  general  use  of  maltose  and  glu- 
cose proof  media  so  as  to  have  a  uniform  standard ;  as  his  work  and  cul- 
ture illustrations  are  practically  based  upon  such,  and  are  necessarily 
the  accepted  standard  of  comparison,  one  or  the  other  of  these  media 
should  always  be  employed.  Other  media  usually  produce  consider- 
able deviation,  often  an  entirely  different  picture,  and  wrould  result  in 
more  or  less  confusion.  His  formula  for  the  maltose  proof  medium  is: 
water,  1000  grams;  crude  maltose  (Chanut),  40  grams;  granulated  pep- 
tone (Chassaing) ,  10  grams ;  gelose,  1 8  grams.  His  formula  for  the  glucose 
proof  medium  is  the  same,  with  the  maltose  replaced  by  glucose  (Chanut) 
in  the  same  quantity.  The  flask  or  test-tube — of  wrhich  several  should 
be  inoculated  with  the  material  from  the  case  under  investigation- 
should  be  corked  with  non-absorbent  cotton;  30°  C.  (86°  F.)  is  found  to 
be  the  most  favorable  temperature;  development  is  noticeable  in  about 
eight  or  nine  days,  and  becomes  quite  characteristic  in  a  few  weeks. 
Ordinarily,  clinical  appearances  in  ringworm  are  diagnostic;  in  doubt- 
ful cases  microscopic  examination  can  be  resorted  to  and  will  usually 
clear  up  the  matter,  but  in  rare  and  obscure  cases,  and  in  epidemics 
where  it  is  interesting  and  of  some  import  to  know  the  exact  etiologic 
fungus,  cultures  should  be  made. 

The  question  of  immunity  and  vaccine  has  recently  come  to  the  fore 
in  this  disease  as  in  others.  It  would  seem,  according  to  the  observations 
and  experiments  of  Plato,1  Truffi,  Bloch  and  Massini,  Bruhns  and  Alex- 

mously  branched  mycelium  with  transverse  septa  in  the  root-shaft,  extending  down- 
ward toward  the  bulb.  There  may  be  finally  a  slight  circumpilary  sheath  resulting  from 
the  surrounding  groups  and  chains  of  spores.  In  the  fragile  endothrix  the  conditions 
found  are  somewhat  similar,  but  the  bands  are  not  so  long  and  continuous,  and  instead 
of  being  ladder-like,  have  more  the  appearance  of  strings  of  beads  or  "chaplets,"  the 
hair  substance  sometimes  so  crowded  that,  as  Sabouraud  suggests,  it  looks  like  "fish- 
roe"  or  a  "bag  of  nuts." 

In  the  ectothrix  variety,  usually  observed  in  ringworm  of  the  bearded  region,  the 
fungus  is  found  principally  in  the  intrafollicular  portion,  consisting  of  large  long  bands 
with  segments  at  irregular,  usually  long,  distances,  and  often  dividing  dichotomously. 
They  run  along  outside  of  the  hair,  slightly  invading  the  cuticular  portion,  sometimes 
markedly  (endo-ectothrix),  although  this  latter  is  rarely  eroded,  as  in  the  small-spored 
variety.  The  spores  vary  considerably  in  size,  from  3  to  1 2  p  in  diameter,  and  are 
situated  around  the  hairs  arranged  in  chains.  Sabouraud  states  that  the  hair  is  not  in- 
vaded, the  fungus  remaining  outside,  but  according  to  Aldersmith,  Colcott  Fox  and 
Blaxall,  the  shaft  is  sometimes,  probably  always  (Fox  and  Blaxall),  implicated  to  some 
extent.  Ravogli's  ("Notes  on  Ringworm,"  New  York  Med.  Jour.,  June  29,  1901) 
studies  showed  that  both  the  endothrix  and  ectothrix  could  be  found  vegetating  inside 
of  the  hair  and  in  the  epidermis.  In  hairs  from  cases  of  tinea  sycosis,  due  to  the  ecto- 
thrix, I  have  often  seen  the  shaft  more  or  less  crowded  with  mycelium,  as  also  shown  in 
accompanying  cut  by  Hartzell .  Fox  and  Blaxall  have  noted  in  several  instances  that 
the  fungus  scarcely  exceeded  that  of  the  microsporon  in  size.  These  represent  Sabou- 
raud 's  later  microid  variety  of  the  ectothrix.  There  is  a  sheath  of  fungus  around  the 
hair  at  the  follicle  mouth,  but  it  fits  less  closely  than  that  observed  with  the  micro- 
sporon. 

1  Plato,  Archiv,  1902,  Ix,  p.  63  (posthumous  paper  edited  by  Neisser);  Truffi, 
Revue  pratique,  1903,  H.  10,  Clinica  Medica,  1904 — abs.  in  Monatshefle,  1904,  xxxix,  p. 
679;  Bloch  and  Massini,  Zeitschr.f.  Hyg.  u.  Infektionskr.,  1909,  p.  69 — abs.  in  Monat- 
shefle, 1909,  Ixix,  p.  419;  Bruhns  and  Alexander,  Dermatolog.  Zeitschr.,  1910,  xvii,  p. 
695;  Amberg,  Jour.  Exper.  Med.,  July,  1910,  xii,  p.  435. 


RINGWORM  1133 

ander,  Amberg,  Sabouraud,  and  others,  that  trichophytosis  of  an  acute, 
but  more  especially  of  a  deep-seated  character,  may  measurably  influence 
the  general  organism,  sufficiently  so  as  to  confer  a  variable  immunity — 
according  to  Sabouraud  the  greater  the  reaction,  the  greater  the  immu- 
nity. Jadassohn  (cited  by  Bruhns  and  Alexander)  has  made  a  similar 
observation  "that  a  patient  never  suffers  from  a  second  infection  after 
an  attack  of  deep-seated  ringworm."  It  has  also  been  found,  as  first 
shown  by  Plato  and  confirmed  by  Truffi,  Amberg,  and  others,  that  the 
vaccination  or  injection  with  "trichophytin"1  gives  rise  to  a  reaction 
even  after  the  disease  had  long  disappeared — a  general  and  local  reaction 
not  unlike  that  of  Von  Pirquet's  test  for  tuberculosis.  The  superficial 
varieties  of  ringworm,  unlike  the  deep-seated  types,  rarely  protect  or 
react;  Bruhns  and  Alexander  suggest  as  an  explanation  that  when  the 
lesions  penetrate  deeply  antibodies  are  thrown  out  in  much  greater 
quantity  than  when  there  is  a  mere  superficial  lesion.  The  few 
attempts  to  influence  the  disease  by  its  use  have,  however,  been  of 
doubtful  effect. 

Prognosis. — Ringworm  is  a  curable  malady,  varying  consider- 
ably in  rebelliousness  in  the  several  regions  involved,  and  also  in  the 
same  regions  in  different  individuals.  The  variety  of  the  fungi  that 
may  be  etiologic  in  a  given  case  has  in  a  measure  also  a  bearing,  but 
for  practical  purposes  this  can  usually  be  ignored.  Ringworm  of  the 
general  surface  is,  as  a  rule,  readily  manageable,  in  average  cases  of  but 
a  few  patches  of  the  mildly  hyperemic  and  scaly  type,  from  several  days 
to  a  few  weeks'  treatment  generally  sufficing  to  remove  the  disease. 
Exceptionally,  however,  the  patches,  especially  of  the  moderately  and 
markedly  developed  type,  are  slow  in  yielding,  and  new  areas  continue 
to  spring  up  irregularly  from  time  to  time.  The  deep-seated  variety 
is  the  most  rebellious,  and  occasionally,  when  apparently  cured,  a  re- 
crudescence gradually  presents  in  the  same  situation  after  treatment 
has  been  discontinued.  Such  exceptional  examples  may  require  a  few 
months'  use  of  somewhat  strong  remedial  applications  before  permanent 
freedom  is  secured. 

In  the  genitocrural  parts  (tinea  cruris,  eczema  marginatum),  as  like- 
wise in  its  analogue  in  the  axillary  region,  it  is  usually,  even  in  its  milder 
varieties,  more  or  less  obstinate,  not  less  than  several  weeks  to  a  few 
months  being  required;  and  if  the  malady  has  been  of  long  duration,  is 
extensive  and  shows  considerable  infiltration,  it  is  quite  refractory, 
although  always  finally  yielding  to  persistent  measures. 

Ringworm  of  the  scalp,  while  often  troublesome,  eventually  gets 
well,  a  regrowth  of  hair  taking  place,  so  that  there  remains  no  disfigure- 
ment. When  limited  to  one  or  two  areas  and  of  short  duration,  with 
prompt,  energetic  management  it  can,  in  the  majority  of  cases  at  least, 
and  especially  in  private  practice,  be  readily  cured,  requiring  on  the  aver- 
age a  few  months'  treatment.  The  same  may  be  said  of  a  small  minority 
of  patients  when  the  disease  has  been  of  longer  duration.  On  the  other 

1  Plato  made  cultures  from  lesions  of  deep-seated  nodular  ringworm  of  the  bearded 
region;  this  culture  was  sterilized,  filtered  and  diluted  with  0.25  per  cent,  carbolic  acid 
— to  this  he  gave  the  name  "trichophytin." 


1 1 34  PARASITIC  AFFECTIONS 

hand,  in  some  cases  it  is  extremely  rebellious,  continued  and  energetic 
treatment  from  six  months  to  a  year  being  necessary  to  bring  about  a 
result;  and  in  not  a  few  instances  it  is  particularly  obstinate,  and  without 
methodic  and  persistent  measures  such  cases  last  almost  indefinitely, 
or  until  nature  begins  to  look  after  the  cure  as  the  child  verges  into  pu- 
berty, it  disappearing  spontaneously  approaching  or  shortly  after  this 
period.  For  this  reason  in  those  instances  in  which  the  malady  begins 
in  advanced  childhood,  if  properly  treated,  it  responds,  as  a  rule,  rapidly. 
In  very  young  children  also  the  fungus  does  not  seem  to  get  so  firm  a 
hold.  It  is  generally  conceded  that  the  small-spored  fungus  is  the 
parasitic  agent  in  most  of  the  refractory  cases.  While  in  those  instances 
due  to  the  large-spored  fungus  the  disease  yields,  as  a  rule,  much  more 
rapidly,  still  there  are  occasional  cases  which  also  prove  persistently 
obstinate.  As  a  general  thing  the  markedly  inflammatory  types,  and 
especially  the  kerion  type,  usually  due  to  the  ectothrix  variety  of  the 
large-spored  fungus,  respond  somewhat  readily.  It  may  be  pretty 
positively  stated,  however,  that  many  of  the  alleged  cures  of  established 
ringworm  of  the  scalp  in  a  period  of  less  than  a  few  months,  whatever 
the  type  of  the  disease,  are  merely  errors  of  observation,  for  not  infre- 
quently the  practitioner  pronounces  it  cured  when  the  hair  has  begun 
to  fill  in  in  the  affected  area  or  areas,  whereas  the  malady  in  reality  may 
still  persist  in  a  less  conspicuous  but  chronic  state,  and  the  case  remain 
an  active  center  of  contagion  for  other  children.  X-ray  treatment 
cautiously  applied  by  a  trained  expert,  usually  in  a  single  dose  suffi- 
cient to  bring  about  epilation,  materially  shortens  the  period  of 
treatment. 

Ringworm  of  the  bearded  region,  although  often  presenting  active 
and  repulsive  symptoms,  is  usually  rapidly  amenable  to  proper  treat- 
ment. Ah1  cases  are  curable,  and  only  in  the  worst  type  and  in  long- 
neglected  instances  is  there  any  significant  permanent  hair  loss  or  other 
disfigurement.  A  period  of  several  weeks  in  the  beginning  and  mild 
cases,  to  several  months  in  the  severe  forms,  is  required  to  bring  about 
a  cure. 

Treatment. — The  management  of  ringworm  varies  slightly  on 
different  parts,  not  so  much  as  to  the  remedies  themselves,  but  as  regards 
the  strength  of  applications,  although  some  applications  are  found  more 
satisfactory  in  certain  situations  than  in  others.  While,  from  the  nature 
of  the  malady,  recourse  is  had  to  practically  external  applications  alone, 
and  constitutional  treatment  usually  considered  of  no  avail,  yet,  in 
chronic  cases,  especially  of  the  scalp,  occurring  in  hospital,  dispensary, 
and  other  patients  of  impaired  nutrition,  it  has  seemed  to  me  that  the 
administration  of  cod-liver  oil  and  iron,  especially  the  former,  has  an 
influence  for  good  directly  upon  the  general  health,  and  indirectly  upon 
the  cutaneous  disease,  in  rendering  the  "soil"  a  less  desirable  one  for 
fungus  vegetation,  and  in  this  manner  lending  some  aid,  although  doubt- 
less slight,  toward  the  final  cure.  It  is  not  unlikely,  moreover,  that  sul- 
phur internally  administered  in  small  doses,  by  its  exhalation  through 
the  skin,  makes  this  structure  a  less  desirable  habitat  for  the  organism, 
and  thus  be  of  contributory  value. 


RINGWORM  1135 

Treatment  of  Ringworm  of  the  General  Surface. — The  patches  are 
to  be  kept  free  from  scaliness  by  soap-and-water  washings,  using  sapo 
viridis  in  sluggish  and  obstinate  cases.  If  temporary  disfigurement  is 
not  objected  to,  an  excellent  plan  of  treatment  consists  in  painting  the 
patch  or  patches  daily  for  three  or  four  days  with  tincture  of  iodin; 
in  young  children  the  tincture  is  to  be  diluted  with  from  \  to  i  part 
of  alcohol.  A  solution  of  sodium  hyposulphite,  i  dram  (4.)  to  the 
ounce  (32.);  fresh  sulphurous  acid;  a  lotion  of  carbolic  acid,  from  10  to 
20  grains  (0.65-1.33)  to  the  ounce  (32.);  a  mercuric  chlorid  lotion,  from 
i  to  3  grains  (0.065-0.2)  to  the  ounce  (32.),  are  all,  as  a  rule,  quickly 
efficacious.  The  same  may  be  said  of  sulphur,  white  precipitate,  and 
tar  ointments,  weakened  somewhat,  or  in  full  strength  in  obstinate 
cases.  In  the  latter  also  I  have  frequently  employed  tincture  of  iodin 
containing  i  to  3  grains  (0.065-0.2)  of  biniodid  of  mercury  to  the  ounce 
(32.);  and  also  the  plan  of  painting  with  a  saturated  solution  of  chrys- 
arobin  in  chloroform,  and  covering  with  a  coating  of  collodion.  In  the 
rather  rare  cases  of  eczematoid  eruption  of  the  hands  and  feet  Sabouraud 
and  Whitfield  have  employed  with  success  a  i  to  3  per  cent,  chrysarobin 
ointment.  Whitfeld  also  commends  using  cautiously  and  not  too  long 
an  ointment  containing  3  per  cent,  of  salicylic  acid  and  5  per  cent,  of 
benzoic  acid,  and  stronger  in  obstinate  cases  when  necessary  and  not 
irritating.  Strong  remedies  must,  of  course,  be  used  with  care. 

Treatment  of  Ringworm  of  the  Genitocrural  Region. — Any  of  the 
several  applications  already  named  will  often  be  found  useful  in  ring- 
worm in  this  location.  In  some  cases,  however,  the  eczematous  aspect 
of  the  disease  is  quite  marked,  and  at  first  only  the  milder  remedies 
are  tolerated.  For  such  types  the  calamin-zinc-oxid  lotion  with  saturated 
solution  of  boric  acid  as  the  base,  and  containing  2  to  10  grains  (0.133- 
0.65)  of  resorcin  and  5  to  10  grains  (0.333-0.65)  of  carbolic  acid  to  the 
ounce  (32.),  materially  benefits  and  sometimes  cures.  The  salicylated 
paste,  containing  30  to  60  grains  (2.~4.)  of  sulphur  or  5  to  20  grains 
(0.33-1.33)  of  resorcin  to  the  ounce  (32.),  also  acts  satisfactorily  in  some 
cases.  As  a  rule,  however,  even  in  seemingly  irritable  cases  the  stronger 
applications  may  be  made  use  of.  It  is  well  to  begin  with  the  lotion  of 
sodium  hyposulphite  already  referred  to,  dabbing  it  on  freely  twice  daily. 
If  the  parts  become  somewhat  dry  and  harsh  from  its  use,  which  fre- 
quently occurs,  after  the  solution  dries  on,  a  small  quantity  of  vaselin, 
cold  cream,  or  a  weak  sulphur  salve,  from  20  to  60  grains  (1.33-4.)  to  the 
ounce  (32.),  may  be  gently  smeared  over.  If  this  fails  to  cure,  a  lotion 
of  resorcin,  from  5  to  15  grains  (0.33-1.)  to  the  ounce  (32.),  is  to  be  tried. 
If  still  persistent,  a  lotion  of  mercuric  chlorid,  from  i  to  3  grains  (0.065- 
0.2)  to  the  ounce  (32.),  is  to  be  applied  twice  daily,  with  or  without  the 
supplementary  application  of  a  plain  unguent  or  the  cautious  use  of  a 
white  precipitate  ointment,  20  to  60  grains  (1.33-4.)  to  the  ounce  (32.). 
In  sluggish  forms  the  mercuric  chlorid  may  be  applied  in  tincture  of 
benzoin  or  myrrh,  from  2  to  4  grains  (0.13-0.265)  to  the  ounce  (32.), 
as  advised  by  R.  W.  Taylor.  In  particularly  rebellious  cases  occasional 
shampooing  of  the  parts  with  sapo  viridis  and  hot  water  is  to  precede  the 
remedial  application.  A  valuable  remedy  in  obstinate  thickened  and 


1136  PARASITIC  AFFECTIONS 

sluggish  types  of  the  disease  is  an  ointment  of  chrysarobin,  from  20  to 
60  grains  (1.3-4.)  to  the  ounce  (32.),  used  cautiously  and  intermittently 
for  only  two  or  three  days  at  a  time;  or  this  drug  may  be  applied  as  a 
paint,  as  employed  in  psoriasis.  Paintings,  once  daily  or  every  other  day, 
with  the  tincture  of  iodin,  full  strength  or  weakened  if  the  skin  is  irritable, 
is  also  valuable,  and  applied  well  at  the  borders  and  slightly  beyond,  will 
sometimes  stop  the  extension  of  the  disease  as  well  as  prove  curative; 
in  sluggish  cases  the  biniodid  of  mercury,  i  to  3  grains  (0.065-0.2)  to 
the  ounce  (32.),  can  be  added.  After  the  disease  is  seemingly  cured, 
occasional  remedial  applications  are  to  be  advised  for  a  few  weeks  in 
order  to  guard  against  a  relapse.  The  same  plans  of  treatment  are  to  be 
pursued  when  the  disease  is  situated  in  and  about  the  axilla. 

Treatment  of  Ringworm  of  the  Scalp.1 — The  hair  around  the  patch 
or  patches  should  be  cut  close  or  even  shaved;  that  of  the  surround- 
ing scalp  is  to  be  kept  short,  so  as  to  permit  of  easy  inspection,  thus 
facilitating  the  discovery  of  any  new  foci  of  disease.  If  there  are  more 
than  several  patches,  it  is  advisable  that  the  hair  of  the  entire  scalp 
should  be  closely  cropped  or  shaved  from  time  to  time.  If  the  area  of 
disease  is  "Small,  the  hair  on  the  patch  and  that  immediately  surrounding 
should  be  carefully  extracted  with  the  depilating  forceps.  It  is  not, 
however,  feasible  in  cases  of  any  extent,  and  often  in  limited  areas  it  is 
difficult  to  have  it  properly  followed  out ;  and  in  some  instances,  too,  the 
broken  hairs  and  hair-stumps  are  so  fragile  and  break  so  easily  that  they 
cannot  be  readily  extracted.  For  these  reasons  in  late  years,  except  in 
selected  cases,  I  have  made  use  (Brayton)  of  a  depilatory  for  ridding  the 
patch  of  the  hair  and  hair-stumps;  owing  to  the  nascent  sulphureted 
hydrogen  evolved,  the  depilatory  has  also  some  direct  remedial  value. 
One  consisting  of  3  drams  (12.)  of  barium  sulphid  and  2\  drams  (10.) 
each  of  zinc  oxid  and  powdered  starch  can  be  employed.  At  the  time 
of  application  enough  water  is  added  to  a  sufficient  portion  to  make  a 
paste,  and  this  is  spread  in  a  thick  layer  on  the  area  or  areas,  slightly 
overlapping  the  edges.  It  is  to  remain  on  from  several  to  ten  minutes, 
according  to  the  character  of  the  hair,  the  sensitiveness  of  the  skin,  as 
well  as  to  the  efficiency  of  the  depilatory;  as  soon  as  heat  of  the  skin  or  a 
burning  sensation  is  felt  it  is  washed  off  thoroughly,  and,  if  it  has  acted  as 
it  should,  the  hairs,  including  the  stumps,  will  have  been  destroyed  deep 
into  the  follicles,  and  sometimes  possibly  to  the  full  depth  of  the  latter. 
Should  there  be  accidentally  much  resulting  irritation,  a  soothing  oint- 
ment can  be  applied  for  a  few  hours  or  so;  as  a  rule,  this  is  not  necessary. 
The  depilatory  should  be  used  every  five  to  ten  days,  depending  upon 
the  rapidity  of  regrowth.  It  should  never  be  applied  to  an  actively  in- 
flammatory patch. 

Before  taking  up  the  consideration  of  the  remedial  applications 
certain  adjuvant  measures  should  be  referred  to.  The  spread  of  the 
disease  to  other  parts  of  the  scalp  and  to  other  children  should  be  pre- 
vented, as  far  as  this  is  possible,  by  certain  routine  measures,  and  these 
can,  as  a  rule,  be  carried  out  even  when  the  active  remedies  are  being 
used  upon  the  patches.  With  this  object  in  view  the  scalp  is  to  be  washed 
1  The  #-ray  treatment  will  be  referred  to  later. 


RINGWORM  1137 

every  second  or  third  day  with  a  medicated  sapo  viridis  such  as  the 
following : 

1$.     Sulphur,  prascip.,  5j  (4-); 

/3-naphthol,  gr.  xx-xl  (1.33-1.65); 

Saponis  viridis,  §j  (32.). 

The  lather  should  be  permitted  to  remain  on  for  five  to  fifteen  min- 
utes, as  it  has  in  itself  an  inhibitory  or  destructive  influence  upon  the 
fungus.1  If  there  is  risk  of  taking  cold,  the  parts  may  be  enveloped 
with  some  covering.  The  lather  is  subsequently  thoroughly  rinsed  off, 
the  scalp  rubbed  dry,  and  then  a  general  parasiticide  application  made. 
For  this  purpose  either  an  ointment  consisting  of  i  dram  (4.)  of  pre- 
cipitated sulphur,  30  grains  (2.)  of  /3-naphthol,  and  an  ounce  (32.)  of 
petrolatum;  or  a  lotion  of  2  drams  (8.)  carbolic  acid,  resorcin  i  dram  (4.), 
and  saturated  solution  of  boric  acid  i  pint  (500.)  can  be  used.  Such  a 
general  application  should  be  made  once  daily.  It  is  possible  that  the 
salve  is  more  effectual  in  preventing  the  dissemination  of  the  spores, 
although  it  is  not  so  agreeable  as  the  lotion.  As  an  additional  measure 
in  preventing  the  spread  of  the  disease,  paper  or  any  other  material  which 
permits  of  daily  destruction  or  washing  should  be  constantly  worn  as  the 
hat  lining.  Whatever  remedial  method  is  adopted,  it  should  be  thor- 
oughly carried  out;  if  a  wash  is  used,  it  is  to  be  first  gently  rubbed  in  for 
a  minute  or  two,  and  then  dabbed  on  for  five  or  six  minutes;  if  an  oint- 
ment, it  should  be  well  worked  in  by  gentle  but  somewhat  firm  rubbing 
for  five  to  ten  minutes.  Many  remedies  have  been  brought  forward 
from  time  to  time  for  the  rapid  cure  of  ringworm  of  this  region,  but 
those  of  large  experience  in  its  treatment  soon  learn  that  it  is  not  so 
much  the  remedy  selected  as  it  is  the  thoroughness  of  its  application  and 
the  perseverance  in  its  use  that  bring  success.  For  recent  patches  the 
white  precipitate  ointment,  sulphur  ointment  weakened  with  i  or  2 
parts  of  lard,  tar  ointment  weakened  or  of  official  strength,  paintings 
with  tincture  of  iodin,  sulphurous  acid,  pure  or  diluted,  resorcin  in  lotion 
or  ointment  from  5  to  10  per  cent,  in  strength,  an  ointment  of  calomel 
from  30  to  60  grains  (2.~4.)  to  the  ounce  (32.),  carbolic  acid  in  lotion  or 
ointment,  from  20  to  60  grains  (1.3-4.)  to  the  ounce  (32.),  will  all  be  found 
valuable  and  frequently  curative  after  several  weeks'  or  a  few  months' 
use.  An  old  method  of  treatment  consists  in  the  use  of  Coster's  paint 
(iodin,  oij  (8.);  oil  of  tar,  3vj  (24.)),  one  or  two  coats  daily  for  two  days, 
allowing  the  crust  that  forms  partly  to  detach  itself,  and  then  gently 
pulling  it  off.  The  application  is  repeated  several  times  and  will  be 
found  satisfactory,  especially  in  the  treatment  of  recent  patches;  it 
should  not  be  used  in  children  under  three  or  four  years  of  age  unless 
the  proportion  of  iodin  is  lessened.  In  many  of  the  chronic  cases,  how- 
ever, stronger  applications  will  be  found  necessary.  Among  the  latter 
may  be  mentioned  mercury  oleate,  strong  sulphur  ointment,  and  a 
paint  or  ointment  of  chrysarobin.  Strong  carbolic  acid  ointments,  from 

1  See  interesting  papers  bearing  upon  this  point  and  the  influence  of  other  sub- 
stances upon  the  vitality  of  the  fungus  by  Thin,  Brit.  Med.  Jour.,  1889,  i,  p.  397,  and 
Schwengers,  Monatshefte,  1890,  vol.  xi,  p.  155. 

72 


1138  PARASITIC  AFFECTIONS 

i  to  2  drams  (2. -8.)  to  the  ounce  (32.),  will  also  prove  useful.  Mercury 
oleate  in  the  form  of  an  ointment,  from  10  to  25  per  cent,  strength,  is 
often  in  itself  a  valuable  remedy.  Mercuric  chloric!  in  solution  is  also  a 
valuable  and  frequently  used  remedy,  applied  in  solution  in  the  strength 
of  i  to  4  grains  (0.065-0.265)  to  the  ounce  (32.),  preferably  of  equal 
parts  of  water  and  alcohol;  it  should  not  be  applied  to  the  entire  scalp 
in  its  stronger  proportion  for  fear  of  absorption. 

While  I  have  employed  most  of  the  remedies  of  older  reputation  and 
the  new  ones  introduced  in  recent  years  with  success,  the  management 
of  these  cases  has  in  recent  years  in  my  own  practice  narrowed  itself  down 
to  the  use  of  sulphur,  /?-naphthol,  iodin,  chrysarobin,  and  croton  oil, 
conjointly  with  the  adjuvant  measures  already  referred  to.  Sulphur 
and  naphthol  are  most  valuable  and  appropriate  for  those  cases  in- 
volving a  greater  part  of  the  scalp;  chrysarobin  and  iodin  for  circum- 
scribed areas,  and  croton  oil  for  those  patches  which  have  persistently 
failed  to  yield  to  the  other  remedies.  Sulphur  and  naphthol  are  pre- 
scribed together  in  ointment,  2  drams  (8.)  of  the  former  and  30  to  60 
grains  (2. -4.)  of  the  latter,  with  enough  benzoated  lard  or  lard  and 
petrolatum  to  make  the  ounce  (32.),  and  will  prove  valuable  in  recent 
cases  and  especially  in  young  subjects.  Occasionally  this  amount  of 
naphthol,  in  those  of  extremely  sensitive  skin,  gives  rise  to  a  feeling  of 
considerable  burning,  and  in  such  instances  this  ingredient  can  be  reduced 
in  quantity.  Exceptionally,  also,  the  quantity  of  sulphur  must  be  less- 
ened in  young  children.  This  ointment  can  also  be  satisfactorily  em- 
ployed as  the  beginning  treatment  in  extensive  cases,  the  more  recently 
affected  parts  usually  soon  yielding,  leaving  the  chronic  areas  for  the 
stronger  remedies  to  be  mentioned. 

Ordinarily,  however,  the  best  application  for  the  patches  in  young 
patients  and  in  recent  areas  in  other  cases  is  iodin  tincture,  containing 
a  small  quantity  of  mercuric  iodid,  as  in  the  following: 

fy     Hydrarg.  biniodid.,  gr.  j-iij  (0.033-0.2); 

Tinct.  iodini,  3j  (32.). 

This  is  painted  on  twice  daily,  two  or  three  coatings  at  each  time,  until 
the  areas  become  somewhat  tender  or  until  the  film  thus  formed  cracks 
or  begins  to  loosen.  The  parts  are  then  anointed  with  a  mild  salve, 
and  as  soon  as  the  film  is  detachable  it  is  picked  or  pulled  off.  If  there 
is  active  underlying  irritation,  which  is  not  usually  observed,  the  same 
ointment  may  be  applied  for  a  day  or  so,  and  the  paintings  resumed. 
If  the  iodin  applications  seem  to  be  slow  in  bringing  about  complete 
cure,  another  plan  is  to  be  instituted. 

Chrysarobin  is  by  far  the  most  valuable  application  in  most  of  the 
cases,  but  this  drug  as  made  by  various  manufacturing  chemists  differs 
considerably  in  quality;  naturally,  an  efficient  preparation  is  an  essential 
for  success.  It  is  also  highly  indorsed  by  Duhring,  Malcolm  Morris, 
Hutchinson,  Unna,  Allen,  Corlett,  and  many  others.1  It  may  be  used 

*  See  papers  by  Duhring,  "Experience  in  the  Treatment  of  Chronic  Ringworm  in  an 
Institution,"  Amer.  Jour.  Med.  Sci.,  vol.  ciii,  1892,  i,  p.  109;  by  Allen,  "Treatment  of 
Ringworm  of  the  Scalp  in  Institutions,"  Pediatrics,  1896,  vol.  ii,  p.  169. 


RING  WORM  1 1 39 

in  all  cases,  but  more  especially  in  those  of  somewhat  limited  extent ;  it 
must  be  employed  with  greater  care  in  patients  under  the  age  of  three 
years;  in  fact,  in  most  of  the  younger  patients  the  sulphur-naphthol 
salve  or  the  iodin  paintings  will  suffice  to  bring  about  a  cure,  and  are  to 
be  preferred.  Chrysarobin  is  most  satisfactorily  applied  as  a  saturated 
solution  in  chloroform,  and  in  the  manner  described  in  psoriasis.  The 
areas  are  painted  over  with  this  until  well  coated  with  a  film  of  chrysaro- 
bin,  the  chloroform  rapidly  evaporating.  Over  this  are  then  painted 
three  or  four  layers  of  good  collodion.  No  further  application  is  to  be 
made  until  the  film  so  formed  begins  to  crack  or  to  detach  itself.  As 
soon  as  it  becomes  detachable  it  is  gently  pulled  off,  and  if  there  is  any 
active  irritation  beneath,  a  mild  ointment  may  be  used  for  a  few  hours 
or  a  day  until  this  is  subdued  and  the  paintings  resumed.  In  some  (but 
if  employed  with  care  not  in  many)  instances  chrysarobin  gives  rise  to 
a  mild  or  moderately  severe  dermatitis  of  the  surrounding  skin,  and  under 
these  circumstances  it  becomes  necessary  to  suspend  its  use  temporarily. 
In  rare  instances  this  tendency  to  dermatitis  may  repeat  itself,  the  skin 
of  the  patient  being  intolerant  of  this  remedy,  and  it  must  be  then  set 
aside  and  give  place  to  another  plan. 

In  some  patients  these  several  methods  will  fail  to  bring  about  a 
cure;  or  more  frequently  will  cure  most  of  the  areas,  but  fail  to  make  suffi- 
cient impression  upon  a  few  patches.  It  is  just  in  such  instances  especially 
that  croton  oil,  so  strongly  advised  by  Aldersmith,  has  its  particular 
field  of  usefulness.  In  those  cases,  too,  in  which,  for  various  reasons,  a 
rapid  cure  is  desired,  recourse  may  be  had  to  this  application.  It  is  a 
severe  remedy,  and  the  parts  are  made  actively  inflammatory;  its  care- 
less use,  and  the  pushing  of  the  inflammatory  action  beyond  a  reasonable 
limit,  would,  of  course,  result  in  considerable  follicular  destruction.  It 
must  always  be  used  with  caution,  and  it  is  never  to  be  employed  in  young 
children,  nor  applied  to  an  area  at  any  one  time  larger  than  an  inch  in 
diameter;  larger  areas  can  be  treated  in  sections.  The  application 
should  be  made  by  the  physician  himself  or  by  a  trained  attendant. 
With  this  plan  of  treatment  the  use  of  the  depilatory,  except  as  a  be- 
ginning measure,  is  to  be  omitted. 

At  first  it  is  desirable  to  have  the  oil  weakened  with  2  or  3  parts 
of  almond  oil,  and  if  it  is  found  that  no  active  inflammation  arises, 
it  should  be  applied  stronger.  In  most  cases,  especially  in  older  children, 
the  pure  oil  is  required.  It  should  be  scantily  used,  as  it  seems  to  have  a 
distinct  tendency  to  spread  beyond  the  part;  a  little  vaselin  at  the  border 
of  the  area  will  circumscribe  its  action.  It  is  to  be  applied  two  or  three 
times  daily,  and  to  bring  about  the  desired  amount  of  inflammatory 
reaction  ordinarily  requires  two  to  six  days.  When  it  is  possible  to  have 
poultices  repeatedly  applied  afterward  the  oil  applications  may  be  dis- 
continued as  soon  as  slight  swelling  and  minute  pustulation  present;  the 
subsequent  poulticing  will  bring  about  sufficiently  pronounced  inflam- 
mation. 

Case's  of  disseminated  ringworm  can  be  treated  by  active  methods — 
iodin  or  chrysarobin  paintings.  If  the  spots  are  numerous,  the  number 
may  be  usually  brought  down  by  the  use  of  the  sulphur-naphthol  oint- 


1 140  PARASITIC  AFFECTIONS 

ment  and  then  the  remaining  obstinate  spots  can  be  treated  with  iodin 
or  chrysarobin;  if  necessary  for  final  cure,  the  oil  can  be  employed.  In 
such  cases  many  of  the  areas  yield  readily  with  any  good  treatment, 
leaving  behind  several  or  more  obstinate  spots.  In  those  instances 
in  which  the  disease  is  so  extensive  as  practically  to  involve  the  greater 
part  of  the  scalp,  presenting  large  and  irregular  areas  or  confluent  sheets, 
it  is  advisable  to  use  the  stronger  sulphur- naphthol  ointment  until  it  is 
reduced  in  extent.  Or  this  can  be  applied  to  the  parts  generally,  and  small 
portions  treated  with  the  iodin  or  chrysarobin  paintings.  Croton  oil,  if 
used  at  all,  should  be  left  until  the  disease  is  reduced  to  several  circum- 
scribed areas ;  it  is  never  to  be  employed  in  the  beginning  of  treatment  in 
these  confluent  cases.  For  the  markedly  inflammatory  types,  and 
particularly  kerion,  the  application  of  boric  acid  ointment,  or  an  oint- 
ment of  sulphur,  30  to  60  grains  (2. -4.)  to  the  ounce  (32.),  or  one  of 
white  precipitate,  20  to  40  grains  (1.33-2.65)  to  the  ounce  (32.),  is  to  be 
advised.  After  the  active  inflammatory  signs  have  subsided  the  same 
can  be  continued,  or  stronger  treatment  instituted.  Ordinarily  in 
kerion  the  inflammatory  process  itself  is  destructive  to  the  fungus,  or 
casts  it  off  and  brings  about  a  cure. 

Among  other  remedies  and  plans  which  are  variously  indorsed  may  be 
mentioned  a  10  to  25  per  cent,  ointment  of  oleate  of  copper  (Shoemaker, 
Crocker) ;  covering  the  diseased  area  nightly  with  a  compress  wet  with  a 
4  to  5  per  cent,  solution  of  calcium  chlorid,  and  enveloping  with  rubber 
tissue,  followed  the  next  morning  by  washing  with  soap  and  water  and 
the  application  of  diachylon  plaster,  with  twice  weekly  a  painting  writh 
tincture  of  iodin  (Sabouraud) ;  applications  of  formaldehyd  in  the  strength 
of  formalin  (40  per  cent.)  or  weakened  (Pottevin,  Salter,  Vidal,  Solares, 
Hutchins,  Allen) ;  the  application  and  penetration  of  corrosive  sublimate 
solution  by  cataphoresis  (Ambrosi,  Reynolds,  Ravogli,  Wessinger); 
and  the  Harrison  method,  consisting  of  the  use  of  two  solutions:  No.  i, 
of  |  dram  (2.)  of  potassium  iodid  and  4  drams  (16.)  each  of  liquor  potassae 
and  spirits  of  wine;  No.  2,  of  4  grains  (0.265)  of  mercuric  chlorid  and  4 
drams  (16.)  each  of  spirits  of  wine  and  water,  applying  No.  i  at  first 
and  following  with  No.  2 ;  it  is  a  severe  method,  exciting  considerable  in- 
flammation and  occasionally  resulting  in  scars,  and  has  been  condemned 
by  some  and  commended  by  others. 

Jackson1  gets  success  in  most  cases  with  an  ointment  made  of  about 
i  dram  (4.)  of  iodin  crystals  and  i  ounce  (32.)  of  goose  grease;  it  is  to 
be  applied  twice  daily  until  it  produces  a  reaction,  which  is  shown  by  a 
slight  swelling  of  the  patch,  and  then  once  daily;  in  two  to  three  weeks  the 
hair  falls  out,  which  usually  presages  the  cure,  the  hair  finally  regrowing 
and  showing  no  evidence  of  disease. 

-3T-ray  treatment,  which  was  introduced  by  Sabouraud  and  Noire,2 

1  Jackson,  Med.  Review,  Feb.  i,  1902,  and  April  n,  1903. 

2  Sabouraud  and  Noire,  La  presse  mcdicale,  1904,  p.  825,  and  Annales,  1904,  p.  80; 
account  also  by  Bunch,  Brit.  Jour.  Derm.,  1904,  p.  265,  and  Lancet,  Feb.  18,  1905,  and 
in  editorials  in  Brit.  Jour.  Derm.,  Feb.,  1905,  and  Jour.  Cutan.  Dis.,  April,  1905;  and 
abstract  translation  of  Sabouraud  and  Xoire's  paper  by  W.  S.  Fox,  in  Brit.  Jour.  Derm., 
Feb.,  1905*  p.  67;  Macleod,  Brit.  Med.  Jour.,  Sept.,  1905;  Adamson,  "A  Simplified 
Method  of  *-ray  Application  for  the  Cure  of   Ringworm  of   the  Scalp  (Kienbock's 


RINGWORM 


II4I 


is  a  remedy  that  is  promptly  curative  in  ringworm  of  the  scalp,  and  whose 
favorable  experience  has  been  repeated  by  others.  Their  method  is 
based  upon  one  measured  application  of  this  agent  sufficient  to  produce 
depilation,  this  latter  ensuing  two  to  three  weeks  after  exposure,  and 


Fig.  302. — The  Sabouraud  method  of  #-ray  treatment  (from  Sabouraud's  Les  Teignes). 

without,  at  the  most,  the  production  of  more  than  the  mildest  #-ray 
erythema.1  Others  have  used  the  x-ray  treatment  cautiously,  at  inter- 
Method),"  Lancet,  1909,  p.  1379;  Dore,  "The  Present  Position  of  the  x-ray  Treatment 
in  Ringworm,"  Lancet,  1911,  clxxx,  p.  432.  In  a  recent  article  (" Radio therapie  des 
teignes,"  Annales,  1900,  p.  452)  Sabouraud  goes  over  the  ground  again,  as  above  de- 
tailed, replying  to  criticisms,  citing  the  possible  accidents  and  the  measures  to  avoid 
them. 

1  The  essence  of  the  method  of  Sabouraud  and  Noire  consists  in  giving  one  exposure 
sufficiently  long  to  produce  depilation,  and  yet  not  long  enough  to  be  productive  of  any 
ill-effects.  This  is  done  by  employing  some  means  of  measuring  the  quantity  of  rays, 
and  by  keeping  the  vacuum  of  the  tube  at  a  point  equal  to  about  a  3-inch  spark  gap.  A 
properly  constructed  milliamperemeter  (in  this  instance  the  D'Arsonval  meter)  can  be 
inserted  in  the  secondary  circuit;  and,  most  important  of  all,  radiometer  pastils  of 
Sabouraud  and  Noire — i.  e.,  circular  wafers  of  paper  coated  with  an  emulsion  of  platino- 
cyanid  of  barium  in  a  collodion  of  amyl  acetate— one  of  which  is  placed  on  a  metal  plate 
(impermeable  to  the  rays)  at  a  distance  of  3  inches  from  the  anticathode.  These 
wafers  have  the  property  of  changing  color  under  the  action  of  the  #-rays  in  proportion 
to  the  quantity  of  rays  absorbed.  Under  similar  conditions  of  current,  tube,  and 
atmosphere  (the  rays  act  more  rapidly  when  the  air  is  dry)  the  time  required  to  change 
the  color  from  its  yellowish-green  to  a  standard  tint  of  fawn  is  that  which  is  requisite  to 
produce  complete  depilation  without  dermatitis  or  danger  of  permanent  alopecia. 
In  short:  "To  cure  a  patch  of  ringworm  of  the  scalp  by  the  x-ray,  place  the  patch  at  a 
distance  of  15  centimeters  from  the  center  of  the  focus  tube,  and  place  at  the  same  time 
a  disk  of  platinocyanid  of  barium  paper  8  centimeters  from  the  center  of  the  tube. 
When  this  disk  has  taken  the  color  corresponding  to  the  tint  'B'  of  Sabouraud  and 
Noire's  radiometer  (and  to  5  H  of  Holzknecht's  scale),  the  operation  is  terminated." 
There  is  a  risk  if  this  exposure  is  exceeded.  If  the  exposures  are  made  in  daylight  it  is 
necessary  to  place  the  pastil  in  black  paper,  and  the  examining  must  be  done  quickly, 
as  the  pastil  returns  to  its  normal  color  rapidly  when  exposed  to  daylight. 

In  the  course  of  a  week  after  exposure  a  faint  erythema  is  usually  noted,  which  is 
succeeded  in  a  few  days  by  a  slight  pigmentation;  after  about  two  weeks  the  hair  begins 


1 142 


PARASITIC  AFFECTIONS 


vals  of  a  few  days,  till  falling  out  of  the  hair  results;  this  method,  however, 
is  not  to  be  commended,  as  there  is  danger  of  overdosage.  Care  should  be 
exercised  that  the  slightest  reaction  is  not  exceeded,  otherwise  there  is 
risk  of  permanent  baldness.  It  is  not  a  method  to  be  used  by  those  in- 


Fig.  303. — The  Kienbock-Adamson  method  of   #-ray  treatment  (from  Sabouraud's 

Les  Teignes). 

experienced  in  the  use  of  the  x-ray,  and  not,  in  my  judgment,  to  be  used 
except  in  chronic  and  rebellious  cases.  It  has  its  particular  field  in  the 

to  fall  out,  which  process  is  usually  completed  in  a  week.  Should  (from  insufficient 
dosage  or  idiosyncrasy)  this  not  take  place,  after  waiting  two  weeks  more,  another  ex- 
posure is  made.  Inasmuch  as  the  fungus  is  not  destroyed  by  the  #-ray,  in  order  to 
prevent  reinfection  after  exposure  an  ointment  of  oil  of  cade  is  rubbed  in  nightly,  and 
in  the  morning  the  scalp  shampooed,  and  an  alcoholic  lotion  containing  tincture  of  iodin 
applied  to  the  entire  scalp.  If  there  is  an  impetiginous  tendency,  an  ointment  of  sali- 
cylic acid  and  sulphur  or  white  precipitate  is  used  instead  of  the  tar  ointment.  After 
thirty  days  a  careful  search  is  made  to  see  that  no  diseased  hairs  have  escaped;  and  every 
fifteen  days  an  examination  is  made  until  complete  regrowth  has  taken  place,  which  is 
usually  a  matter  of  several  months;  about  two  months  after  exposure  the  hair  is  visible, 
and  normal  growth  complete  three  months  later. 

In  preparing  for  the  exposure  the  scalp  is  carefully  examined,  and  if  there  are  not 
more  than  five  patches,  circles  are  drawn  around  each  patch,  going  i  cm.  beyond  the 
diseased  area;  these  areas  are  then  painted  with  tincture  of  iodin,  and  the  hair  cropped 
close.  Each  area  is  then  exposed  to  the  rays  seriatum,  all  on  the  same  day.  If  the  dis- 
ease is  more  extensive  and  scattered,  the  whole  scalp  is  exposed  successively  in  six  sec- 
tions, being  careful  not  to  expose  any  point  twice.  The  parts  not  treated  are,  of  course, 
protected  by  tin  or  lead-foil;  or  the  tube  is  enclosed  with  a  projected  opening  adjusted  to 
treat  only  the  part  desired.  According  to  Sabouraud  and  Noire,  only  three  months  are 
now  required  for  a  cure  of  cases  (in  1'ecole  lailler,  H6pital  St.  Louis,  Paris)  that  formerly 
took  two  years. 


RINGWORM  1143 

treatment  of  epidemic  institutional  scalp  ringworm.  Until  somewhat 
recently  the  Sabouraud  method  of  application  had  been  that  usually 
employed,  cylindric  metallic  or  lead-foil  localizers  or  protectors  being 
used.  In  extensive  cases,  however,  in  which  the  disease  involves  a  large 
or  greater  portion  of  the  scalp  and  complete  epilation  of  the  entire 
scalp  is  desirable,  the  Kienbock-Adamson1  method  is  rapidly  growing  in 
favor. 

In  all  cases  of  ringworm  of  the  scalp  treatment  is  to  be  discontinued 
temporarily  after  several  weeks  or  a  few  months,  according  to  the  grade 
of  the  disease,  for  the  purpose  of  noting  the  progress  made.  As  long  as 
stumps  are  to  be  seen  and  a  tendency  to  scaliness  persists,  especially 
the  former,  a  cure  has  not  been  effected.  If  there  should  be  any  doubt 
upon  this  point  several  of  the  suspected  hairs  and  also  the  new-growing 
hairs  should  be  subjected  to  microscopic  examination.  If  it  is  shown  that 
there  has  not  been  any  or  much  progress  toward  cure,  a  change  of  appli- 
cation is  to  be  instituted.  If,  however,  considerable  progress  has  been 
made,  it  is  advisable  to  adhere  to  the  same  line  of  treatment. 

Ringworm  of  the  Bearded  Region. — Extraction  of  the  hairs  from 
the  affected  areas  is  a  measure  that  will  aid  considerably  in  promoting 
a  cure,  and  is,  therefore,  to  be  considered  an  essential  part  of  the  manage- 
ment of  the  disease.  The  hair  on  other  parts  of  the  bearded  region 
should  be  kept  sufficiently  short  or  shaved  to  permit  of  easy  inspection, 
so  that  any  new  foci  developing  will  be  readily  discovered  and  treated 
before  the  fungus  is  firmly  established.  Almost  any  of  the  applications 
mentioned  in  the  treatment  of  the  other  varieties  will,  if  perseveringly 
used,  prove  efficacious  in  this  form  also.  Experience  teaches  that  the 
best  remedies,  however,  are  the  lotions  of  sodium  hyposulphite  and 
mercuric  chlorid,  and  ointments  of  white  precipitate  or  calomel,  of  sul- 
phur, and  of  oleate  of  mercury.  The  treatment  in  my  own  practice  has 
gravitated  to  two  plans  as  being  the  most  promising  of  rapid  results — 
one  a  sulphur  treatment  and  the  other  a  mercurial.  Both  are,  doubtless, 
in  the  aggregate  of  cases  equally  efficacious,  but  in  some  instances,  when 
progress  is  slow  or  unsatisfactory  from  one  plan,  a  change  to  the  other 
is  found  to  be  of  advantage.  In  the  sulphur  treatment  a  lotion  of  so- 
dium hyposulphite,  i  dram  (4.)  to  the  ounce  (32.),  and  an  ointment  of 

1  By  Adamson's  method  only  five  exposures  are  necessary  to  depilate  the  entire 
scalp,  thereby  reducing  the  time  of  irradiation  to  one  and  one-half  hours.  The  scalp  is 
divided  into  five  areas,  with  each  of  the  marked  points  as  a  center;  a  sagittal  line  is 
drawn— the  hair  having  been  previously  clipped  off  short— from  front  to  back,  and 
markings  (A,  B,  C)  made  at  three  points — one  (A)  about  i  inch  from  the  anterior 
forehead  hair  border,  one  (C)  about  i  inch  above  the  posterior  occipital  hair  border, 
and  the  other  (B)  midway  between  these  two.  Another  line  is  made  extending  through 
the  middle  scalp  point  (B)  across  from  ear  to  ear,  marking  points  (D,  D.')  about  i 
inch  above  the  ears.  An  exposure  is  made  consecutively  to  each  of  the  five  points  as 
the  centers,  with  a  tube  enclosed  in  a  box-shield  having  an  aperture  of  3  inches  in 
diameter;  the  adjacent  bare  skin  must  be  properly  shielded.  Each  area  is  to  have  a 
Sabouraud  pastil  dose.  In  this  manner  those  sections  of  the  scalp  where  overlapping 
of  the  exposed  areas  occurs,  the  incidence  of  the  rays  is  so  oblique,  and  so  much  further 
from  their  source,  that  the  dose  of  *-rays  impinging  on  these  overlapping  parts  is  not 
excessive,  but  just  sufficient  to  cause  a  defluvium  of  the  hair.  To  the  tube-shield  are 
attached  three  pegs  made  of  soft  wood,  against  which  the  scalp  rests,  so  that  the  head 
is  retained  throughout  the  exposure  at  a  distance,  at  the  central  point,  of  6£  inches 
from  the  anticathode. 


1 1 44  PARASITIC  AFFECTIONS 

precipitated  sulphur  of  from  10  to  20  per  cent,  strength,  are  conjointly 
prescribed.  The  mercurial  plan  consists  in  the  use  of  a  corrosive  sub- 
limate lotion,  from  i  to  3  grains  (0.033-0.2.)  to  the  ounce  (32.),  together 
with  the  employment  of  an  ointment  of  10  per  cent,  oleate  of  mercury, 
2  or  3  drams  (8.-I2.)  of  the  oleate  with  sufficient  simple  cerate,  or  simple 
cerate  and  lard,  to  make  up  the  ounce  (32.) ;  or,  with  a  10  to  20  per  cent, 
white  precipitate  or  calomel  ointment.  The  plan  being  selected,  the 
method  of  carrying  it  out  is  as  follows:  The  lotion  is  applied  freely,  being 
thoroughly  dabbed  over  the  affected  areas  and  somewhat  less  liberally 
over  the  whole  bearded  region — over  the  latter  in  order  to  prevent  the 
infection  of  new  areas;  after  the  wash  has  dried  the  ointment  is  to  be 
well  rubbed  in,  usually  over  the  diseased  places  only,  but,  if  there  is  a 
decided  disposition  toward  spreading,  the  ointment  as  well  as  the  lotion 
should  be  applied,  once  daily  at  least,  to  the  entire  bearded  part  of  the 
face  and  neck.  The  applications  should  be  made  morning  and  evening, 
and  in  urgent  cases  three  or  four  times  daily.  Before  the  application, 
or  once  or  twice  daily,  the  parts  should  be  washed  off  with  warm  or  hot 
water  and  soap.  Treatment  should  be  continued  vigorously  until  all 
vestiges  of  the  disease  have  disappeared;  and  then  intermittently  or 
less  actively  for  several  weeks  in  order  that  the  possibility  of  a  relapse 
may  be  guarded  against.  As  in  ringworm  of  the  scalp,  the  x-ray  can  also 
be  employed  in  this  form,  but  its  use  always  requires  caution,  and  most 
cases  can  be  as  well  managed  without  it. 

TINEA  IMBRICATA 

Synonyms. — Tokelau  ringworm;  Scaly  ringworm;  Bowditch  Island  ringworm; 
Chinese  ringworm;  India  ringworm;  Burmese  ringworm;  Malabar  itch;  Gune  (Fox); 
Cascadoe  (Meederwort) ;  Herpes  desquamans  (Turner);  Lafa  Tokelau;  Tinea  circinata 
tropica;  Le  peta;  Buckwar. 

Definition.— A  vegetable  parasitic  disease  of  moist,  tropical 
countries,  characterized  by  the  formation  of  patches  composed  of  con- 
centrically arranged,  imbricated,  scaly  rings. 

Ill-defined  accounts  of  this  peculiar  malady  are  found  in  the  contri- 
butions of  voyagers,  but  the  first  accurate  description  is  that  by  Fox,1 
a  United  States  medical  officer,  in  1841.  Since  then  other  careful  re- 
ports have  appeared,  among  which  the  more  recent  by  Koniger,2 
McCall  Anderson,3  Roux,4  Bonnafy  and  Mialaret,5  Manson,6  Nieuwen- 
huis,7  Tribondeau,8  Henggeler  and  others.9 

^ox,  "Narrative  of  the  United  States  Exploring  Expedition,  1838-42,  under 
command  of  C.  Wilkes,"  vol.  v,  p.  401,  cited  by  Corlett,  Bangs  and  Hardaway's 
American  Text-Book. 

2  Koniger,  Virchow's  Archiv,  1878,  vol.  Ixxii,  p.  413. 

3  McCall  Anderson,  Edinburgh  Med.  Jour.,  1880,  vol.  xxvi,  pt.  i,  p.  204  (with  case 
and  fungus  illustrations). 

4  Roux,  Traite  prat,  mal  des  pays  chauds,  1888,  vol.  in,  p.  231  (cited  by  Corlett). 

5  Bonnafy  and  Mialaret,  Arch,  de  med.  navale,  1891,  vol.  Ivi,  p.  269. 

6  Manson,  Brit.  Jour.  Derm.,  1892,  p.  5. 

7  Nieuwenhuis,  Archiv,  1898,  vol.  xlvi,  p.  163. 

8  Tribondeau,  Arch,  de  med.  navale,  July,  1899,  p.  5,  Compt.  rend,  de  la  Reunion 
Biologique  de  Bordeaux,  Jan.  19,  1901,  and  Jan.  13,  1903. 

9  Other  recent  valuable  contributions  on  tinea  imbricata  are:  R.  Koch,  "Frambcesia 
tropica  und  Tinea  imbricata,"  Archiv,  1902,  vol.  lix,  p.  5  (with  case  illustrations); 
Wehmer,  "Der  Aspergillus  des  Tokelau,"  Centralbl.  f.  Bakteriol,  1903,  xxxv,  p.  140; 


PLATE  XXXI. 


Tinea  imbricata  (courtesy  of  Dr.  ().  Henggeler. ) 


TINEA   I  MB  R  1C  ATA  1 145 

Symptoms. — The  malady  begins,  according  to  Manson,  at  one 
or  sometimes  at  several  points,  as  a  brownish  spot,  slightly  raised,  and 
which  gradually,  in  the  course  of  a  few  weeks,  increases  in  size  by 
peripheral  extension  to  almost  \  inch  in  diameter,  when  the  central  epi- 
dermal covering  breaks  and  the  epidermis  cracks  from  the  center  toward 
the  border,  becomes  somewhat  detached  centrally,  and  bent  upward. 
Soon  this  spot  is  surrounded  by  a  brownish  zone  about  yg-  inch  wide, 
which  in  turn  shows  the  epidermic  detachment  and  curling  at  its 
inner  side,  and  so  the  malady  spreads.  The  renewed  epidermis  of  the 
central  part  of  the  patch  goes  again  through  the  same  process,  and  in 
this  manner  the  ever-increasing  area  is  made  up  of  several  or  more  con- 
centrically arranged,  imbricated,  shingled-like  rings.  When  several 
such  patches  are  close  together,  fusion  takes  place,  and  the  concentric 
regularity  is  broken  and  the  pattern  becomes  more  complicated,  although 
the  gross  features  of  the  epidermic  shingles  are  maintained.  The  erup- 
tion may,  in  the  course  of  months,  invade  a  great  part  of  the  surface. 
The  skin  beneath  the  curling  epidermis  is  noted  to  be  paler  than  the  gen- 
eral surface,  whereas  at  the  part  attached  the  surface  is,  as  already  indi- 
cated, somewhat  darker.  It  will  be  seen  that  "all  the  scales  are  arranged 
so  that  the  free  border  of  each  is  toward  the  center  of  the  circle  or  system 
of  circles  to  which  it  belongs,  and  that  the  attached  border  is,  therefore, 
toward  the  periphery.  The  effect  is  something  like  the  rings  of  light  and 
dark  surface  on  watered  silk."  According  to  Koniger,  the  patches  may 
at  first  consist  of  concentrically  arranged,  small,  itchy  papules,  which 
subsequently  exhibit  the  scaliness.  In  some  extreme  cases  the  ring-like 
configuration  is  lost,  the  whole  surface  appearing  as  if  covered  with 
branny  scaliness,  and  presenting  a  picture  resembling  that  of  a  mild 
ichthyosis,  with  which  it  has  sometimes  been  confused  (Henggeler). 
As  a  rule,  there  are  no  distinct  evidences  of  inflammatory  action.  While 
the  malady  is  persistent,  chronic,  and  progressive,  there  is  no  effect 
upon  the  general  health.  There  may  be  a  variable  degree  of  itching. 

Etiology  and  Pathology.— The  cause  of  the  malady,  which  is 
of  contagious  nature,  is  a  vegetable  parasite  closely  similar  to  the  tricho- 
phyton.  In  fact,  Nieuwenhuis,  Sabouraud,  and  some  others  believe 
the  fungus  to  be  the  large-spored  trichophyton  of  animal  origin.  For 
this  reason  some  have  considered  it  as  an  aggravated  or  unusual  form  of 
ringworm,  a  view,  however,  that  is  not  in  consonance  with  the  observa- 
tions of  those  who  come  in  contact  with  the  disease.  Manson's  inocula- 
tion experiments  always  produced  the  same  type,  and  in  2  instances  he 
inoculated  one  arm  with  the  ringworm  fungus  and  the  other  with  that 

Jeanselme,  La  pratique  Dermatologique,  1904,  vol.  iv,  p.  445;  Bassett-Smith,  Jour.  Trap. 
Med.,  1904,  p.  265;  Paranhos  (new  process  for  microscopic  diagnosis),  Jour.  Trap. 
Med.,  1905,  p.  341;  Henggeler,  Monatshefte,  1906,  vol.  xliii,  p.  325  (in  Sumatra;  a  full 
critical  exposition,  with  bibliography  and  an  excellent  illustration,  herein  reproduced). 
It  has  been  generally  believed  that  this  peculiar  disease  was  confined  to  the 
Eastern  Hemisphere,  but  Paranhos  (Jour.  Trop.  Med.,  1904,  p.  153  and  Paranhos  and 
Leme,  ibid.,  1906,  p.  129),  of  Brazil,  states  that  it  also  occurs  in  certain  tropical  parts  of 
South  America — in  the  States  of  Goyaz,  Minas,  Matto-Groso,  and  San  Paulo.  Cas- 
tellani  ("Note  on  Tinea  Imbricata  and  its  Treatment,"  Jour.  Cutan.  Dis.,  1908,  p.  400, 
with  good  case  illustration)  also  records  its  occurrence  in  Ceylon,  having  had  1 1  cases 
under  observation. 


1146  PARASITIC  AFFECTIONS 

of  tinea  imbricata,  the  resulting  diseases  having  the  distinguishing  char- 
acters of  their  respective  species.  Tribondeau,  Bassett-Smith,  Paranhos, 
Wehmer,  and  Henggeler  consider  the  fungus  as  belonging  to  the  asper- 
gillus.1  Castellani2  has  found  a  plurality  of  fungi  in  this  type  of  ringworm, 
called  by  him  the  "endodermophytons."  The  malady  is  not  uncommon 
in  tropical  countries,  requiring  for  its  development  heat  and  moisture. 
While  seen  at  any  age,  children  are  especially  liable. 

The  fungus  is  found  in  much  greater  abundance  than  that  of  ring- 
worm, although  the  gross  features  are  admittedly  much  alike.3  Its 
chief  field  of  invasion  is  the  lower  part  of  the  corneous  layer.  The 
stronger  hairs  and  their  follicles  are  not  attacked;  Koniger  states  that 
it  appears  to  cause  falling  of  the  body  hair,  but  Manson  cannot  confirm 
this,  although  not  able  positively  to  deny  it.  The  rapid  development  of 
the  organism  from  the  point  of  invasion  apparently  causes  the  separation 
of  the  horny  layer  from  the  rete  and  the  formation  of  the  uplifted  scales. 

Diagnosis. — The  peculiar,  shingled-like  characters  of  the  con- 
centric scaly  rings  are  quite  characteristic  and  serve  to  distinguish 
it  from  tinea  circinata.  The  latter  seldom  presents  any  pronounced 
scaliness,  and,  while  rarely  there  may  be  two  or  three  rings,  they  are 
lacking  in  the  other  features  of  those  of  tinea  imbricata,  besides  usually 
presenting  distinctly  inflammatory  signs.  Moreover,  tinea  circinata 
is  never  extensive,  while  tinea  imbricata  sometimes  involves  a  great 
part  of  the  surface. 

Prognosis  and  Treatment.— The  disease  is  usually  readily 
cured,  the  fungus  lying  superficially,  but,  as  Manson  states,  owing  to 
its  profusion  and  the  great  extent  of  surface  involved,  and  consequent 
saturation  of  the  patient's  garments  with  the  fungus  elements,  relapses 
very  generally  occur.  The  latter  can  be  prevented,  however,  by  burning 
or  boiling  the  clothing  worn  during  the  treatment.  Manson  finds  the 
application  of  iodin  liniment  the  most  satisfactory  remedy,  applying 
it  to  a  part  of  the  body  at  a  time.  Castellani  commends  Manson's 
treatment,  and  also  lauds  the  application  of  a  solution  of  resorcin  in  com- 
pound tincture  of  benzoin — 30  to  60  grains  (2. -4.)  to  the  ounce  (32.). 
Bonnafy  and  Mialaret  speak  well  of  sulphur  fumigations  repeated  at 
intervals  for  a  period  of  two  months  or  so.  Nieuwenhuis  refers  to  the 
efficacy  of  petroleum  rubbed  on  once  or  twice  daily  for  fourteen  days, 
no  bath  being  taken  during  the  treatment.  Almost  any  of  the  parasit- 
icides advised  in  ringworm  will,  in  fact,  suffice  if  thoroughly  employed; 
a  3  to  10  per  cent,  chrysarobin  salve  cautiously  used  often  being  resorted 
to  in  obstinate  cases.  As  prophylactic  measures  may  be  mentioned 
extreme  cleanliness,  the  disinfection  of  the  underwear,  and  oiling  of  the 
body. 

1  Tribondeau  suggested  the  name  of  "lepidophyton"  for  the  fungus;  Wehmer,  that 
of  "aspergillus_  lepidophyton"  or  "aspergillus  Tokelau." 

2  Castellani,  Jour.  Trap.  Med.  and  Hygiene,  March  15,  1911,  p.  n   (successful 
inoculation  with  cultures). 

3  In  the  microscopic  examination  the  same  method  may  be  employed  as  in  ringworm. 


TINEA     VERSICOLOR 


1147 


TINEA  VERSICOLOR 

Synonyms. — Pityriasis  versicolor;  Chromophytosis;  Dermatomycosis  furfuracea; 
Mycosis  microsporina;  Chloasma  (of  older  writers);  Liver-spots  (of  older  writers); 
Fr.,  Pityriasis  versicolore;  Gr.,  Kleienflechte. 

Definition. — A  vegetable  parasitic  disease,  characterized  by  vari- 
ously sized  and  shaped,  furfuraceous,  macular  patches  of  a  yellowish, 
fawn  color,  and  occurring  for  the  most  part  on  the  upper  portion  of  the 
trunk. 

Symptoms. — The  disease  begins  as  one  or  more  yellowish  or 
brownish,  macular  points,  frequently  at  the  follicular  outlets  (Besnier 
and  Balzer),  and  commonly  upon  the  chest  anteriorly  or  posteriorly, 
although  the  earliest  spots  are  sometimes  seen  lower  down  or  at  or  near 
the  axillary  folds.  Their  growth  is  usually  slow,  several  months  or  more 


Fig.  304. — Fungus  of  tinea  versicolor — microsporon  furfur  (X  about  500;  partly  dia- 
grammatic). 


elapsing  before  the  eruption  is  of  conspicuous  extent.  The  beginning 
points  or  spots  extend  peripherally,  and  together  with  other  patches 
that  are  present  or  subsequently  arise  may  finally  result,  in  some  in- 
stances, in  an  almost  continuous  sheet  of  eruption,  and  involve  the 
greater  part  of  the  upper  trunk,  often  extending  lower  down.  In  an 
average  case  this  former  region  is  noted  to  be  the  seat  of  variously  sized 
spots  and  areas,  varying  in  size  from  the  beginning  lesions  to  large 
plaques.  There  is  slight,  sometimes  scarcely  perceptible,  furfuraceous 
scaliness,  less  noticeable  in  those  of  naturally  moist  skin  or  who  perspire 
easily.  The  color  of  the  patches  is  pale  yellow  or  brownish  yellow,  ex- 


1148  PARASITIC  AFFECTIONS 

ceptionally  a  yellowish  brown;  in  rare  instances,  in  those  of  delicate 
skin,  there  may  be  more  or  less  hyperemia,  and  in  consequence  the 
eruption  is  of  a  pinkish  or  reddish-yellow  tinge,  most  marked  at  the  edge 
of  the  patches.  The  eruption  is  wholly  macular,  with  practically  no 
elevation;  exceptionally,  however,  there  is  slight  elevation  at  the  follicu- 
lar  orifices,  a  faint  attempt  at  follicular  papulation.1  Beyond  the  dis- 
figurement caused,  the  disease  never  gives  rise  to  any  trouble,  except 
that  slight  or  moderate  itching,  especially  when  the  patient  is  warm  or 
perspiring,  is  frequently  complained  of. 

While  in  most  patients  the  eruption  is  practically  limited  to  the 
upper  half  of  the  trunk,  in  many  instances  the  whole  lower  part  is  also 
more  or  less  invaded,  and  in  extreme  cases  the  axillae,  portions  of  the 
arms,  flexures  of  the  elbows,  and  even  the  genitocrural  region  and  pop- 
liteal spaces  are  likewise  involved.  The  eruption  exceptionally  is  noted 
to  be,  for  a  time  at  least,  more  or  less  limited  to  the  genitocrural  region. 
Quite  frequently  it  extends  from  the  chest  well  up  on  the  neck,  and  in 
occasional  examples  still  higher  on  to  the  lower  part  of  the  chin.  It  is 
generally  believed  that  the  face  is  never  the  seat  of  the  eruption,  but  in 
occasional  instances  this  has  been  observed  (Biart,  Payne,  Gottheil, 
Allen,  Sobel,  Powell2),  producing  chloasma-like  patches  of  diffused  dis- 
coloration, of  which  one  well-marked  example  has  come  to  my  own  notice; 
it  is  usually,  however,  in  connection  with  the  eruption  extensively  de- 
veloped on  the  favorite  situation.  While  on  the  face  it  is  essentially 
similar  in  color  to  that  on  the  trunk,  it  may  be  somewhat  darker,  or  it 
may,  in  the  negro,  be  somewhat  lighter,  as  in  Gottheil's  case,  in  which 
the  spots,  doubtless  owing  to  the  scaliness,  were  of  a  dingy- white,  vitiligo- 
like  aspect.  In  Biart's  patient  the  scalp  was  encroached  upon;  and  in 
Payne's  it  was  both  in  the  bearded  and  scalp  regions,  where  it  appeared 
to  be  a  simple  furfuraceous  scaliness,  the  scrapings  disclosing  the  fungus. 
Both  his  and  Biart's  patient  had  the  eruption  on  the  trunk  also.  In 
my  patient,  a  woman,  it  had  the  appearance  of  an  extensive  chloasma, 
for  which,  unless  closely  inspected,  it  could  have  been  readily  mistaken. 

1  McEwen,  "An  Unusual  Case  of  Tinea  Versicolor,"  Jour.  Cutan.  Dis.,  Jan.,  191 1 
(with  case  illustrations),  records  an  instance   in  which  while  the  eruption  was  pre- 
dominantly of  the  usual  clinical  type,  it  presented  quite  a  large  number  of  follicular 
papular  lesions,  giving  parts  where  such  lesions  were  numerous  the  impression  of  a 
"lichenoid  follicular  inflammation." 

2  Biart,  Jour.  Cutan.  Dis.,  1885,  p.  73;  Payne,  cited  by  Crocker,   Diseases  of  the 
Skin,  second  ed.,  p.  892;  Gottheil,  Med.   Record,  1901,  vol.  lix,  p.  649;  C.  W.  Allen, 
Jour.  Amer.  Med.  Assoc.,  1901,  i,  p.  938;  Sobel,  Pkilada.  Med.  Jour.,  1901,  vol.  vii, 
p.  1061;  Powell,  Brit.  Jour.  Derm.,  1900,  p.  142,  states  that  it  is  quite  common  on  the 
face  in  Assam,  and  the  fungus  seems  identical  with  that  met  in  Europe,  and  which 
Pernet,  to  whom  scrapings  had  been  sent,  demonstrated  by  examination  before  the  Der- 
matological  Society  of  Great  Briain  and  Ireland;  Castellani,  Brit.  Med.  Jour.,  Nov.  n, 
1905,  and  Jour.  Trop.  Med.,  1905,  p.  252,  states  that  in  Ceylon  two  types  are  met  with: 
tinea  versicolor  nigra,  the  eruption  being  black  and  lusterless,  and  found  on  any  part  of 
the  body  except  the  face;  and  tinea  versicolor  flava,  of  which  there  are  two  varieties — one 
attacking  the  face,  neck,  and  upper  part  of  the  trunk,  and  the  other  presenting  a  lighter 
yellow  or  nearly  white  patches,  generally  seen  on  the  arms  and  legs;  it  is  not  uncommon 
to  see  the  different  types  on  the  same  individual.     In  a  later  paper  ("Tropical  Forms  of 
Pityriasis  Versicolor"),  Jour.  Cutan.  Dis.,  1908,  p.  393  (with  2  case  illustrations,  fungus, 
cuts,  etc.),  Castellani  adds  another  variety,  tinea  versicolor  alba,  in  which  the  color  is 
extremely  light,  sometimes  altogether  white;  it  is  oftener  seen  on  the  arms  and  legs  than 
on  the  face  and  chest.     These  several  types,  he  states,  are  due  to  different  fungi. 


PLATE  XXXII. 


Tinea  versicolor,  showing  the  confluent  areas  and  the  variously  sized  patches ;  of 
several  years'  duration.  The  eruption  is  not  elevated,  the  chief  characteristics  being  the 
fawn  or  brownish-yellow  color,  upper  trunk  distribution,  and  usually  a  slight,  sometimes 
scarcely  perceptible,  branny  or  furfuraceous  scaliness.  Jn  this  instance  extends  well  up 
the  neck  and  some  spots  on  arms. 


TINEA     VE  RSICOL  OR  1 1 49 

Smith1  met  with  an  instance  of  its  limitation  to  the  soles,  and  Gottheil2 
to  one  palm,  probably  the  only  examples  on  record. 

The  course  of  the  disease  is  slow,  and  usually  progressive  up  to  a 
variable  extent,  and  then  it  remains  more  or  less  stationary,  showing 
little,  if  any,  tendency  to  spontaneous  retrogression. 

Etiology  and  Pathology.— The  disease  is  due  to  the  vegetable 
parasite  known  as  the  microsporon  furfur,  discovered  by  Eichstedt  in 
1846.  Both  sexes  are  liable,  but  men  more  frequently.  It  is  rarely  seen 
before  adolescence  or  in  advanced  years.  While  the  fungus  is  abundant, 
yet  observations  show  that  the  malady  is  but  mildly  contagious.  Not 
more  than  two  or  three  instances  of  its  occurrence  in  two  members  of  a 
family  have  come  under  my  own  notice.  Huble3  cites  9  cases  of  con- 
tagion from  man  to  wife,  or  vice  versd,  and  Knowles  and  Corson,4 
in  three  sisters.  Huble  and  several  others  have  been  successful  with 
inoculation  experiments,  but,  as  a  rule,  success  is  only  occasional.  It 
is  commonly  believed,  and  doubtless  true,  that  those  who  sweat  freely 
are  its  more  common  subjects.  It  is  thought  to  be  relatively  frequent 
in  phthisical  patients,5  but  this  is  probably  more  apparent  than  real, 
inasmuch  as,  owing  to  the  exposure  of  the  chest  in  such  patients  for  the 
purpose  of  physical  examination,  the  eruption  is  oftener  disclosed. 

The  fungus  consists  of  mycelium  and  spores,  the  latter  being  dis- 
posed in  distinct  groups  or  masses.  It  is  readily  demonstrated  by  plac- 
ing some  scrapings  in  a  little  liquor  potassae  on  a  glass  slide,  and  placing 
over  it  the  cover-glass,  and  allowing  it  to  soak  for  a  few  minutes;  a 
power  of  200  to  500  diameters  gives  sufficient  amplification.  The  para- 
site luxuriates  in  the  corneous  layer  of  the  epidermis,  sparing  the  rete, 
hairs,  and  true  skin. 

Diagnosis. — The  color,  peculiar  characters,  and  distribution  of  the 
eruption  are  the  diagnostic  factors;  added  to  these  is  the  fact  that  in 
most  cases  coming  under  observation  the  malady  has  already  lasted  for 
a  year  or  more.  These  points,  as  well  as  the  large  patchy  or  sheet-like 
character  usually  noted,  will  serve  to  distinguish  it  from  the  macular 
syphiloderm.  It  can  scarcely  be  confounded  with  chloasma  (q.  v.).  It 
is  well  to  bear  in  mind,  however,  that  exceptionally  the  eruption  may 
invade  the  face  and  simulate  this  latter  malady.  Occasionally,  when  in 
profusion,  the  spared  skin  looks  relatively  white  and  might  suggest 
vitiligo,  the  fawn  color  of  tinea  versicolor  being  mistaken  for  the  hyper- 
pigmented  border  of  vitiligo  patches.  The  inflammatory  characters  of 

1  E.  D.  Smith,  New  York  Med.  Jour.,  1896,  vol.  Ixiv,  p.  583  (on  both  soles,  ante- 
riorly, in  male  adult,  of  some  duration;  nowhere  else). 

2  Gottheil,  Med.  Record,  1899,  vol.  Ivi,  p.  15  (left  palm  in  male  adult,  of  dark 
color  and  some  years'  duration;  illustration);  Campana,  Clinica  Derm,  della  Universite 
de  Rome,  1903,  p.  13 — abs.  in  Jour.  Cutan.  Dis.,  1904,  p.  55 — reports  a  case  in  which 
tinea  versicolor  affected  the  fingers  and  finger-nails. 

3  Huble,  Revue  med.  de  Toulouse,  July  15,  1886;  abs.  by  Thibierge  in  Annales,  1887, 
P-  414- 

4  Knowles  and  Corson,  New   York  Medical  Record,  Sept.  30,  1911  (three  sisters; 
occupied  the  same  bed  and  used  the  same  towels). 

6  Duguet  and  Hericourt,  "Sur  la  nature  mycosique  de  la  tuberculose  et  sur  1'eVolu- 
tion  bacillaire  du  microsporon  furfur,  son  champignon  pathogene,"  Compt.  rend.  Acad. 
de  Sci.,  Paris,  1886,  vol.  cii,  p.  943,  have  even  alleged  that  the  microsporon  furfur  is 
etiologic  in  the  production  of  phthisis. 


1  150  PARASITIC  AFFECTIONS 

dermatitis  seborrhoica,  and  the  inflammatory  characters  and  the  acute- 
ness  of  pityriasis  rosea,  will  prevent  confusion  with  these  maladies.  In 
all  doubtful  cases  recourse  should  be  had  to  microscopic  examination. 

Prognosis  and  Treatment.  —  Tinea  versicolor  is,  as  a  rule,  a 
readily  curable  disease.  In  some  instances  the  fungus  seems  to  be  some- 
what deeply  and  firmly  seated,  extending  into  the  follicles,  and  such 
cases  yield  more  slowly.  Unless  proper  precautions  be  taken  relapses 
are  not  infrequent.  A  plan  of  treatment  that  will  be  found  especially 
satisfactory  in  many  cases  is  that  consisting  of  soap-and-water  washings 
and  the  application  of  a  solution  of  sodium  hyposulphite.  When  the 
skin  is  somewhat  irritable,  ordinary  toilet-soap  may  be  used  at  least  once 
daily  for  the  washing,  shampooing  the  parts  pretty  thoroughly,  and  rins- 
ing off  and  rubbing  dry.  Immediately  afterward  the  hyposulphite 
solution,  i  to  2  drams  (4--8.)  to  the  ounce  (32.),  is  freely  rubbed  in  for  a 
minute  or  two  and  then  dabbed  on  and  allowed  to  dry.  The  solution 
should  be  applied  twice  daily.  In  those  of  sluggish  skin,  instead  of  plain 
toilet-soap  sapo  viridis  should  be  used  for  the  washing;  or  in  obstinate 
cases  instead  of  plain  sapo  viridis  the  following  may  be  employed  with 
advantage: 

]$.     Sulphuris  praecipitati,  3ij  (8.); 

Saponis  viridis,  q.  s.  adgij  (64.)- 


In  other  instances  a  manufactured  soap  containing  sulphur  or  sulphur 
and  naphthol  will  be  found  efficient.  During  the  treatment  the  under- 
wear should  be  thoroughly  baked  or  boiled  or  soaked  in  the  hyposulphite 
solution.  With  the  treatment  outlined  carefully  carried  out  a  suc- 
cessful result  is  almost  certain  in  the  course  of  one  to  three  months. 
After  the  cure  is  apparently  effected  a  remedial  application  should  be 
made  once  or  twice  weekly  for  two  or  three  months,  in  order  to  guard 
against  recurrence.  In  fact,  it  is  a  good  plan  for  those  who  seem  espe- 
cially liable  to  recurrences  to  make  a  practice  of  using  regularly  a  medi- 
cated soap,  such  as  above  named,  as  the  body  soap.  It  can  be  readily 
understood  that  even  in  apparent  cures  some  deep-seated  fungus  may 
have  remained,  and  if  the  precautionary  measures  named  are  not  fol- 
lowed out,  this  develops  and  a  relapse  follows.  Attention  to  these  details 
of  the  management  of  the  disease  will  do  much  toward  insuring  perma- 
nence of  the  cure.  I  have  been  in  the  habit  also  of  prescribing  a  few 
grains  of  sulphur  daily  internally  in  this  disease,  believing  that  its  exhala- 
tion through  the  skin  makes  the  tissues  a  less  satisfactory  "soil"  for  the 
fungus. 

Many  remedial  applications  other  than  that  named  will  likewise 
act  satisfactorily,  but  need  not  be  specifically  mentioned,  inasmuch 
as  they  are  the  same  as  the  milder  remedies  advised  in  ringworm. 


ER YTHRA  SMA  1 1 5  I 

ERYTHRASMA1 

Definition. — A  vegetable  parasitic  disease  characterized  by  reddish- 
brown  patches,  presenting  in  situations  where  there  are  moist  and  op- 
posing surfaces,  as  the  genitocrural  and  axillary  regions. 

The  original  observations  by  Burchardt  (1859),  Barensprung  (1862), 
and  Kobner  (1866),  which  led  to  the  recognition  of  the  individuality  of 
this  affection,  have  been  corroborated  by  the  studies  of  Besnier,  Balzer, 
Dubreuilh,  Riehl,  Weyl,  Kobner,  Payne,  Boeck,  Ducrey  and  Reale,  and 
others,  and  have  dispelled  the  belief  held  by  a  few  German  writers  as  to 
its  kinship  with  either  tinea  trichophytina  or  tinea  versicolor. 

Symptoms. — The  malady  is  slow  in  its  development,  beginning  as 
small  spots  of  a  reddish-brown  or  orange-red  color,  and  usually  in  the 
genitocrural  region.  The  color  is  somewhat  like  that  of  the  Indian  skin. 
The  spots,  which  may  be  few  or  many  in  number,  gradually  increase  in 
size,  and  result  in  coalescence  and  the  formation  of  confluent  areas  or 
sheets  of  eruption.  In  its  general  aspects,  except  the  shade  of  coloring 
and  the  parts  invaded,  it  bears  considerable  resemblance  to  tinea  versi- 
color. The  patches  are  not  perceptibly  elevated,  although  the  edges  are 
well  denned.  Scaliness,  furfuraceous  or  mealy  in  character,  is  generally 
so  scanty  that  its  existence  is  scarcely  recognizable;  it  is  more  readily 
seen  at  the  border.  While  the  most  frequent  region  involved  is  the 
genitocrural,  the  axillae  are  also  almost  as  common  a  site,  these  two  loca- 
tions, in  fact,  being  both  affected  in  most  instances.  It  occasionally  ex- 
tends from  these  parts,  and  may  cover  considerable  surface;  in  a  case 
observed  by  Riehl  extending  high  up  on  the  pubic  region  and  to  the 
middle  of  the  thighs,  and  in  one  by  Besnier  involving  the  latter  and 
also  the  upper  arms.  Exceptionally  patches  may  arise  independently 
near  by  or  not  far  distant.  The  malady  is  insidious  and  slowly  progress- 
ive, but  generally,  after  attaining  a  variable  development,  remains 
practically  stationary.  There  is  rarely  any  tendency  to  spontaneous 
disappearance.  Its  presence,  as  a  rule,  gives  rise  to  no  inconvenience, 
but  occasionally  there  may  be  slight  itching. 

Ktiology  and  Pathology. — The  disease  is  rare  in  our  country, 
but  more  common  in  France  and  Germany.  It  is  seldom  seen  in  those 
under  the  age  of  fifteen.  It  is  caused  by  the  parasite,  the  microsporon 
minutissimum,  considered  a  vegetable  organism  somewhat  similar  to 

important  recent  literature:  Besnier,  Besnier-Doyon's  French  translation  of 
Kaposi's  treatise,  second  ed.,  1891;  Balzer,  "De  1'erythrasma,"  Annales,  1883,  p.  681; 
Balzer  and  Dubreuilh,  "Observations  et  recherches  sur  Perythrasma  et  sur  les  parasites 
de  la  peau  a  1'etat  normal,"  ibid.,  1884,  pp.  597  and  661  (with  review  and  literature 
references);  Behrend,  Lehrbuch  der  Hautkrankheiten,  1883,  second  ed.,  p.  560,  and 
Eulenberg's  Real  Encyclopedic,  third  ed.,  1895,  vol.  vii,  p.  360  (with  bibliography); 
Riehl,  Wien.  med.  Wochenschr.,  1884,  pp.  1209  and  1247 — full  abstract  in  Jour.  Cutan. 
Dis.,  1885,  p.  84;  Kobner  (second  paper),  Monalshefte,  1884,  p.  349;  Bizzozero,  "Ueber 
die  Mikrophyten  der  normale  Oberhaut  der  Menschen,"  Virchow's  Archiv,  1884,  vol. 
xcviii,  p.  441  (with  review  and  literature  references);  Weyl,  Monatshefle,  1884,  p.  33; 
Boeck,  Archiv,  1886,  p.  119;  Payne,  London  Patholog.  Soc'y  Trans.,  1886,  vol.  xxxvii,  p. 
516,  and  Observations  on  Some  Rare  Diseases  of  the  Skin,  London,  1889  (a  clear 
presentation  with  review) ;  Pasquale  de  Michele,  Giorn.  internaz.  d.  sci.  med.,  1890 — abs. 
by  Thibierge  in  Annales,  1891,  p.  796;  Ducrey  and  Reale,  abs.  in  Brit.  Jour.  Derm., 
1894,  p.  126,  and  abs.  of  later  paper,  ibid.,  1895,  p.  97. 


I  I  52  PARASITIC  AFFECTIONS 

that  of  tinea  versicolor,  although  there  is  some  doubt  as  to  its  exact 
status,  whether  it  should  be  classed  among  the  ordinary  tinea  fungi  or 
bacteria.  Payne  believes  the  organism  bears  a  strong  resemblance  to 
involution  forms  of  bacilli,  being  doubtful  as  to  the  presence  of  any 
spores,  although  other  observers  (Burchardt,  Barensprung,  Balzer, 
Ducrey,  Reale,  Weyl,  de  Michele,  Riehl,  Dubreuilh,  and  others)  for  the 
most  part  are  in  agreement  as  to  the  existence  of  both  mycelium  and 
spores.  Some  have  found  several  organisms  (Weyl,  de  Michele),  al- 
though de  Michele's  inoculation  experiments  show  the  microsporon  to  be 
the  etiologic  one.  The  alleged  successful  cultures  of  the  organism  by  de 
Michele  and  Ducrey  and  Reale  are  not,  however,  free  from  suspicion 
(Jarisch).  Inasmuch  as  Balzer  and  Dubreuilh  and  Ducrey  and  Reale 
have  found  the  same  organism  on  apparently  normal  skin,  they  are  in- 
clined to  believe  that  only  under  certain  unknown  conditions  does  it 
become  pathogenic. 

The  microsporon,  seated  in  the  superficial  horny  layers,  consists  of 
short,  jointed  threads  and  spores,  being  in  size  about  one-third  that  of  the 
microsporon  furfur,  and  requires,  therefore,  a  somewhat  higher  power 
for  its  recognition.  The  threads  show  no  disposition  to  branching, 
exhibit  sometimes  cylindric  swellings,  and,  according  to  Payne,  some- 
times with  slightly  bulbous  blind  extremities.  Unlike  the  fungus  of  tinea 
versicolor,  as  Unna  states,  it  shows  no  isolated  collections  of  spores. 

Diagnosis. — The  disease  is  to  be  distinguished  from  tinea  versi- 
color, to  which  it  bears,  as  already  stated,  considerable  resemblance, 
although  it,  unlike  the  former,  has  a  reddish  tinge.  Tinea  versicolor, 
however,  rarely  exists,  any  length  of  time  at  least,  on  the  favorite  regions 
of  erythrasma  without  marked  involvement  of  its  common  situation, 
the  trunk.  Erythrasma,  on  the  contrary,  is  only  exceptionally  seen 
outside  of  the  genitocrural  and  axillary  regions,  and  then  scantily,  and, 
as  a  rule,  only  in  association  with  its  extensive  development  on  the  parts 
named.  In  doubtful  cases  recourse  can  be  had  to  the  microscope,  al- 
though the  treatment  of  both  maladies  is  the  same.  The  inflammatory 
characters  of  tinea  cruris  (eczema  marginatum)  and  dermatitis  sebor- 
rhoica,  not  uncommon  in  the  same  localities,  will  prevent  error.  The 
peculiar  patchy  and  scaly  features  of  pityriasis  rosea,  as  well  as  its 
acute  development  and  distribution,  are  totally  different  from  those 
of  erythrasma. 

Prognosis  and  Treatment — The  malady  is  persistent,  and 
with,  as  in  tinea  versicolor,  a  marked  tendency  after  apparent  cure  to 
recurrence.  The  treatment  is  the  same  as  in  the  latter  disease,  and 
the  same  measures  as  to  guarding  against  relapse  should  also  be  advised. 


PI  NT  A   DISEASE  1153 

PINT  A  DISEASE1 

Synonyms. — Mai  del  pinto;  Mai  de  los  pintos;  Tina  (Mexico);  Caraate;  Cute 
(Venezuela  and  Granada);  Quirica  (Panama);  Spotted  sickness;  Fr.,  Carate. 

Definition. — A  contagious  affection  of  certain  tropical  countries, 
due  to  several  fungi,  characterized  by  variously  sized  and  shaped  scaly 
discolorations,  occurring  mostly  on  exposed  parts. 

This  peculiar  malady,  of  which  the  earliest  accounts  were  given  by 
Zea,  Alibert,  Rayer,  Gomez,  and  more  recent  ones  by  Hirsch,  Iryz, 
Lier,  Montoya,  and  Barbe,  is  seen  chiefly  in  the  tropical  portions  of 
South  America.  It  was  also  prevalent  among  the  Aztec  Indians  in  the 
lowlands  of  Southern  Mexico,  where  it  had  existed  for  centuries  (Corlett). 

Symptoms. — The  spots  appear  first  most  frequently  upon  the 
face  or  neck.  They  also  develop  on  other  exposed  regions,  as  the  fore- 
arms, hands,  lower  part  of  the  legs  and  feet,  and  upper  part  of  the  chest. 
The  palms  and  soles  are  not  invaded.  They  quite  frequently  develop 
upon  some  other  previously  existing  eruption.  Their  appearance  is  some- 
times preceded  by  slight  itchiness.  Their  color  varies  in  different  cases 
from  a  white  to  a  bluish  gray  and  various  shades  to  a  black;  in  some  in- 
stances it  is  of  a  red  hue.  The  spots  may  be  said  (Barbe)  ordinarily  to 
pass  through  two  stages:  an  active  or  developmental  period  or  that  of 
coloration,  and  a  second  stage,  that  of  retrogression  or  pseudovitiliginous, 
of  which  the  traces  are  indelible.  In  whites  the  first  evidences  consist  of  a 
faint  erythema,  soon  becoming  coated  over  with  furfuraceous  scaliness; 
in  the  colored  races  the  spots  are  of  a  yellowish,  reddish,  or  grayish  color. 
The  spots  become  larger  by  peripheral  extension,  and  new  points  arise 
near  by  which  in  turn  extend,  so  that  finally  considerable  surface  may  be 
invaded.  The  central  portion  of  the  patches  gradually  begins  to  change 
color  to  a  bluish,  violaceous,  or  reddish,  from  two  to  five  years  elapsing 
before  they  attain  their  final  definite  color.  The  scaliness  often  becomes 
more  marked,  changing  from  a  furfuraceous  to  that  of  lamellar  character. 
A  variable  degree  of  hyperkeratinization  frequently  develops.  The 
itching  commonly  increases  in  degree  as  the  disease  progresses.  In 
extreme  instances  most  parts  are  invaded,  the  tongue,  buccal,  preputial, 
and  vulvar  mucous  membranes  not  escaping.  Fissures  and  ulcerations 
sometimes  occur  in  the  flexures.  The  hairs  may  loosen  and  fall  out,  in 
consequence,  according  to  Montoya,  of  the  development  of  a  form  of 
folliculitis.  The  general  health  does  not  seem  to  suffer.  Some  writers 
describe  the  occurrence  of  precursory  symptoms  of  the  gastro-intestinal 
tract. 

The  malady  is  persistent,  and  in  some  instances  leaves  behind  promi- 
nent atrophic  whitish  spots.  It  is  seen  in  both  sexes,  and  in  both  whites 
and  blacks,  although  the  dark  races  are  its  more  common  subjects.  It 

1  Chief  recent  literature:  Hirsh's  Geograph.  and  Histor.  Pathol.,  New  Sydenham 
Soc'y  Translation,  1885,  vol.  ii,  p.  379  (with  bibliography);  Tryz,  Independentia  med., 
Mexico,  1881-82,  vol.  ii,  p.  254;  review  in  London  Med.  Record,  1882,  vol.  x,  p.  175, 
and  Brit.  Med.  Jour.,  1882,  vol.  ii,  p.  903;  Lier,  Monatshefte,  1892,  vol.  xiv,  p.  447; 
Montoya  Y.  Florez,  "Recherches  sur  les  carates  de  Colombie,"  These  de  Paris,  1898; 
Barbe,  Annales,  1898,  p.  985  (with  colored  plate);  also  an  excellent  account  by  this 
same  writer  in  La  pratique  Dermatologie,  1900,  vol.  i;  Woolley,  Jour.  Cutan.  Dis.,  1904, 
p.  479;  Sandwith,  Brit.  Med.  Jour.,  1905,  ii,  pp.  479  and  1270  (with  bibliography). 

73 


1 1 54  PARASITIC  AFFECTIONS 

is  due,  as  Montoya's  studies  indicate,  to  several  kinds  of  fungi,  of  the 
class  aspergillus,  each  having  a  distinguishing  color.  This  writer  states 
that  he  has  found  similar  organisms  in  certain  cereals  and  plants,  in 
stagnant  mine  waters,  and  that  the  malady  is  contracted  from  such 
sources  directly  or  through  the  intermedial  agency  of  insects,  especially 
mosquitos.  They  consist  of  mycelium  and  spores,  differing  somewhat,  in 
minor  characters,  in  the  several  varieties.  The  epidermis,  especially  the 
corneous  layers,  is  the  seat  of  the  parasitic  invasion,  often  involving  the 
rete  and  causing  atrophy  of  the  latter,  and  finally  complete  disappear- 
ance of  the  pigment-cells.  Iryz  states  that  in  some  cases  the  corium  is 
also  involved.  Recently  Blanchard  and  Bodin  have  found  a  trichophyton. 
The  treatment  is  essentially  the  same  as  that  employed  in  the 
other  vegetable  parasitic  diseases,  more  especially  of  ringworm.  Tinc- 
ture of  iodin  applications  seem  most  in  favor  for  recent  patches,  and 
chrysarobin  for  those  of  some  duration  or  great  obstinacy. 

MYRINGOMYCOSIS 

Synonyms. — Myringomycosis  aspergillina;  Mycomyringitis;  Otomycosis;  Otitis 
externa  parasitica;  Fungous  disease  of  the  external  ear. 

Wreden,  in  1867,  following  the  observations  of  Mayer,  in  1844, 
and  Paccini,  in  1851,  as  to  the  existence  of  fungi  in  the  external  auditory 
canal,  was  the  first  to  call  particular  attention  to  this  affection,  and  al- 
though still  of  somewhat  obscure  nature,  the  later  writings  by  Politzer 
and  Gruber,  and  in  this  country  by  J.  O.  Green,  Roosa,  Burnett,  and 
Barclay,  have,  especially  those  by  the  last  two,  added  materially  to  our 
knowledge  concerning  it.1  Its  chief  characters  consist  of  a  scurfy,  moist- 
looking,  blotting-paper-like  coating,  of  a  dirty  gray  or  brownish-gray 
color,  with  commonly  here  and  there  slightly  raised,  yellowish,  brownish, 
greenish,  or  blackish  points  or  spots.  It  is  often  distinctly  moist,  and  may 
exhibit  a  candied-looking  or  glazed  surface,  due  to  the  serous  effusion 
provoked.  This  latter  is  sometimes  present  in  considerable  quantity. 
The  whole  canal,  including  the  drum,  may  be  involved,  although  not 
infrequently  only  parts  of  the  meatus  are  apparently  the  seat  of  the 
disease,  the  drum  being  implicated  to  but  a  slight  degree.  It  is  generally 
believed,  however,  that  the  drum  is  primarily  attacked,  and  from  here 
it  extends  along  the  canal.  The  former  may  in  some  instances  be  so  much 
damaged  as  to  result  in  perforation.  If  the  scales  or  crusts  are  forcibly 
removed,  the  underlying  surface  is  ordinarily  noted  to  be  more  or  less 
abraded  and  raw  looking,  bleeding  easily.  The  first  symptoms  consist 
of  itchiness,  stinging,  sometimes  slight  or  great  pain,  and  a  variable 
impairment  of  hearing,  usually  together  with  a  scanty  watery  discharge. 
While  there  is  some  difference  of  opinion  as  to  the  specific  fungus,  it  is  the 
common  belief  that  the  malady  is  due  to  the  aspergillus  niger  and  the 
aspergillus  glaucus. 

There  is  no  tendency  to  spontaneous  disappearance.  If  neglected, 
a  variable  degree  of  deafness  or  permanent  damage  may  result. 

1  Burnett,  Amer.  Jour.  Otology,  1879,  vol.  i,  pp.  10  and  93  (a  report  of  20  cases 
with  review  of  the  subject  and  references) ;  Barclay,  in  Burnett's  System  of  Diseases  of 
the  Ear,  Nose,  and  Throat,  1893,  vol.  i,  p.  190  (with  review  and  references). 


ACTINOMYCOSIS 


"55 


Treatment  consists  in  an  occasional  syringing  with  a  weak  alkaline 
solution  to  remove  the  fungus  and  other  accumulations,  and  the  applica- 
tion of  a  mild  parasiticide,  such  as  a  i  per  cent,  solution  of  sodium  hy- 
posulphite (Burnett)  and  of  alcohol  full  strength  or  weakened  (Lo wen- 
berg).  Ointments  may  have  to  be  used  occasionally,  if  needed  to  soften 
any  accumulation,  but  are  to  be  avoided  when  possible,  as,  according  to 
Bezold,  fatty  matter  favors  the  growth  of  the  fungus.  When  deeply 
seated  or  seriously  involving  the  drum,  the  case  belongs  more  properly 
to  the  aurist. 

ACTINOMYCOSIS 

Synonyms. — Actinomycosis  of  the  skin;  Lumpy  jaw;  Fr.,  Actinomycose;  Ger., 
Aktinomykose. 

Definition. — Actinomycosis  of  the  skin  is  an  affection  due  to 
the  ray  fungus,  characterized  by  a  sluggish,  red,  nodular,  or  lumpy  in- 
filtration, usually  with  a  tendency  to  break  down  and  form  sinuses,  and 
most  commonly  involving  the  cervicofacial  region. 


Fig.  305. — Actinomycosis  (courtesy  of  Dr.  W.  T.  Corlett). 

The  condition  known  as  lumpy  jaw  and  osteosarcoma  of  the  jaw 
in  cattle  had  long  been  known,  but  it  was  Israel  who  first  recognized  the 
pathogenic  role  of  the  special  fungus,  named  by  Harz  the  ray  fungus. 
About  the  same  time  the  existence  of  a  similar  looking  affection  in  man 
was  described  by  Israel,  and  which  was  subsequently  shown  by  the  im- 
portant contribution  by  Ponfick  to  be  not  only  similar  to  that  in  animals, 
but  of  identical  nature.  Since  then  the  malady  and  its  fungus  have 
received  considerable  attention  from  various  observers,  among  whom  are 
Illich,  Majocchi,  Bertha,  Gasperini,  Krause,  Miiller,  Poncet  and  Berard, 


1156  PARASITIC  AFFECTIONS 

Murphy,  and  many  others.1  While  the  fungus  may  gain  access  to  the 
internal  organs  and  give  rise  to  grave  disease,  the  dermatologist  is  chiefly 
interested  in  the  manifestations  observed  when  the  integumentary 
tissues  are  invaded.  The  invasion  of  the  latter  may  be  primary,  but,  as  a 
rule,  it  is  secondary  to  a  deeper-seated  involvement. 

Symptoms. — The  usual  situation  of  actinomycosis  of  the  skin  is 
about  the  jaw,  neck,  and  face.  The  organism  finds  entrance  through 
the  mouth,  most  frequently  to  the  jaw  through  a  decayed  tooth.  The 
first  evidence  is  a  hard,  subcutaneous  swelling  or  infiltration,  which 
may  attain  moderate  or  quite  conspicuous  dimensions,  the  overlying 
skin  soon  becoming  of  a  sluggish  or  dark-red  color.  Sooner  or  later 
softening  is  detected,  the  skin  giving  way  at  one  or  several  points,  from 
which  there  oozes  a  discharge  of  a  seropurulent,  purulent,  or  sanguino- 
lent  and  purulent  character.  Contained  in  the  discharge,  recognizable  in 
most  instances,  are  minute,  friable,  yellowish  or  yellowish-gray  bodies, 
representing  conglomerate  collections  of  the  fungus.  Instead  of  begin- 
ning or  continuing  as  a  well-defined  single  swelling  or  tumor,  the  in- 
volved and  infiltrated  area  is  distinctly  nodular,  often  finally  becoming, 
when  at  all  advanced,  quite  extensive.  It  is  then  noted  to  consist  of  a 
variously  and  irregularly  infiltrated  and  swollen  area,  dark  red  or  bluish 
red,  beset  with  several  or  more  distinct  nodulations  or  anthracoid  for- 
mations, with  here  and  there  openings  leading  down  or  through  the  in- 
volved mass,  with  slight,  moderate,  or  profuse  discharge.2  In  some  cases 
the  surface  exhibits  ulcerofungoidal  and  papillomatous  characters. 
Occurring  on  other  parts  of  the  body  the  same  conditions  are  presented, 
occasionally  involving  considerable  surface.3  Sometimes  it  remains 
limited  to  a  more  or  less  circumscribed  area,4  several  finger  cases 
having  been  recorded. 

The  course  of  the  malady  may  be  slow  and  insidious,  or  somewhat 
rapid,  usually  the  former,  some  months  generally  elapsing  before  the 
involvement  is  extensive.  As  a  rule,  there  are  no  subjective  symptoms, 
but  when  suppuration  takes  place  the  parts  may  become  quite  painful. 
The  lymphatic  glands  are  not  implicated  except  secondarily  as  a  result 
of  the  suppurative  inflammation.  The  general  health  in  those  instances 

1  Poncet  and  Berard's  monograph,  Traite  dinique  de  V actinomycose  humaine,  Paris, 
1898,  gives  an  admirable  and  exhaustive  presentation  and  review  of  the  subject,  with 
complete  bibliography. 

2  Wallhauser,  Jour.  Cutan.  Dis.,  1904,  p.  77  (with  illustration),  reports  an  extensive 
case  of  this  kind  beginning  as  a  small  pimple  on  point  of  chin,  and  gradually  involving 
the  whole  regions  of  the  upper  part  of  the  neck  and  the  jaws. 

3  Pringle,  London  Med.-Chir.  Soc'y  Trans.,  1895,  vol.  Ixxviii,  p.  21  (with  colored 
case  illustration),  reports  an  extensive  case  in  a  boy  of  eleven,  implicating  part  of  the 
chest,  the  back,  and  hip,  and  developing  secondarily  to  involvement  of  the  pleura. 

4  Sicard,  La  presse  meditate.  Aug.  15,  1903,  reports  a  case  in  which  it  was  confined  to 
the  finger,  and  the  earliest  symptoms  (following  an  accidental  cut  in  a  field-worker) 
were  of  a  vesicular  character;  Massaglio,  ibid.,  Aug.  31,  also  a  finger  case;  Thevenot, 
ibid.,  1903,  vol.  Ixxvii,  p.  659,  reports  a  case  of  a  nodular  type  of  paronychia  of  the  finger 
caused  by  the  actinomyces;  Wright,  Amer.  Jour.  Med.  Sci.,  July,  1904,  p.  74,  a  tonsil 
case. 

Some  later  general  papers:  Sawyer,  Jour.  Amer.  Med.  Assoc.,  March  n,  1901; 
Ewing,  Bull.  Johns  Hopkins  Hospital,  Nov.,  1902;  von  Baracz,  Annals  of  Surgery, 
March,  1903 — abs.  in  Jour.  Amer.  Med.  Assoc.,  March  21,  1905:  Howard,  Jour.  Med. 
Research,  1903,  vol.  be,  p.  301;  Dor  (researches  on  fungus),  La  presse  medicale,  Sept.  16, 
1903;  Stokes,  Amer.  Jour.  Med.  Sci.,  Nov.,  1904,  p.  861;  Knox,  Lancet,  Oct.  29,  1904. 


A  CTINOM  YCOSIS  1157 

where  the  invasion  is  from  a  superficial  part  ordinarily  remains  unin- 
fluenced unless  systemic  pyemic  infection  occurs  or  the  fungus  elements 
find  their  way  to  the  deeper  organs  or  structures. 

Etiology  and  Pathology. — The  disease  is  due  to  the  ray  fungus. 
It  is  somewhat  rare,  and  apparently  oftener  observed  in  Germany  and 
France  than  elsewhere.  The  first  cases  described  in  our  own  country 
are  those  by  Murphy  (1885),  Schirmer,  Ochsner,  and  Bodamer  (iSSQ).1 
It  is  contagious  by  inoculation,  and  commonly  contracted  from  cattle 
and  horses,  and  therefore  seen  most  frequently  in  those  who  have  to  do 
with  these  animals.  It  is  probable,  too,  that,  in  some  instances,  as  in 
that  noted  by  Baracz2  from  kissing,  it  may  be  communicated  from  one 
individual  to  another.  As  the  fungus  is  also  believed  to  flourish  on 
straw,  corn,  and  other  grain,  the  habit  among  farmers,  dairymen,  and 
others  of  chewing  upon  such  substances3  is  very  likely  responsible  for  the 
common  method  of  inoculation  through  the  mouth,  taking  place,  as  a 
rule,  through  a  decayed  tooth.  According  to  Lord,4  actinomycetes  can 
be  demonstrated  in  the  contents  of  carious  teeth  and  the  crypts  of  the 
tonsils  in  persons  without  actinomycosis,  indicating  that  the  buccal  cavity 
may  be  a  possible  source  of  the  disease.  The  fungus  has  also  been  found 
in  bovine  vaccine  virus  (Howard).5  Successful  inoculation  ordinarily 
presupposes  an  abrasion  or  break  of  continuity,  and  this  has  usually 
been  noted  in  those  instances,  relatively  few,  in  which  the  integument 
was  primarily  involved.6  In  most  of  these  latter  cases  the  area  involve- 
ment was  small. 

1  Bodamer's  paper,  Med.  News,  March  2,  1889,  gives  abstract  of  the  others,  with 
references. 

2  Baracz,  Wiener  med.  Presse,  1889,  p.  6  (man  to  wife). 

3Ljunggren,  Nordiskt  med.  Arkiv,  1895,  No.  27,  p.  i — brief  abs.  in  Annales,  1896, 
p.  763,  refers  to  27  cases  (13  personal)  occurring  in  those  in  the  habit  of  chewing  grain 
or  straw;  Zeisler's  case.  Jour.  Culan.  Dis.,  1906,  p.  510,  was  attributed  to  the  chewing 
of  grass;  Varney's  case,  ibid.,  1909,  p.  235  (systemic,  neck,  cheek,  and  leg;  ray  fungus 
found  in  the  sputum) ,  had  been  in  the  habit  of  chewing  wheat  kernels  whenever  he 
could  obtain  them. 

4  Lord,  "A  Contribution  to  the  Etiology  of  Actinomycosis:  Experimental  Produc- 
tion of  Actinomycosis  in  Guinea-pigs  Inoculated  with  the  Contents  of  Carious  Teeth," 
Boston  Med.  and  Surg.  Jour.,  July  21,  1910;   and   "The  Etiology  of  Actinomycosis; 
The  Presence  of  Actinomycetes  in  the  Contents  of  Carious  Teeth  and  the  Tonsillar 
Crypts  of  Patients  Without  Actinomycosis,"  Jour.  Amer.  Med.  Assoc.,  Oct.  8,  1910, 
p.  1261. 

5  Kendall  (Australasian  Med.  Gaz.,  Feb.  i,  1913,  p.  108;  review  editorial),  at  a  re- 
cent Congress  in  Melbourne,  stated  that  during  the  last  few  years  over  600  cases  of 
actinomycosis  of  the  udder  had  been  met  with  in  the  dairy  herds  of  Victoria  and  that 
actinomycosis  of  other  parts  was  also  common. 

*  Kopfstein,  Wiener  klin.  Rundschau,  1901,  p.  21,  reports  the  case  of  a  woman,  a 
farm  laborer,  who  developed  the  disease  in  the  hand,  presumably  inoculated  while  bind- 
ing corn,  through  a  cut  accidentally  made  a  few  days  previously.  He  refers  also  to 
Miiller's  case,  in  which  infection  was  apparently  due  to  the  entry  of  a  splinter  of  wood 
into  the  palm  of  the  hand;  and  another  instance  (Von  Partsch)  where  it  followed  a  sur- 
gical operation,  inoculation  occurring  apparently  by  means  of  the  surgeon's  instruments. 
Merian,  "Ein  Fall  von  primarer  Hautaktinomykose,"  Dermatolog.  Wochenschr.,  1912, 
vol.  Ivi.,  p.  45,  reports  a  case,  nineteen-year-old  girl,  of  primary  skin  infection  occurring 
in  the  left  nasolabial  fold  at  its  lower  part;  the  lesion  being  pea-sized,  with  a  reddish- 
blue  zone;  the  growth  was  soft,  and  with  slight  yellowish-red  pus  oozing  from  its  apex: 
began,  according  to  the  patient,  three  weeks  previously  as  a  red  itching  spot  about  the 
size  of  a  hemp-seed.  Several  important  papers  on  the  disease  are  mentioned,  with 
references.  This  case,  according  to  the  author,  makes  about  25  cases  of  primary  skin 
infection  to  be  found  in  literature;  brief  review  with  references. 


1158 


PARASITIC  AFFECTIONS 


The  fungus,  called  the  actinomyces,  consists  of  a  central  network 
mass  of  interwoven  threads,  from  which  threads,  or  mycelia,  radiate 
like  projecting  rays,  and  terminate  in  bulbous  expansions;  these  latter 
are  thought  to  represent  the  fructifying  bodies.  One  to  several  may  pro- 
ject beyond  the  others.  In  tissue-section  examination  sometimes  small, 
oval,  apparently  homogeneous  bodies  are  seen  lying  near  the  ray  fungus, 

and  suggestive  of  spore  forms  of  the 
organism  (Rosenberger) -1  While  pre- 
viously the  fungus  was  thought  to  be- 
long to  the  molds,  Bostroem's  (1885) 
investigations  seemed  to  show  it  to  be  a 
variety  of  cladothrix,  of  the  class  schizo- 
mycetes,  although  on  this  point  there  is 
still  uncertainty  and  difference  of  opinion.2 
Of  the  various  staining  methods  for  its 
demonstration,  that  of  Gram  seems  to  be 
most  generally  satisfactory.  The  fungus 
is  usually  readily  demonstrable,  both  in 
the  discharge  (the  yellowish  grains)  and 
in  sections  of  involved  tissue.  In  some 
instances,  however,  especially  in  the 
earlier  stages,  it  is  not  always  found 
(Legrain,  Mackenzie,  Knox,  Galloway, 
and  others),3  and  exceptionally  only  in 
the  sections  from  the  outlying  invading 
borders.4 

Histologically,  the  nodular  and  infiltrated  mass  is  made  up  of  granu- 
lation tissue  having  a  resemblance  to  that  of  round-celled  sarcoma;  in 
some  instances  epithelioid  giant-cells  and  mast-cells  are  to  be  seen. 
Diagnosis. — The  disease  is  to  be  distinguished  from  syphilis, 

1  Rosenberger,  Jour.  Applied  Microscopy,  Nov.,  1900,  vol.  iii,  p.  1051. 

2  In  an  interesting  paper  on  the  biology  of  the  micro-organisms,  J.  H.  Wright,  publi- 
cation of  the  Mass.  Gen'l.  Hasp.,  1905,  vol.  i,  No.  i,  thinks  from  his  studies  and  re- 
view that  the  widely  disseminated  branching  micro-organisms  thought  by  Bostroem 
and  others  to  be  the  specific  infectious  agent  of  actinomycosis  are  really  quite  different, 
having  spore-like  reproductive  elements,  and  should  be  grouped  together  as  a  separate 
genus  with  the  name  Nocardia  and  that  infection  by  them  should  be  called  nocardiosis, 
and  not  actinomycosis;  that  the  term  "actinomycosis"  should  be  used  only  for  those 
inflammatory  processes  the  lesions  of  which  contain  the  characteristic  granules  or 
"drusen,"  composed  of  dense  aggregates  of  branched  filamentous  micro-organisms  and 
of  their  transformation  or  degeneration  products — these  products  including  the  charac- 
teristic refringent  club-shaped  bodies  radially  disposed  at  the  periphery  of  the  granule, 
and  which  may  or  may  not  be  present.     Apropos  of  this  may  be  mentioned  a  recent 
paper  by  Kieseritzky  and  Gerhardt,  Archiv.  klin.  Chirnrg.,  1905,  pp.  835,  et  seq.,  which 
shows  that  some  cases  clinically  resembling  the  disease,  and  even  containing  radiating 
filaments  are  rather  negatived  by  more  careful,  especially  laboratory,  investigation; 
Fernet  also  shows  (Brit.  Jour.  Derm.,  1905,  p.  265),  in  some  cases  clinically  present- 
ing the  picture  of  actinomycosis,  the  microscopic  examination  discloses  the  character- 
istic appearances  of  streptothrix. 

3  Legrain,  Annales,  1891,  p.  772;  Mackenzie,  Brit.  Jour.  Derm.,  1894,  p.  370;  Knox, 
Glasgow  Med.  Jour.,  1896,  vol.  xlv,  p.  382;  Galloway,  Brit.  Jour.  Derm.,  1895,  p.  116. 

4  In  a  case  of  a  physician,  involving  the  arm,  operated  upon  several  times  at  the 
Jefferson  Medical  College  Hospital,  repeated  examinations  of  the  discharge  and  tissue 
from  the  main  portion  failed  to  disclose  the  fungus,  but  it  was  finally  found  in  sections 
from  the  extreme  outer  edge  of  the  spreading  border. 


Fig.  306. — Actinomyces,  show- 
ing the  ray  arrangement  and  the 
club-shaped  ends  of  the  mycelial 
threads  (after  Ponfick). 


A  CTINOMYCOSIS  1159 

sarcoma,  carcinomata,  tuberculous  affections,  mycetoma,  and  phleg- 
monous  inflammation.  The  presence  of  the  peculiar  yellowish  bodies  or 
granules  in  the  discharge  would  be  of  conclusive  import.  The  common 
location  about  the  angle  of  the  lower  jaw  and  neck  and  cheek,  and  espe- 
cially occurring  in  those  who  have  to  do  with  animals  and  grain  products, 
should  always  lead  to  the  suspicion  of  actinomycosis,  which  can  be 
verified  or  disproved  by  observation  and  by  examinations  for  the  fungus; 
in  doubtful  instances  repeated  examinations  should  be  made  for  the 
latter  in  the  discharge,  and  also  in  the  deeper  bordering  tissue,  before  its 
absence  can  be  accepted  as  proved. 

Prognosis. — Actinomycosis  of  the  skin  and  superficial  parts  is 
usually  a  remediable  disease,  although  always  fraught  with  the  possi- 
bility of  deeper  involvement  and  grave  consequences.  Schlange,1  from 
a  study  of  a  number  of  patients,  takes  a  rather  favorable  view  of  these 
cases,  stating,  from  his  analytic  study,  that,  excepting  when  involving 
the  internal  organs,  it  has  a  pronounced  tendency  to  spontaneous  recov- 
ery. It  does,  however,  in  some  instances  continue  almost  indefinitely 
without  exhibiting  such  disposition.  The  advent  of  pyemic  symptoms 
is  always  of  serious,  and  usually  fatal,  import.  Involvement  of  the 
upper  jaw  is  more  serious  than  that  of  the  lower  jaw  or  other  surface 
situations,  as  there  is  more  danger  of  deep  invasion.2  Involvement  of  the 
orbit  is  also  of  serious  portent.  It  is  a  matter  of  observation  that  some 
cases  are  inherently  mild  and  others  more  or  less  malignant,  doubtless 
due  to  the  virulence  of  the  fungus  and  the  varying  resisting  power  of 
different  individuals,  and  on  the  influence  of  accidental  secondary  in- 
fective processes. 

Treatment. — The  management  of  this  malady  consists  in  the 
administration  of  potassium  iodid  in  moderate  or  large  dosage,  con- 
jointly with,  in  obstinate  or  spreading  cases,  curetting  or  excision  of  the 
diseased  mass.  This  remedy  varies  in  its  effect  in  different  instances, 
but  it  has  proved  beneficial  or  curative  (Carless,  Pringle,  Morris,  Rydy- 
gier,  Jurinka,  Nocard,  Netter,  Dubreuilh,  Audry,  Ljunggren,  Claisse, 
Berard,  and  many  others)  in  many  cases,  and  should  always  be  given  a 
good  trial  before  operative  measures  are  instituted.  According  to  Berard 
and  others,  its  most  rapid  and  brilliant  results  are  in  those  instances 
in  which  the  malady  is  recent  and  uncomplicated,  but  when  there  is 
associated  secondary  infection  by  streptococci,  staphylococci,  or  the 
bacterium  coli  commune  the  remedy  is  less  satisfactory.  Rydygier3 
successfully  treated  2  cases  by  local  injections  of  a  i  per  cent,  solution  of 
potassium  iodid  and  sodium  iodid,  injecting  at  first  one  Pravaz  syringeful, 
later  half  as  much  again;  one  of  these  cases  had  been  previously  treated 
without  result  by  surgical  means  and  the  internal  administration  of  the 
drug.  Bevan4  and  Zeisler  report  favorably  of  copper  sulphate,  j-grain 
(0.017)  doses  four  times  daily. 

1  Schlange,  "Zur  Prognose  der  Aktinomykose,"  Verhandl.  f.  Deutsch.  Gesellsch.  f. 
Chirurg.,  1892,  part  ii,  p.  24. 

2  See  paper  by  Bourquin  and  de  Quervain,  "Sur  les  complications  cerebrates  de 
1'actinomycosis,"  Rev.  med.  de  la  suisse  rom.,  1897,  vol.  xvii,  p.  145  (with  references). 

3  Rydygier,  Wien.  klin.  Wochenschr.,  1895,  p.  649;  also  Sawyer,  loc.  tit. 

4  Bevan,  Jour.  Amer.  Med.  Assoc.,  Nov.  n,  1905. 


PARASITIC  AFFECTIONS 

The  local  treatment  of  the  lesions  is  essentially  that  of  similar  nodular 
ulcerative  and  suppurative  formations — the  maintenance  of  cleanliness 
and  the  applications  of  mild  antiseptics,  a  frequently  changed  wet  dress- 
ing of  Lugol's  solution  being  one  of  the  best,  and  probably  of  some 
direct  inhibitory  influence  upon  the  growth  or  effects  of  the  fungus. 
I  have  found  the  x-r&y  valuable. 

MYCETOMA1 

Synonyms. — Fungus  foot  of  India;  Madura  foot;  Tubercular  disease  of  the  foot; 
Podelcoma;  Ulcus  grave;  Morbus  pedis  entophyticus;  Fr.,  Mycetome;  Pied  de  Madura; 
Gcr.,  Madurafuss;  Mycetoma. 

Definition. — An  endemic  disease,  chiefly  of  India,  commonly 
involving  the  foot,  and  characterized  by  swelling  and  the  formation 
of  tubercular  or  nodular  lesions  which  tend  to  break  down  and  form 
sinuses  leading  into  the  subcutaneous  structures,  and  finally  resulting 
in  disintegration  of  the  affected  part. 

Symptoms. — With  some  exceptions  the  foot  is  the  site  of  the  dis- 
ease, only  rarely,  in  fact,  the  hand,  knee,  or  other  region  being  attacked. 
It  is  observed  chiefly  in  those  who  go  barefooted,  generally  following 
a  slight  injury.  It  begins,  as  a  rule,  as  a  small  papule  or  nodule,  and  either 
upon  apparently  normal  skin  or  is  preceded  by  slight  edematous  swelling. 
The  nodule  increases  slowly  in  size,  new  lesions  appearing  from  time  to 
time  near  by.  When  at  all  established,  the  involved  area  or  part  is 
somewrhat  reddened,  variably  swollen,  and  the  seat  of  scanty  or  numerous 
nodular  formations,  which  are  usually  most  conspicuous  toward  the 
periphery.  The  nodules  are  elevated,  some  quite  firm  or  hard,  others 
softer  or  even  sluggishly  furuncular,  and  others  perforated  centrally  by 
an  opening  which  is  the  external  end  of  a  sinus  leading  down  to  muscle 
or  bone;  from  these  sinuses  is  discharged  a  puriform  liquid  containing 
small  round,  black,  gunpowder-like  bodies  or  "grains,"  or  a  fish-roe-like 
substance;  in  other  instances  the  discharge  is  of  a  whitish  color,  and  ex- 
ceptionally of  a  reddish  hue. 

Occasionally,  in  addition  to  or  in  place  of  the  papular  or  nodular 
lesions,  pustules  may  be  seen,  and  also  vesicles,  blebs,  and  abscesses 

1  Principal  literature:  Vandyke  Carter,  On  Mycetoma  or  Fungus  Foot  of  India, 
London,  1874;  Fox  and  Farquhar's  Endemic  Skin  and  Other  Diseases  of  India;  Manson, 
Tropical  Diseases,  1898,  p.  568;  Hyde,  Senn  and  Bishop,  "A  Contribution  to  the  Study 
of  Mycetoma  in  America,"  Jour.  Ciitan.  Dis.,  1896  (with  colored  plate  case  illustra- 
tion, review,  and  bibliography;  and  abstract  of  case  in  Canada  reported  by  Adami  and 
Kirkpatrick).  In  addition  to  these  2  American  cases,  3  others  have  since  been  reported: 
Pope  and  Lamb,  New  York  Med.  Jour.,  1896,  vol.  Ixiv,  p.  386  (with  case  and  fungus 
illustrations);  Wright,  Trans.  Assoc.  Amer.  Phys.,  1898,  vol.  xiii,  p.  471;  and  Arwine 
and  Lamb,  Amer.  Jour.  Med.  Sci.,  1899,  vol.  cxviii,  p.  393.  Libouroux,  "Contribution 
a  l'6tude  de  la  maladie  dite  pied  de  Madura  considere  comme  une  tropho-nevrose," 
Paris,  1886;  Kanthack,  "Madura  Disease  (Mycetoma)  and  Actinomycosis,"  Jour. 
Pathol.  and  Bacterial.,  Edinburgh,  1892-93,  vol.  i,  p.  140  (with  illustration);  Unna  and 
Delbanco,  "Beitrage  zur  Anatomic  des  indischen  Madurafuss,"  Monatshefte,  1900,  vol. 
xxxi,  p.  545  (with  review,  10  colored  histologic  cuts,  and  complete  bibliography) ;  Unna, 
"Aktinomycosis  und  Madurafuss,"  Deutsche  Medicinalzcitung,  1897,  p.  49;  Oppenheim, 
Archh,  1904,  vol.  Ixxi,  p.  209;  Hooton,  "Some  Clinical  Aspects  of  Mycetoma;  an  Un- 
usual form  of  Callosity  Complicating  it,"  Philippine  Jour,  of  Sci.,  July,  1910,  p.  215 
(based  upon  an  observation  of  26  cases;  in  several  the  mycetoma  was  complicated  by  a 
thickening  of  the  sole  by  multiple  callosities;  as  a  rule,  surgical  extirpation  of  the  fungus 
gave  satisfactory  results;  illustrations). 


MYCETOMA  Il6l 

have  rarely  been  noted.  The  progress  of  the  malady  is  slow,  usually 
several  years  or  more  elapsing  before  material  damage  has  been  done. 
The  sinuses  finally  encroach  upon  the  bony  structures,  the  latter  being 
eroded  and  disintegrated  by  the  presence  and  action  of  the  causative 
fungus.  The  local  conditions  in  the  advanced  disease  are  also  often 
partly  due  to  secondary  infective  processes,  as  from  pus  cocci,  etc. 

Etiology  and  Pathology.— The  malady  is  most  frequent  in 
India,  and  relatively  rare  elsewhere.  Five  unquestioned  cases  have 
been  recorded  in  our  own  country.  For  obvious  reasons  males  are  more 
prone  to  it,  as  they  are  more  in  the  habit  of  going  barefooted.  A  slight 
traumatism  or  break  in  the  continuity  of  the  skin  apparently  gives 
access  to  the  pathogenic  fungus.  The  organism  is  the  actinomyces 
Madurae,  consisting  of  mycelium  of  branching  threads  and  hyphae  and 
ovoid  spores.  Two  varieties  of  the  malady  have  been  noted,  based  upon 
the  color  of  the  discharged  bodies  or  "granules":  the  black  or  melanoid, 
and  the  pale,  ochroid,  or  yellow,  the  former  being  of  greater  frequency. 
The  black  granules  bear  resemblance  to  poppy-seeds  or  gunpowder,  the 
pale  or  pale  yellowish  to  fish-roe.  These  granules  microscopically  are 
seen  to  present  a  central  network  of  mycelia  with  radiating  mycelial 
threads,  which  may  terminate  in  bulbous  swellings.  In  fact,  the  close 
resemblance  to  the  fungus  of  actinomycosis  and  the  gross  clinical  simi- 
larity have  led  some  to  believe  the  maladies  identical,  but  the  majority 
of  observers  (Hyde,  Paltauf,  Unna,  and  others)  are  satisfied  that  the 
etiologic  fungi  are  not  the  same;  that  of  actinomycosis  is  highly  colored 
by  acid  fuchsin,  while  that  of  mycetoma  is  not  materially  affected. 

Section  of  the  tissues  of  the  involved  part  shows  small  and  large 
cavities  or  spaces  connected  by  the  sinuses;  these  spaces  contain  a  fatty 
or  gelatinous  substance,  which  in  the  black  variety  is  dark  colored  and 
hard,  and  in  the  pale  or  pale-yellowish  variety  soft  and  ochre  colored. 
According  to  Kanthack  and  others,  there  are  the  usual  evidences  of  reac- 
tionary inflammation  surrounding  the  fungus  collections,  and  the  pres- 
ence of  granulation  tissue  with  epithelioid  cells  and  many  vessels,  and  a 
scattered  formation  of  pigment;  in  the  later  stages  the  granulation  tissue 
undergoes  change  into  fibrous  tissue  and  the  formation  of  abscesses  and 
fistulas. 

Diagnosis. — The  region  involved,  the  character  of  the  discharge, 
and  the  absence  of  any  tendency  to  visceral  involvement  are  usually 
sufficient  to  distinguish  the  malady  from  actinomycosis.  This  latter, 
moreover,  is  commonly  seen  in  those  who  have  to  do  with  cattle  or  grain. 
Microscopic  examination  of  the  discharge  will  show  the  fungus,  which, 
though  presenting  some  resemblance  to  that  of  actinomycosis,  stains 
differently  with  acid  fuchsin. 

Prognosis  and  Treatment.— The  disease  pursues  a  chronic 
course — ten  to  twenty  years — resulting  in  total  disorganization  of  the 
affected  structures.  Instances  of  spontaneous  cure  are  unknown. 
Treatment  consists  in  thorough  removal  of  the  diseased  part  by  the 
curet  or  knife,  together  with  the  administration  of  potassium  iodid  in 
full  dosage.  When  of  long  standing  and  a  large  area  is  involved,  am- 
putation is  indicated,  care  being  exercised  to  include  all  infected  points. 


1 1 62  PARASITIC  AFFECTIONS 

BLASTOMYCOSIS 

Synonyms. — Blastomycetic  dermatitis;  Saccharomycosis  hominis;  Dermatitis 
blastomycotica;  Oidiomycosis  of  the  skin;  Fr.,  Blastomycose  cutanee;  Ger.,  Hefenmy- 
kose;  Hautblastomykose. 

It  is  especially  to  the  studies  primarily  of  Gilchrist,  and  later  of 
Hyde,  Hektoen,  Bevan,  F.  H.  Montgomery,  and  Ricketts,  that  the  ex- 
istence of  this  cutaneous  malady  has  been  made  known.1  It  begins,  as 

1  Gilchrist,  Johns  Hopkins  Hospital  Reports,  1896,  vol.  i,  p.  269;  Hyde,  Hektoen, 
and  Bevan,  Brit.  Jour.  Derm.,  1899,  p.  261;  F.  H.  Montgomery  and  Ricketts,  Jour. 
Cutan.  Dis.,  1901,  p.  26;  Hyde  and  Ricketts,  ibid.,  p.  44  (with  analytic  table  and 
references);  Stelwagon,  Amcr.  Jour.  Med.  Set.,  Feb.,  1901;  and  Ricketts,  Jour.  Med. 
Research,  Dec.,  1901.  This  last  by  Ricketts,  which  is  largely  based  upon  the  work  and 
case  reports  by  Hyde  and  F.  H.  Montgomery,  with  their  photographs  and  photomicro- 
graphs, gives  a  presentation  of  the  literature  and  a  resume  of  the  published  cases  of 
Hessler,  Wells-Senn,  Brayton,  Anthony-Herzog,  Dyer,  and  others  to  date;  F.  H.  Mont- 
gomery, Jour.  Cutan.  Dis.,  1902,  p.  195  (2  cases). 

Later  literature:  F.  H.  Montgomery,  Jour.  Amer.  Med.  Assoc.,  June  7,  1902  (cases 
of  Hyde  and  Montgomery;  finely  illustrated);  Busch,  Bibliotheca  Medica,  1902,  vol.  ii, 
part  10  (illustrations  and  bibliog.) ;  "Second  Annual  Report  of  the  Cancer  Committee  to 
the  Surgical  Dept.  of  the  Harvard  Med.  School,"  Jour.  Med.  Research,  1902,  vol.  vii, 
No.  3;  Gilchrist,  Brit.  Med.  Jour.,  1902,  vol.  ii,  p.  1321  (negro;  with  illustrations, 
review,  and  bibliography);  Sheldon,  Jour.  Amer.  Med.  Assoc.,  1902,  vol.  ii,  p.  1356; 
Walker  and  F.  H.  Montgomery,  Jour.  Amer.  Med.  Assoc.,  April  5,  1902  (death  from 
systemic  infection);  Dyer,  American  Medicine,  Oct.  25,  1902;  Sequeira,  Brit.  Jour. 
Derm.,  1903,  p.  121;  Pusey,  Jour.  Cutan.  Dis.,  1903,  p.  223  (2  case  demonstrations, 
with  illustration);  McCarrison,  Indian  Med.  Gaz.,  April,  1903;  Lowenbach  and  Op- 
penheim,  Archiv,  1904,  vol.  Ixix,  p.  121  (3  plates);  F.  H.  Montgomery,  Jour.  Cutan. 
Dis.,  1903,  p.  19  (followed  by  systemic  tuberculosis  and  death);  Ormsby  and  Miller, 
Jour.  Cutan.  Dis.,  1903,  p.  121  (illustrations;  cutaneous  and  systemic  case;  death; 
autopsy);  Evans,  Jour.  Amer.  Med.  Assoc.,  June  27,  1903  (infection  was  introduced 
through  a  punctured  wound  inflicted  while  performing  an  autopsy  on  a  patient  that  had 
died  of  systemic  blastomycosis) ;  Shepherd,  Jour.  Cutan.  Dis.,  1902,  p.  158;  H.  R. 
Varney,  Detroit  Med.  Jour.,  1903-4,  vol.  iii,  p.  73;  Fischkin,  Chicago  Med.  Recorder, 
1903,  p.  408;  Wright,  Northwest.  Lancet,  1904,  p.  149;  Dubreuilh,  Jour,  de  med.  de 
Bordeaux,  1904,  p.  529,  and  Annales,  1904,  p.  865  (first  French  case);  Unna,  Mtinch. 
med.  Wochenschr.,  1904,  p.  1367;  Clary,  Medicine,  1904,  p.  818;  Koehler  and  Hall, 
Jour.  Cutan.  Dis.,  1904,  p.  581  (in  a  negro);  Eisendrath  and  Ormsby,  Jour.  Amer. 
Med.  Assoc.,  1905,  vol.  xlv,  p.  1045  (case  with  systemic  involvement,  illustrated;  with 
a  review  of  the  previously  reported  cases  of  generalized  infection);  Christensen  and 
Hektoen,  ibid.,  1906,  vol.  xlvii,  p.  247  (2  cases,  generalized);  Bowen,  Jour.  Cutan. 
Dis.,  1906,  p.  30  (case  demonstration);  and  Bowen  and  Wolbach,  Jour.  Med.  Research, 
1906,  p.  167  (first  Boston  case);  Sakurane,  Archil),  1906,  vol.  Ixxviii,  p.  211  (probable 
case — first  Japan  case;  with  case  illustrations);  Bevan,  Jour.  Amer.  Med.  Assoc.,  Nov. 
n,  1905  (copper  sulphate  treatment);  Primrose,  Edinburgh  Med.  Jour.,  Sept.,  1906, 
p.  215  (Toronto  case;  lived  there  since  aged  ten,  except  two  years  spent  in  Chicago, 
1897-1900;  disease  developed  early,  1901);  Kessler,  "Blastomycosis  in  an  Infant," 
Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlix,  p.  550  (with  good  illustrations.  Child  five 
months  old;  face  and  scalp);  Herrick,  "Generalized  Blastomycosis:  Report  of  a  Case 
with  Recovery,"  Jour  Amer.  Med.  Assoc.,  1907,  vol.  xlix,  p.  328;  L.  Hektoen,  "Sys- 
temic Blastomycosis  and  Coccidioidal  Granuloma,"  Jour.  Amer.  Med.  Assoc.,  1907,  vol. 
xlix,  p.  1071  (review  and  references;  believes  these  two  allied  but  distinct);  A.  W. 
Brayton,  "Blastomycosis  and  Its  Congeners:  Report  of  Eight  Cases  Observed  by  the 
Writer  in  Indiana,"  Trans.  Indiana  State  Med.  Assoc.,  1907-8;  F.  H.  Montgomery, 
"Systemic  Blastomycosis;  Autopsy  and  Successful  Animal  Inoculations,"  Jour.  Cutan. 
Dis.,  1907,  p.  393  (with  case,  culture,  and  histologic  illustrations);  Shields,  "Two 
Cases,  One  Becoming  Systemic  with  Fatal  Termination,"  Jour.  Cutan.  Dis.,  1909,  p. 
156  (illustrations  of  i  case);  Ormsby,  "Cases  of  Bromid  Eruption  Mistaken  for 
Blastomycosis,"  Jour.  Cutan.  Dis.,  1909,  p.  445;  Hutchins,  Jour.  Cutan.  Dis.,  1908,  p. 
523  (2  cases,  i  a  negro;  in  i  case,  left  lower  lid  and  contiguous  tissue;  negro  case  illus- 
trated, disease  involving  eyelids,  face,  and  back  of  left  hand);  Fontaine,  Haase,  and 
Mitchell,  "Systemic  Blastomycosis:  Report  of  a  Case,"  Archives  Int.  Med.,  Aug.,  1909 
(with  excellent  photomicrographs  of  sections  of  liver  and  lung  showing  organisms); 
Washburn,  "Systemic  Blastomycosis,"  Jour.  Amer.  Med.  Assoc.,  April  15,  1911  (ex- 
ternal lesions  mostly  of  abscess  character;  death;  necropsy  showed  lung  involvement); 


PLATE  XXXIII. 


Blastomycosis  dermatitis.  The  black-and-white  text-cut  (Fig.  307)  shows  the  same 
case  at  a  later  period,  partly  healed  on  the  back  of  the  hand,  but  extending  further  on  the 
fingers  and  with  a  new  centre  on  the  wrist. 


BLASTOMYCOSIS 


1163 


a  rule,  as  a  small,  pea-sized  papule  or  papulopustule,  which  slowly,  in  the 
course  of  days  or  several  weeks,  has  enlarged  to  the  diameter  of  a  dime,  flat- 
tening down  centrally  and  showing  crusting.  Upon  removal  of  the  crust 
the  surface  is  noted  to  be  irregular  and  somewhat  papillomatous,  with 
occasionally,  at  this  stage,  and  almost  always  later,  a  variable  amount 
of  seropurulent  fluid  between  the  papillary  projections.  The  border 
of  the  patch  is  elevated,  reddish,  usually  of  a  deep  red  tinge,  and  well 
denned  by  moderate  infiltration.  Either  by  increase  peripherally,  as 
well  as  sometimes  with  the  arising  of  new  foci  just  outside  the  border,  the 
area  covered  may  in  several  months  or  a  year  or  so  be  considerable  in 
extent.  The  enlargement  may  occur  in  all  directions  or  preponderantly 
on  one  side,  or  it  may  be  somewhat  linear  in  extension.  When  at  all 
developed  the  malady  consists  of  an  elevated,  irregular,  papillomatous 


Fig.  307. — Blastomycosis;  man  aged  forty-nine;  duration  four  years;  healing  tendency 

in  central  portions. 

area,  of  a  deep-red  or  florid  color,  and  with  a  moderate  or  tolerably  free 
seropurulent  secretion.  In  places,  especially  the  oldest  parts,  partial 
or  complete  healing  may  take  place,  the  surface  skinning  over  and  ex- 
hibiting a  thin,  atrophic,  or  scar-like  appearance.  There  is  but  little 
tendency  to  actual  ulcerative  action.  Exceptionally,  as  in  one  of  my 
cases,  foci  of  disease  present  some  distance  off,  as,  for  example,  up  the 
arm  when  the  back  of  the  hand  is  the  site,  and  may  assume  the  same 
features  or  present  as  a  small,  flattened,  sluggish,  carbuncle-like  for- 
mation, breaking  at  several  points  and  discharging;  in  some  respects 
resembling  sporotrichosis.  In  many  cases  in  its  gross  features  it  is 

Posey,  Carpenter,  and  Allen  J.  Smith,  "Peculiar  Blastomycetoid  Organisms  Met  in 
Two  Cases  of  Parasitic  Conjunctivitis,"  Univ.  Pa.  Med.  Bull.,  Nov.,  1908;  Shepherd 
and  Rhea,  "A  Fatal  Case  of  Blastomycosis,"  Jour.  Cutan.  Dis.,  Nov.,  ion,  p.  588  (case 
illustration  and  histologic  cuts;  blastomycosis  of  skin,  bones,  peritoneum,  lymph-nodes, 
pleura  and  lungs,  kidneys,  left  adrenal,  prostate,  and  esophagus). 


1164 


PARASITIC  AFFECTIONS 


almost  a  clinical  counterpart  of  tuberculosis  verrucosa.  In  other 
cases  the  clinical  aspects  are  closely  analogous  to  those  of  lupus  vul- 
garis.  The  general  health,  except  in  the  comparatively  uncommon 
cases  of  systemic  infection,1  does  not  seem  to  suffer;  in  the  latter 
instances  the  general  symptoms  are  such  as  are  usually  seen  in  tu- 
berculous and  septic  conditions,  terminating  sooner  or  later  in  most 
such  cases  in  a  fatal  outcome.  On  the  other  hand  the  disease  may  be 
purely  a  local  affair,  and  be  even  limited  to  a  very  small  area — in  one 
instance  reported  to  the  nail  region,2  in  another  to  the  tongue,3  and  in 
the  case  herein  pictured  to  one  ear. 

Etiology  and  Pathology. — The  malady  is  rare,  and  in  about 
75  per  cent,  of  the  cases  is  seen  in  men,  and  for  the  most  part  in  those 
over  forty.  The  family  history  has  shown  no  special  tendency  or  vul- 
nerability. The  investigations  have  disclosed  the  presence  of  the  yeast 
fungus  as  the  causative  agent.  In  a  few  instances  the  disease  started  at 
the  point  of  a  slight  abrasion  or  traumatism.  The  back  of  the  hand, 


Fig.  308. — Blastomycosis,  showing  hypertrophied  epidermis  (e),  numerous  miliary 
abscesses  (a),  which  contain  parasitic  organisms  (/>).  In  the  corium  (c)  are  miliary 
abscesses  (b),  pseudotubercles  (»),  with  giant-cells  (g)  and  parasites  (p)  (courtesy  of  Dr. 
T.  C.  Gilchrist). 

face,  and  lower  part  of  the  leg  are  the  favorite  localities.    A  blastomy- 
cetic  infection  on  other  skin  diseases  is  a  possibility. 

The  histopathologic  characters  are  in  a  measure  similar  to  those 
found  in  tuberculosis  verrucosa  cutis.  These  findings,  as  shown  by 
the  investigations  of  Gilchrist,  Hyde,  Hektoen,  F.  H.  Montgomery, 
Ricketts,  and  others,  are  succinctly  expressed  by  Ricketts:  "Naked- 
eye  inspection  of  a  cross-section  shows,  from  without  inward:  (i)  A 
papillary  zone,  composed  of  a  superficial  layer  of  isolated  villiform  proc- 

1  F.  H.  Montgomery  and  Ormsby,  "Systemic  Blastomycosis:  Its  Etiologic,  Patho- 
logic, and  Clinical  Features,  as  Established  by  a  Critical  Survey  and  Summary  of 
Twenty-two  Cases — Seven  Previously  Unpublished;  the  Relation  of  Blastomycosis  to 
Coccidioidal  Granuloma,"  Archives  Int.  Med.,  Aug.,  1908. 

2  Selenew,  "Onychia  Blastomycotica,  Ikonographia  Dermatologica  Fasc.  3,  plate 
23," — abs.  in  Jour.  Cutan.  Dis.,  1910,  p.  540  (mother  and  four  children  with  nail  condi- 
tions resembling  trichophyton  infection,  due  to  blastomyces). 

3  Capelli,  Giom.  Hal.,  Sept.  23,  1912,  p.  467 — abs.  in  Jour.  Cutan.  Dis.,  Jan.,  1913, 
p.  51  (case  of  a  woman  presenting  tumor  consisting  of  six  nodules  on  the  back  of  the 
tongue,  which  upon  investigation  and  culture  was  proved  to  contain  blastomyces; 
guinea-pig  experimental  inoculation  were  confirmatory;  the  paper  is  illustrated). 


BLASTOMYCOSIS 


1165 


esses,  and  a  deeper  layer  of  similar  processes  which  are  united  side  by 
side.  (2)  A  homogeneous,  vascularized,  grayish-red,  cellular  zone,  in 
which  are  formed  minute  abscesses.  (3)  An  unaltered  layer  of  subcuta- 
neous fat,  as  the  limit  of  deep  extension.  .  .  .  Stained  sections 
exhibit  the  following  histologic  features:  (i)  A  vast  amount  of  'carcino- 
matoid'  epithelial  hyperplasia.  (2)  Minute  intra-epithelial  abscesses. 
(3)  A  granulomatous  condition  in  the 
corium,  characterized  by  masses  of  plasma 
cells,  minute  abscesses,  and  tuberculoid 
nodules  and  giant-cells.  (4)  The  presence 
of  a  spheric,  capsulated,  budding  organ- 
ism, particularly  in  the  epidermal  and  sub- 
epidermal  abscesses,  but  also  distributed 
unevenly  and  in  small  numbers  in  epi- 
thelial masses  and  granulation  tissue." 
The  organism,  or  fungus — the  blasto- 
myces — is  sometimes  but  scantily  found. 
It  consists  of  a  rounded,  doubly  con- 
toured, vacuolated  body,  averaging  in  size 
10  to  12  (Ji.  They  are  often  seen  in  pairs, 
and  also  as  budding  forms,  but  in  the 
tissues  never  exhibit  threads,  as  observed 
in  cultures.  Proliferation  in  the  former 
is  by  gemmation;  it  seems  probable, 
also,  that  endogenous  spores  may  form 
(Ricketts) ;  Hyde  and  F.  H.  Montgomery 

state  that  under  certain  conditions  blastomyces  multiply  by  sporula- 
tion.1  The  pathogenic  role  of  the  blastomyces  has  been  shown  by  the 
animal  experimental  inoculations  recorded  (Gilchrist  and  Stokes,  Hyde 
and  Hektoen,  F.  H.  Montgomery  and  Ricketts). 

1  It  had  been  generally  believed  and  conceded  that  the  so-called  protozoic  disease  of 
Posadas,  Wernicke,  Rixford  and  Gilchrist,  D.  W.  Montgomery,  and  others,  Busse's  and 
Curtis'  saccharomycosis  hominis,  and  Gilchrist's,  Hyde  and  F.  H.  Montgomery's  blas- 
tomycetic  dermatitis,  are  practically  expressions  of  the  same  disease  process;  and  that 
the  organisms  isolated  from  the  various  cases  differ  in  minor  respects,  but  are  so  closely 
related  morphologically  and  biologically  as  to  justify  their  inclusion  in  a  common  genus. 
This  still  stands  as  the  view  of  an  increasing  majority  of  observers;  but  dermatitis  cocci- 
dioides  (D.  W.  Montgomery)  as  an  independent  malady  has  still  some  earnest  advo- 
cates. 

In  later  papers,  D.  W.  Montgomery  and  his  associates  (see  "Dermatitis  Coccidi- 
oides,"  by  D.  W.  Montgomery,  Ryftsogel,  and  H.  Morrow,  Jour.  Cutan.  Dis.,  1903,  p. 
5,  with  illustrations  showing  the  organism;  and  "Dermatitis  Coccidioides;  Reasons  for 
Considering  It  an  Independent  Disease,"  by  D.  W.  Montgomery  and  H.  Morrow,  ibid., 
1904,  p.  368)  contend  strongly  against  the  view  that  the  blastomycosis  and  the  coccidial 
cases  are  identical.  Their  principal  differences  stated  are  "that  in  dermatitis  coccidioi- 
des  there  is  a  great  diversity  in  the  clinical  picture;  the  skin  lesions,  which  resemble  the 
rotten-tomato-like  lesions  of  the  tuberous  iodid  of  potassium  eruption,  may  be  scattered 
widely  over  the  skin,  or  occur  as  subcutaneous  abscesses;  the  cutaneous  lesions  are  fre- 
quently secondary  to  internal  infection;  it  tends  strongly  to  become  generalized  and  end 
fatally;  the  organism  has  a  double  cycle  of  growth  without  any  feature  in  common,  one 
in  the  tissues,  and  one  in  culture  media;  the  organism  increases  by  endogenous  spore- 
formation,  and  budding  has  not  been  seen;  in  fresh  specimens  the  double-contoured 
sphere  may  often  be  seen  to  be  surrounded  by  a  halo  of  short  filaments  like  the  cilia  of 
ciliated  epithelium;  the  organism  is  larger  than  blastomyces;  the  administration  of  po- 
tassium iodid  has  no  control  over  the  disease."  In  discussing  the  last  paper  and  the 


309. — Blastomycosis — in- 
volving ear  only. 


ii66 


PARASITIC  AFFECTIONS 


Diagnosis. — The  disease  is  to  be  distinguished  from  tubercu- 
losis verrucosa  cutis,  vegetating  syphiloderm,  lupus  vulgaris,  and 
sporotrichosis.  Its  resemblance  to  the  first  is  striking,  but  ordinarily 
the  border  of  the  tuberculous  eruption  has  a  deeper,  usually  more  viola- 
ceous, color,  and  is  less  apt  to  be  extensive.  Its  usual  method  of  begin- 
ning, course,  and  behavior  are  different  from  those  of  syphilis.  The 
latter  is,  moreover,  more  distinctly  purulent,  the  discharge  having  a 
greenish  tinge  and  often  an  offensive  odor.  Lupus  vulgaris  is  relatively 
slow  in  its  course,  with  often  distinct  ulcerative  tendency,  and  frequently 


Fig.  310. — Blastomyces — fungus  of  blastomycosis.  Nos.  2-13  represent  various 
budding  forms  found  in  the  sections.  Nos.  8  and  o  show  the  organisms  with  some  form 
of  fibrous  coating  (courtesy  of  Dr.  T.  C.  Gilchrist). 

rather  tough,  firm  scarring.  The  indolent  abscess  formation  of  sporotri- 
chosis is  more  or  less  characteristic,  and  serves  usually  to  differentiate. 

conclusions,  Gilchrist,  Hyde,  and  F.  H.  Montgomery  reiterated  their  already-known 
changed  views,  accepting  the  identity  of  these  various  coccidial  cases  with  those  of 
blastomycosis,  citing  cases  of  the  latter  which  seemed  to  show  phases  similar  to  those 
described  by  D.  W.  Montgomery.  In  the  material  from  a  case  (Wright-Bolles  case) 
more  recently  examined  by  Wohlbach  ("The  Life  Cycle  of  the  Organism  of  Dermatitis 
Coccidioides,"  Jour.  Cutan.  Dis.,  1905,  p.  18)  the  organism  found  was  identical  with  that 
observed  by  D.  W.  Montgomery,  Ryfkogel,  and  Morrow,  and  the  writer  also  believes  it 
a  distinct  type;  D.  W.  Montgomery,  ibid.,  1905,  p.  115  (The  Mould  of  Dermatitis 
Coccidioides);  Ophiils,  Coccidioidal  Granuloma  (3  cases;  with  review  of  similar  cases), 
Jour.  Amer.  Med.  Assoc.,  1905,  vol.  xlv,  p.  1291,  and  P.  K.  Brown,  Coccidioidal  Granu- 
loma, ibid.,  March  2,  1907  (2  cases;  with  review),  also  agreed  with  these  observers.  See 
also  later  paper,  discussing  this  point  from  the  negative  side,  by  F.  H.  Montgomery 
and  Ormsby,  Archiv  Int.  Mcd.,  Aug.,  1908. 


SPOR  O  TRICHOSIS  1 1 6/ 

It  is  to  be  stated,  however,  that  a  positive  conclusion  in  the  differentia- 
tion with  tuberculosis  verrucosa,  and  to  a  less  extent  with  lupus  vulgaris 
and  with  sporotrichosis,  is  possible  only  by  microscopic  examination, 
cultures,  or  experimental  animal  inoculations. 

The  rare  cases  of  the  confluent  papulopustular,  papillomatous 
eruption  due  to  the  ingestion  of  bromids  and  iodids  present  at  times 
a  rough  resemblance  to  blastomycosis.  (See  illustration  under  Dermatitis 
medicamentosa.) 

Prognosis  and  Treatment.— The  ordinary  verrucous  type, 
which  remains  distinctly  cutaneous,  is  not  dangerous  to  life,  but  it  is 
obstinate  and  sometimes  destructive  and  distorting.  The  possibility 
of  systemic  infection  must  be  borne  in  mind,  however,  as  the  number 
of  such  cases  recorded  is  gradually  increasing;  they  are  always  of  serious 
import. 

Treatment,  consisting  of  medication,  re-ray ,  and  excision  or  curet- 
ing,  is,  as  a  rule,  successful  in  the  cutaneous  cases.  The  iodids  in- 
ternally in  full  dosage,  with  the  maintenance  of  cleanliness  and  the 
local  use  of  weak  iodin  solutions  or  other  antiseptic  lotions,  conjointly 
with  #-ray  exposures  (Bevan,  Hyde  and  Montgomery,  Ricketts,  Shep- 
herd, and  others) ,  is  the  plan  that  most  frequently  brings  about  marked 
improvement  and  sometimes  cure.  The  iodids  act  slowly,  however, 
and  must  be  continued  for  some  months,  the  malady,  in  this  respect, 
differing  materially  from  the  vegetating  syphiloderm,  which  usually  re- 
sponds rapidly  to  the  iodid  treatment.  Bevan  has  seen  favorable 
influence  from  j-grain  (.016)  doses  of  copper  sulphate,  and  the  applica- 
tions of  a  i  per  cent,  solution  of  the  same  drug.  A  persistent  area  or 
remnant  can  be  thoroughly  cureted  or  excised.  In  systemic  cases  the 
iodids  should  be  pushed  to  extreme  dosage,  along  with  tonics  and  sup- 
porting measures. 

SPOROTRICHOSIS 

It  is  due  to  Schenck's1  (1898)  paper,  the  Brayton2  (1899),  Hektoen 
and  Perkins  (1900), 3  and  De  Beurmann  and  Ramond  (1903) 4  reports,  and 
more  recently  to  the  distinguished  work  of  De  Beurmann  and  Gougerot,5 

1  Schenck,  "On  Refractory  Subcutaneous  Abscesses  Caused  by  a  Fungus,  Possibly 
Related  to  Sporotricha,"  Johns  Hopkins  Hasp.  Bull.,  1898,  p.  286. 

2  Brayton,  "Chronic  Abscesses,"  Indianapolis  Med.  Jour.,  1899,  vol.  xviii,  p.  272. 

3  Hektoen  and  Perkins,  "Refractory  Subcutaneous  Abscesses  Caused  by  Sporothrix 
Schenckii:  A  New  Pathogenic  Fungus,"  Jour.  Exper.  Med.,  1900,  p.  77. 

4  De  Beurmann  and  Ramond,  "Absces  sous-cutanes  multiple  d'origine  mycosique," 
Annales,  1903,  p.  678. 

8  De  Beurmann  and  Gougerot,  Bull,  de  la  Soc.  Franc,  de  Derm.,  Jan.  3,  1907,  p.  26 
(dermic  sporotrichoses) ;  Annales,  1906,  pp.  837,  914,  and  933  (subcutaneous  sporotri- 
choses;  complete  exposition  with  many  illustrations);  ibid.,  1907,  pp.  497,  603,  and  654 
("sporotrichoses  tuberculoldes,"  case  and  histologic  illustrations,  review  and  references) ; 
Tribune  Medicate,  Nov.  2,  1907,  p.  693  (etiology  and  pathogeny);  Bull,  de  la  Soc.  Med. 
des  Hdp.  de  Paris,  June  7,  1907,  p.  585  (mucous  membranes);  De  Beurmann,  Gougerot, 
and  Vaucher,  ibid.,  Oct.  25,  p.  107  (in  cat);  ibid.,  May  22,  1908,  p.  718  (in  rat);  ibid., 
June  5,  p.  800  (in  rats — experimental);  De  Beurmann  and  Gougerot,  ibid.,  May  28, 
1908,  p.  733  (wide  diffusion;  North  and  South  America);  Annales,  1909,  p.  81  (acute, 
subacute,  and  sluggish  types,  and  comparison  with  other  somewhat  similar  infections; 
review  and  references);  Archiv,  1911,  ex,  p.  25  (general  review);  "Les  Sporotrichoses," 
Paris,  Libraire  Felix  Alcan,  1912;  and  many  other  papers  (chiefly  case  reports). 


1 1 68  PARASITIC  AFFECTIONS 

Monier-Vinard,1  and  others,2  that  the  importance  of  this  malady  and  its 
pathogenic  fungus,  the  sporotrichium,  is  being  gradually  fully  recognized. 
Symptoms. — While  the  symptomatology  may  vary  considerably 
within  certain  limits,  there  is  a  family  likeness:  quite  often  a  case  pre- 
sents an  ill-defined  symptom  medley  of  a  tuberculous  and  a  syphilitic 
gumma,  tuberculosis  verrucosa  cutis,  and  a  variable  degree  of  pyo- 
genic  inflammation.  In  one  set  of  cases  the  malady  takes  its  origin 

1  Lesne  and  Monier-Vinard,  Bull,  de  la  Soc.  Anal.,  May,  1906,  p.  422  (multiple 
chronic  abscesses);  Bull,  de  la  Soc.  Med.  des  Hop.  de  Paris,  March  21,  1907,  p.  268 
(subcutaneous);  Gaucher  and  Monier-Vinard,  ibid.,  May  2,  1907,  p.  353  (2  cases; 
cutaneous  and  visceral  sporotrichosis;  one  had  pulmonary  tuberculosis);  Monier- 
Vinard,  Presse  Medicale,  July  6,  1907,  p.  426  (clinical  types  and  diagnosis);  Rubens- 
Duval  and  Monier-Vinard,  Bull,  de  la  Soc.  Med.  des  Hop.,  Oct.  25,  1907,  p.  1074;  and 
several  others. 

2Adamson,  Brit.  Jour.  Derm.,  1908,  p.  296,  gives  an  excellent  resume,  with  full 
bibliography;  Mewborn,  Jour.  Cutan.  Dis.,  1908,  p.  140,  also  a  good,  but  somewhat 
briefer,  one  with  partial  bibliography;  Chipman,  "A  Resume  of  the  Views  of  De  Beur- 
mann  and  Gougerot  on  the  Subject  of  Sporotrichosis,"  Jour.  Cutan.  Dis.,  1912,  p.  339. 
Among  other  case  reports  and  valuable  contributions  during  the  past  few  years  are: 

Arndt,  Berlin,  klin.  Wochenschr.,  1909,  No.  44  (preliminary  report  of  first  German 
case,  patient  male,  aged  twenty-nine,  with  gummatous  type  on  right  arm) ;  and  later 
report,  "Beitrage  Zur.  Kenntniss  der  Sporotrichose  der  Haul  mit  besonderer  Beriick- 
sichtigung  der  Lymphangitis  Sporotrichotica;  expermentelle  Sporotrichose,"  Derma- 
tolog.Zeitschr.,  1910,  H.  i  and  3  (histologic  and  clinical  study  with  review  and  resume 
of  literature  and  bibliography;  experimental  inoculation  successful  in  rats,  apes,  but 
negative  in  guinea-pigs);  and  Archiv,  1911,  ex,  p.  25  (present  status  of  the  question  and 
general  review);  Kren  and  Schramek,  Wien.  klin.  Wochenschr.,  1909,  xxii,  p.  1519  (leg 
first,  later  other  parts;  nodular  and  furunculoid) ;  Burlew,  S.,  Col.  Pract.,  Jan.,  1909,  p. 
i  (abscess  on  left  cheek,  and  numerous  small  abscesses  on  the  right  anterior  leg  some- 
what deep);  Trimble  and  Shaw,  Kansas  Med.  Jour.,  Sept.,  1909;  Sutton,  Jour.  Amer. 
Med.  Assoc.,  Sept.  17,  1910,  p.  1000  (illustrations;  woman  aged  thirty,  beginning  on 
ball  of  right  thumb,  possibly  from  a  splinter) ;  "Sporotrichosis  in  America,"  Jour.  Amer. 
Med.  Assoc.,  Dec.  24,  1910  (2  new  cases,  with  illustrations);  and  "Sporotrichosis  in 
Man  and  in  the  Horse,"  Boston  Med.  and  Surg.  Jour.,  Feb.  9,1911  (also  reports  a  case  in 
which  infection  was  probably  from  a  horse);  Hyde  and  Davis,  "Sporotrichosis  in  Man, 
with  Incidental  Consideration  of  its  Relation  to  Mycotic  Lymphangitis  in  Horses,"  Jour. 
Cutan.  Dis.,  1910,  p.  321  (with  many  illustrations,  review,  and  full  bibliography;  i  case, 
beginning  on  hand  thought  to  have  been  derived  from  a  similar  infection  in  a  horse) ; 
Adamson,  June  1911,  p.  182  (case  demonstration);  and  ibid.,  p.  239  (full  report  of  same 
case,  Englishman  infected  in  Brazil,  beginning  in  slight  wound  in  back  of  his  right 
thumb,  with  small  chain  of  arm  lesions;  illustrations  of  case  and  fungus);  Brit.  Jour. 
Derm.,  1913,  p.  33  (case  demonstration;  second  case;  disseminated,  ulcerative,  gumma- 
tous type  with  acute  synovitis,  woman  aged  sixty;  under  potassium  iodid  case  much 
improved,  but  this  drug  seemed  to  start  up  the  first  trouble) ;  and  "A  Case  of  Sporo- 
trichosis Simulating  Blastomycosis,"  Brit.  Jour.  Derm.,  1913,  p.  60  (third  case;  patient 
in  the  United  States  when  first  symptoms  appeared;  first  lesions  upon  right  leg  followed 
by  others  on  trunk  and  hands;  lesions  papillomatous) ;  Ofenheim,  Lancet,  March  n, 
1911  (doubtful  case);  Norman  Walker  and  Ritchie,  Brit.  Med.  Jour.,  July  i,  1911  (male; 
injury  of  hand,  extended  up  arm):  Hodare  and  Bey,  Archiv,  1911,  ex,  p.  387  (a  case 
of  one  and  one-half  years  duration  with  septicemic  symptoms,  the  eruption  being 
generalized  and  consisted  of  acneiform  papules  and  nodules,  many  of  which  were  vesico- 
pustular,  others  necrotic  and  covered  with  a  crust  which  on  healing  left  small  cica- 
trices and  persistent  pigmentation,  finally  recovered);  and  Dermatolog.  Wochenschr., 
Jan.  13,  1912,  p.  50 — abs.  in  Jour.  Cutan.  Dis.,  April,  1912  (3  cases  in  same  family, 
two  sisters  and  a  brother,  one  sister  had  purplish,  lentil-sized  nodules  on  the  face  for 
three  months'  duration,  some  of  the  lesions  being  crusted;  the  other  sister  had  a  chest- 
nut-sized tumor  on  the  ala  nasi  resembling  lupus  verrucosus,  with  smaller  lesions  on  the 
face,  the  hands,  and  left  elbow,  and  of  eight  months'  duration;  the  brother  had  a  single 
lesion  on  the  wrist  of  eight  months'  duration;  fungus  found  and  cultured);  Hamburger, 
Jour.  Amer.  Med.  Ascoc.,  Nov.  2,  1912,  p.  1590  (case  male,  farmer,  aged  twenty-eight; 
chain  of  lesions  on  leg  similar  to  arm  cases;  interesting  and  valuable  summary  and  ana- 
lytic tabulation  of  the  American  cases,  with  bibliography);  Kenneth  Taylor,  "Sporo- 
trichium Schenkii,"  ibid.,  April  12,  1913,  p.  1142  (chiefly  on  morphology  and  cultural 
characteristics,  and  review,  with  references) — a  helpful  paper  to  those  interested. 


SPOR  O  TRICHOSIS 


1169 


at  some  point  of  trifling  injury — for  example,  on  the  hand.1  The  seat 
or  injury  may  or  may  not  become  sluggishly  inflamed,  and  develop  into 
a  small  dermic,  sometimes  subdermic  nodule,  and  which  may  or  may  not 
soften  or  break  down;  or  the  point  of  injury  may  develop  into  a  sluggishly 
inflamed  discharging  sore;  or  there  may  simply  result  an  insignificant 
abrasion  or  sore,  which  has  almost  or  entirely  disappeared  before  the  other 
formations  have  developed.  At  about  the  same  time  or  a  little  later 
a  subcutaneous  nodule  will  be  felt  at  the  lower  end  of  the  forearm;  this 
gradually  enlarges  to  the  size  of  a  cherry,  flattens  somewhat,  and  is  not 
much  elevated,  but  may  spread  out  peripherally;  it  softens,  the  overlying 
skin  thinning  and  becoming  of  a  purplish-red  color,  and  finally  breaking 
through,  the  discharge  being  of  a  viscid,  gelatinous,  seropurulent  charac- 


Fig.  311. — Sporotrichosis  (Stelwagon-Stout  Jefferson  Hospital  case). 

ter.  Its  formation  is  successively  followed  by  several  or  more  such  for- 
mations higher  up  the  arm,  along  the  lymphatic  vessel,  which  can 
usually  be  felt  as  a  hard  cord.  They  all  may  not  open,  one,  two,  or 
more  remaining  as  cold  sluggish  subcutaneous  tumors,  from  the  size 
of  a  cherry  to  that  of  a  mandarin  orange;  the  smaller  ones  usually  hard, 
the  larger  ones  being  of  the  nature  of  a  partly  or  more  completely  softened 
indolent  abscess.  As  a  rule,  however,  softening  is  followed  by  gradual 

1  In  Schenck's  case,  as  well  as  in  the  Hektoen  and  Perkins  case,  it  was  a  slight  injury 
to  the  finger  from  a  nail;  and  in  Brayton's  case  it  was  the  puncture  of  the  skin  of  the 
finger  by  a  wire.  In  an  instance  at  my  service  at  the  Jefferson  Medical  College  Hospital 
it  originated  in  an  injury  of  the  palm,  just  at  the  base  of  the  thumb  (this  case  was  shown 
before  the  Philadelphia  Dermatological  Society,  Nov.  24,  1908,  and  appears  in  Society 
Transactions,  "Case  for  Diagnosis,"  Jour.  Culan.  Dis.,  1909,  p.  131). 


PARASITIC  AFFECTIONS 

extension  to  the  surface,  breaking  through  with  a  resulting  irregular 
crateriform  opening.  It  takes  generally  several  weeks  to  a  few  months 
for  the  malady  to  reach  this  stage.  After  discharging,  a  lesion  may  grad- 
ually undergo  partial  involution,  and  then  remain  stationary;  or  it  may 
extend  laterally  somewhat  as  a  slightly  nodular  purplish-red  infiltration, 
in  a  measure  similar  to  that  seen  associated  with  a  broken-down  tubercu- 
lous gland. 

In  the  other  cases,  by  far  the  larger  number,  the  port  of  entry — • 
point  of  infection — is  not  discoverable.  In  one  class  of  these  cases, 
chiefly  described  by  French  observers,  the  development  of  the  lesions 
is  about  similar  to  that  described,  but  they  are  irregularly  disseminated 
over  the  limbs  and  trunk,  beginning  primarily  in  the  subcutaneous  tissue 
as  somewrhat  hard,  painless  nodules,  slowly  increasing  in  size;  usually 
breaking  down,  the  contents  discharging  through  the  fistulous  opening 
as  a  grayish-yellow  homogeneous  pus.  These  cases  represent  the  so- 
called  "syphiloid"  type  of  De  Beurmann  and  Gougerot.  It  is  not  im- 
possible that  exceptionally  there  may  be  not  more  than  one  such  forma- 
tion, and  seated  at  almost  any  region;  but,  as  a  rule,  there  are  from  five 
to  thirty.  Sometimes  a  number  of  these  may  not  develop  beyond  the 
size  of  a  large  pea  to  small  cherry-sized  hard  nodules,  which  can  be  felt 
as  an  irregular,  subcutaneous,  nodular  chain  along  an  enlarged  lymphatic. 
Some  of  the  broken-down  lesions  finally  heal,  leaving  a  scar;  or  they  tend 
to  become  papillomatous,  resembling  tuberculosis  verrucosa  cutis.  In 
some  instances  this  fungating  tendency  is  so  marked  as  to  give  the  malady 
a  distinctly  tuberculous  aspect,  the  "tuberculoid"  type  of  De  Beurmann 
and  Gougerot;  although  in  this  type  the  lesions  usually  have  their  origin 
closer  to  the  surface.  In  fact,  some  of  the  tuberculosis  verrucosa  type 
of  lesions  may  apparently  begin  as  such,  or  as  a  small  ulcer,  resulting 
from  a  rapid  breaking  down  of  the  surface  of  a  superficial  nodule  or  papu- 
lotubercular  infiltration.  It  is  more  especially  this  verrucous  or  papil- 
lomatous type  that  presents  some  resemblance,  usually  slight,  to  blasto- 
mycosis. 

In  another  class  of  cases  the  lesions  develop  primitively  in  the 
dermis,  as  in  the  Monier-Vinard  case.  In  this  instance  it  presented 
as  a  number  of  distinctly  elevated,  moderately  sized,  roundish  nodules 
on  the  face;  the  surface  of  the  lesions  was  at  first  smooth  and  moist, 
but  later,  after  weeks  or  a  few  months,  rough  and  irregular  with  a  yel- 
lowish coating;  the  scars  that  followed  resembled  those  left  by  lupus 
tubercles.  Another,  secondary  form — the  epidermic  form — is  also  ex- 
ceptionally observed,  in  which  an  irregular  ring  of  vesicopapules  or  opal- 
ine vesicles  develop  around  the  central  opening  of  the  discharging  or 
discharged  nodule,  presenting  a  rough  resemblance  of  trichophytosis. 
In  rare  instances  intramuscular  abscesses  and  gumma-like  formations 
beneath  the  periosteum  (usually  a  tibial  periostitis)  have  also  been  noted; 
the  latter,  with  one  exception  only,  has  been  associated  with  the  more 
usual  subcutaneous  abscesses.  Exceptionally,  a  large  abscess  type  (Dor) 
has  been  observed. 

Mucous  membrane  (buccopharynx)  lesions  have  also  occasionally 
been  noted  (De  Beurmann  and  Gougerot,  Brodier  and  Gaston,  and 


SPOR  O  TRICHOSIS  1 1 7 1 

Letulle);  De  Beurmann  and  Gougerot  discovered  (i  case)  that  the  organ- 
ism may  exist  in  this  region  in  sporotrichosis  without  producing  lesions. 
The  sporotrichium  was  found  by  Monier-Vinard  in  the  expectoration  of 
a  patient  (sporotrichosis  case)  affected  with  pulmonary  tuberculosis, 
possibly  a  mixed  infection ;  it  has  likewise  been  found  in  the  sputum  of  a 
sporotrichosis  patient  when  the  lungs  were  apparently  healthy.  In 
a  few  other  instances  there  seemed  to  be  evidences  of  systemic  and  pos- 
sibly visceral  involvement  (Massery,  Doury,  Monier-Vinard,  and 
Widal  and  Weill).  While  the  lymphatic  vessels  concerned  may  be,  and 
usually  are,  affected — a  decided  lymphangitis  sometimes — the  glands 
are  rarely  enlarged. 

The  course  of  the  malady,  as  is  to  be  already  inferred,  is  slow;  and 
it  is  persistent,  with  only  rarely,  except  as  to  individual  lesions,  any 
tendency  to  complete  spontaneous  recovery. 

Etiology  and  Pathology.— The  malady  is  most  frequently  seen 
in  France;  the  United  States  (Schenck,  Bray  ton',  Hektoen  and  Perkins, 
Burlew,  Trimble  and  Shaw,  Hyde  and  Davis,  Pusey,  Stelwagon  and 
Stout,  Sutton,  and  several  others)  coming  next  in  number  of  cases; 
England  (Adamson,  Norman  Walker)  and  Germany  (Kren  and  Schramek 
and  Arndt)  so  far  recording  but  few  cases;  the  disease  is,  however,  doubt- 
less world-wide.  It  is  due  to  a  fungus,  the  sporotrichium,  as  primarily 
discovered  by  Schenck,  and  later  confirmed  by  Hektoen  and  Perkins, 
and  since  thoroughly  established  by  the  observations  and  experimental 
investigations  of  De  Beurmann  and  Gougerot.  At  first  it  was  generally 
accepted  that  the  organism  was  identical  in  all  the  cases,  but  De  Beur- 
mann and  Gougerot.  and  several  others  now  believe  that  there  are 
several  forms  of  the  fungus,  three  of  which  are  thought  to  have  been 
identified:  sporotrichium  Beurmanni  in  the  European  and  Brazilian 
cases,  sporotrichium  Schencki  in  the  North  American  cases,  and  sporo- 
trichium indicum  in  Ceylon  cases.  It  can  rarely  be  demonstrated  in  the 
lesions,  but  is  readily  cultured  and  on  almost  any  of  the  usual  media.1 
The  parasite  has  been  isolated  from  the  blood  of  a  patient  with  cutaneous 
sporotrichosis  (Widal  and  Andre).  The  malady  has  been  produced  (De 
Beurmann  and  Gougerot  and  others)  experimentally  by  cutaneous  or 
intraperitoneal  inoculation  in  animals  (guinea-pig,  cat,  rat,  mouse,  and 
monkey),  the  rat  being  especially  susceptible,  and  the  guinea-pig  the 
least;  although  De  Beurmann  has  produced  a  generalized  subcutaneous, 
gummatous  sporotrichosis  in  a  newborn  guinea-pig  by  feeding  it  upon 
milk  containing  the  parasite.  In  the  rat  visceral  reactions  are  quite 
common.  Spontaneous  sporotrichosis  has  been  noted  in  the  mule 

1  Sabouraud's  peptone-glucose-agar  is  the  best.  Streak  cultures  are  made  upon 
this  medium  of  the  pus  taken  from  the  suspected  lesions,  taking  the  usual  precautions 
to  avoid  contamination  and  avoiding  the  use  of  rubber  caps  over  the  cotton  plugs. 
The  fungus  is  best  grown  at  room  temperature;  small  white  colonies  appear  on  the 
fourth  to  the  eighth  day  along  the  line  of  the  streak.  They  slowly  increase  in  size,  and 
become  convoluted  and  brown  in  color.  In  bouillon  the  growth  may  form  a  veil  or  a 
flocculent  down  without  the  medium  becoming  cloudy.  In  the  hanging-drop  the  para- 
site appears  as  a  fine  ramified  mycelium,  with  partitions  at  long  intervals.  Films  from 
cultures  show  long  filaments  2  fi  broad,  together  with  numerous  ovoid  spores  5  to  6  I* 
in  length  by  3  to  4  u  broad;  here  and  there  single  spores,  or  bunches  of  three  to  thirty, 
are  seen  attached  bouquet-like  to  the  mycelial  filaments  by  a  short  pedicle. 


1 1 72  PARASITIC  AFFECTIONS 

(Fontegnot  and  Carongean),  in  the  dog  (Gougerot  and  Caraven),  and 
in  the  rat  (Lutz  and  Splendore) ;  and  the  saprophytic  nature  of  the  fungus 
has  been  demonstrated  by  its  culture  upon  yarious  animal  structures, 
such  as  caterpillars,  flies,  larvae,  etc.,  and  upon  vegetables  as  well.  Hyde 
and  Davis'  investigations  show  that  some  of  the  American  cases  of  my- 
cotic  lymphangitis,  or  epizootic  lymphangitis,  in  horses  are  due  to  this 
same  Sporotrichium,  and  are  in  reality  cases  of  sporotrichosis,  thus 
furnishing  another  source  for  the  infection  in  man.  It  can  be  readily  seen, 
therefore,  how  easily  infection,  under  favoring  circumstances,  might 
take  place,  and  in  many  ways  either  externally  or  internally.  The  port 
of  entry  has  remained  unknown,  however,  in  many  cases.  It  is  seen  in 
both  sexes  and  at  almost  all  ages,  although  uncommon  in  childhood;  in 
74  cases  (collected  by  Sutton)  the  youngest  patient  was  aged  five,  the 
oldest  aged  seventy-eight;  there  were  14  females  and  60  males;  in  30 
instances  the  initial  lesion  was  on  the  hand  or  forearm,  and  in  1 1  on  the 
foot,  legs,  or  thigh.  The  malady  is  probably  not  so  rare  as  recorded  ob- 
servations would  indicate,  as  cases  simulative  of  syphilitic  gummata  may 
have  been  treated  as  such  with  the  iodids  with  recovery,  and  the  error 
in  diagnosis  remain  undiscovered. 

In  their  histologic  study  De  Beurmann  and  Gougerot  found  that 
the  malady  is  of  the  nature  of  a  chronic,  nodular,  suppurative  affection, 
and  that  the  histologic  picture  showed  resemblance,  as  the  affection 
often  does  clinically,  to  that  of  tuberculous  and  of  syphilitic  lesions. 
There  seems  to  be  a  mixture  of  the  three  types  of  reaction — (i)  a  lympho- 
connective  tissue  or  syphiloid;  (2)  an  epithelioid  (with  giant-cells)  or 
tuberculoid;  and  (3)  a  polynuclear  or  suppurative. 

Diagnosis. — The  peculiar  conditions  in  the  hand  and  arm  cases, 
already  described,  are  more  or  less  suggestive.  In  the  more  general 
cases  the  varying  characters  of  the  lesions,  due  to  their  different  stages, 
the  cold  sluggish  nature  of  the  softening  and  abscess-formation,  the  cra- 
teriform  aspect,  the  slow  course,  and  the  usually  undisturbed  general 
health,  are  to  be  taken  into  consideration.  The  histologic  picture  is 
not  distinctive  enough  to  be  of  much  aid.  The  suspicion  aroused,  the 
diagnosis  can  be  confirmed  or  disproved  by  cultural  methods.1  The 
diseases  with  which  it  might  most  likely  be  confused  are  those  previously 
mentioned:  tuberculous  and  syphilitic  affections,  simple  indolent, 
staphylococcic  abscesses,  and  blastomycosis.2  It  is  to  be  remembered 
that  it  is  not  impossible  that  sporotrichosis  may  coincidentally  also  be 
present  in  a  subject  with  syphilis,  tuberculosis,  or  any  other  disease. 

Prognosis   and   Treatment.— The    disease    usually    responds 

1  De  Beurmann  and  Gougerot  have  found  that  an  early  orchitis  (in  fifteen  to  twenty 
days)  in  the  rat  after  intraperitoneal  inoculation  with  material  from  the  suspected  case 
is  diagnostic. 

2  De  Beurmann  and  Gougerot,  "Eine  Neue  Mykose  Die  Hemisporose,"  Archiv, 
April,  1910,  ci,  p.  298, — abs.  in  Brit.  Jour.  Derm.,  1910,  p.  297;  under  the  name  "fiemi- 
sporosis"  these  observers  describe  3  cases  due  to  the  hemispora  stellata,  and  which 
might  possibly  be  mistaken  for  the  gummatous  types  of  sporotrichosis;  the  first  case 
(Gougerot  and  Caraven)  simulated  a  syphilitic  ostitis  of  the  tibia,  the  second  case  simu- 
lated a  tuberculous  abscess  on  the  neck,  and  the  third  case  simulated  a  gumma  of  the 
penis;  histologically,  there  was  but  little  difference  in  the  findings  from  those  of  tubercle 
or  syphilis. 


PEDICUL  OSIS  1173 

more  or  less  rapidly  to  potassium  iodid,  in  medium  to  large  dosage. 
Applications  externally  to  the  broken-down  lesions  and  ulcers  of  com- 
presses of  weak  lotions  of  the  same  drug,  or  diluted  Lugol's  or  other  weak 
iodin  solution,  are  helpful.  The  #-ray  would  doubtless  be  of  some  aid. 
Surgical  measures  are  not  to  be  commended  unless  the  pus-collection 
should  be  large. 

B.  DISEASES    DUE   TO    ANIMAL    PARASITES 
PEDICULOSIS 

Synonyms. — Phthiriasis;  Morbus  pedicularis;  Morbus  pediculosis;  Malis  pediculi; 
Lousiness;  Fr.,  Phtiriase;  Maladie  pediculaire;  Ger.,  Lausesucht. 

Pediculosis,  while  signifying  mere  lousiness,  is  commonly  under- 
stood as  a  designation  of  that  condition  of  local  or  general  cutaneous 
irritation  due  to  the  presence  of  the  animal  parasite — the  pediculus, 
or  louse.  The  parasite  belongs  to  the  class  insecta,  of  the  subdivision 
hemiptera,  and  the  family  pediculidae.  Three  species  of  the  parasite  are 
encountered,  each  having  its  particular  field  of  operation — pediculus 


Fig.  312.  Fig.  313.  Fig.  314. 

Pediculus  capitis.  Pediculus  corporis.  Pediculus  pubis. 

(Female;  dorsal  surface;  X  25)  (courtesy  of  Dr.  L.  A.  Duhring). 

capitis,  pediculus  corporis,  and  pediculus  pubis.  The  first  is  found  upon 
the  scalp  region,  and  only  accidentally  and  temporarily  on  other  parts; 
the  second  has  the  general  body  surface,  or  in  reality  the  clothing,  as  its 
special  habitat,  while  the  pediculus  pubis,  especially  the  pubic  region, 
but  also  other  parts  where  there  are  short  stiff  hairs,  as  the  axillae,  the 
breast  and  leg  hairs,  the  eyebrows,  and  the  eyelashes.  Only  rarely  do 
these  three  parasites  invade  other  than  their  own  special  regions  named,1 
and  then,  as  a  rule,  only  accidentally  and  temporarily.  Depending  upon 


,  "The  Migration  of  Pediculi,"  The  Med.  Fortnightly,  March  15,  1893, 
gives  a  few  examples  and  cites  others,  with  references. 


1 174 


PARASITIC  AFFECTIONS 


this  fact,  three  varieties  of  the  malady  are  presented,  named,  according 
to  the  parts  involved,  pediculosis  capitis,  pediculosis  corporis,  and  pedic- 
ulosis pubis. 

In  appearance,  shape,  and  other  features  the  head  and  body-lice 
are  practically  alike,  the  former  being  from  ii-  to  $\  mm.  in  length,  or 
averaging  about  one-third  less  in  size  than  the  latter,  which  varies  from 
i  \  to  4-i  mm.  long.  Upon  the  whole,  clinical  observation  shows  the  body- 
louse  to  be  predominantly  much  the  larger — much  more  so  than  these 
figures  would  indicate.  Their  breadth  is  about,  or  a  little  less  than, 

half  their  length.  The  male  is  smaller  than 
the  female;  the  sexual  organ  of  the  former 
is  on  the  dorsal  surface,  and  consists  of  a 
conic  or  wedge-shaped,  protruding,  and 
relatively  large  structure;  the  vaginal  open- 
ing in  the  female  is  on  the  ventral  surface. 
These  pediculi  are  of  an  elongate,  ovalish 
shape,  having  six  strongly  jointed  legs 
with  stout  claws  coming  off  from  the 
thoracic  portion;  the  longer  abdominal 
part  shows  laterally  well-defined  deep 
notches.  The  rounded,  acorn-shaped  head, 
somewhat  ovalish  in  the  body-louse,  has 
two  prominent  eyes  and  two  antennae. 
Both  the  head-louse  and  body-louse  are 
grayish  in  color,  with  blackish  margins. 
After  feeding,  the  contained  blood  imbibed 
gives  the  parasite  a  slight  or  decided  red- 
dish tinge,  more  noticeable,  as  a  rule,  in 
the  pediculus  corporis.  The  pediculus 
pubis,  or  crab-louse,  averages  much  shorter 
than  either  the  head-  or  body-louse,  the 
thoracic  and  abdominal  portions  show 
apparently  no  division,  and  the  head  seated 
squarely  upon  the  body.  It  varies  in  length 
from  i  to  2^  mm.,  and  is  almost  as  broad 
as  it  is  long.  In  addition  to  the  usual 
number  of  jointed  claws  it  has  eight  strong, 
teat-shaped,  prehensile  feet  going  off  from 
the  margin  of  the  abdomen.  In  color  it 

is  grayish,  with  a  yellow  tinge,  and  is  more  or  less  translucent.  In  other 
respects  it  is  similar  to  the  other  varieties,  except  that  there  are  no  well- 
defined  notches  laterally.  The  reproductive  capacity  of  these  parasites 
is  very  great,  from  fifteen  to  twenty  eggs  for  the  pubic  variety  to  fifty 
or  more  for  the  others.  The  ova,  or  nits,  are  found  attached  to  the  hair- 
shafts  in  the  scalp  and  pubic  varieties,  and  in  the  clothing  and  on  the 
lanugo  hairs  in  pediculosis  corporis.  The  ova  are  minute,  dirty-white  or 
grayish-looking,  pear-shaped  bodies,  visible  to  the  naked  eye,  and  glued 
to  the  hair  by  a  chitinous  substance,  with  the  projecting  butt  end  point- 
ing toward  the  distal  end  of  the  shaft.  They  hatch  out  within  a  week 


Fig.  315. — Ova  of  the  head- 
louse  attached  to  a  hair  (mag- 
nified) (after  Kaposi). 


PEDICUL  OS  IS  1175 

and  the  young  are  sexually  competent  in  less  than  two  weeks  more. 
It  can  readily  be  seen  how  rapidly  they  multiply.  While  the  parasites 
cannot  be  said  to  be  elective  in  the  choice  of  subjects,  yet  some  individ- 
uals seem  to  be  less  desirable  as  hosts  than  others. 

The  symptoms  produced  by  the  parasites  primarily  or  secondarily 
vary  within  considerable  limits,  and  this  is  not  always  necessarily  de- 
pendent upon  the  number  present,  but  to  some  extent  upon  the  irritabil- 
ity of  the  skin  and  other  individual  factors.  In  marked  examples^  of 
pediculosis,  owing  to  the  constant  irritation  and  itching,  and  sometimes 
to  the  consequent  disturbed  sleep,  the  general  health  may  be  influenced. 
In  fact,  in  some  instances  there  seems  to  be  an  appearance  of  impaired 
nutrition,  the  skin  being  of  a  dingy,  unhealthy  color,  and,  especially  in 
the  scalp  variety,  the  hair  dry  and  lifeless  looking.  This  may  possibly 
be  in  a  measure  due  to  the  absorption  of  some  toxic  substance  from  the 
pediculi  themselves,  transferred  when  pricking  the  skin  for  nourishment. 
At  all  events,  the  changed  general  appearance,  the  healthier  tone  of  the 
skin,  and  improved  nutrition  ensuing  upon  a  cure  of  the  malady  are  some- 
times striking  and  scarcely  otherwise  explainable. 

While  the  symptoms  of  pediculosis  are  to  a  great  extent  the  same  in 
the  three  varieties  of  the  malady,  they  are  somewhat  modified  by  the 
locality  invaded,  and  are  therefore  best  described  separately. 

PEDICULOSIS  CAPITIS 

Synonyms. — Piithiriasis  capitis;  Pediculosis  capillitii;  Head-lice;  Head-lousiness; 
Fr.,  Phtiriase  de  la  tSte. 

Pediculosis  capitis,  or  head-lousiness,  due  to  the  presence  of  the  pe- 
diculus  capitis,  occurs  much  more  frequently  in  children  than  in  adults, 
although  it  is  quite  common  in  grown  girls  and  women,  the  occipital 
region  being  that  predominantly  infested.  Men,  owing  doubtless  to  the 
shorter  hair  and  fewer  opportunities  for  a  successful  lodgment  of  the  para- 
site, are  rarely  its  subjects.  In  some  instances  beyond  slight  itchiness 
there  are  no  other  symptoms,  except,  of  course,  the  presence  of  the  para- 
sites, and  their  ova  attached  to  the  hairs.  In  many  subjects,  however,  the 
affection  is  characterized  not  only  by  marked  itching,  but  also  by  the  for- 
mation of  various  inflammatory  lesions,  such  as  papules,  pustules,  ex- 
coriations, and  small  crusted  areas — resulting  from  the  irritation  produced 
by  the  parasites  and  from  the  scratching  to  which  the  intense  pruritus 
often  gives  rise.  In  fact,  commonly  an  eczematous  eruption  of  an  oozing 
and  pustular  type  soon  develops,  attended  with  more  or  less  crust  forma- 
tion, and  such  is  often  practically  limited  to  or  most  pronounced  pos- 
teriorly just  at  the  region  of  the  occiput.  Impetiginous  lesions  over  the 
scalp,  and  sometimes  a  few  on  face  or  neck,  together  occasionally  with  a 
few  excoriations  on  these  parts,  may  be  seen  in  some  cases.  In  extreme 
instances,  as  a  result  of  the  exudation  and  negligence  and  the  collection 
of  extraneous  dirt,  the  hair  becomes  glued  together,  forming  irregular, 
tangled,  more  or  less  felted  masses,  and  emitting  an  exceedingly  offensive 
odor.  Most  of  the  cases  of  the  so-called  plica,  or  plica  polonica,  so  com- 
mon in  former  times  among  the  poorer  classes,  especially  in  certain 


1176  PARASITIC  AFFECTIONS 

countries,  as  in  Poland,  were  unrecognized  instances  of  this  kind;  some 
were  examples  of  tangled  felting  and  massing,  doubtless  resulting  from 
uncomplicated  oozing,  crusted  eczemas. 

In  addition  to  the  various  other  symptoms,  few  or  many  pediculi 
can  commonly  be  discovered  scattered  around  in  the  hair,  and  ova,  or 
nits,  generally  in  great  numbers,  are  to  be  seen  attached  to  the  hair- 
shafts.  Several  or  a  profusion  of  them  may  be  found  on  a  single  shaft. 
They  are  minute,  pin-head-sized,  pear-shaped,  whitish  or  grayish-white 
bodies,  firmly  glued  to  the  hair  with  the  projecting  butt  end  pointing 
toward  the  distal  extremity  of  the  shaft. 

The  diagnosis  of  pediculosis  capitis  is  a  matter  of  no  difficulty. 
The  pediculi  are  usually  to  be  found,  sometimes  requiring  some  hunting; 
but  even  if  they  exist  in  small  numbers  and  are  not  readily  discovered, 
the  presence  of  ova,  or  nits,  on  the  hair-shafts,  always  to  be  seen  upon 
careful  inspection,  will  indicate  the  nature  of  the  affection.  They 
should  not,  however,  be  confused  with  the  minute  seborrheic  scaly 
particles  quite  frequently  to  be  observed  scattered  through  the  hair, 
and  occasionally  slightly  encircling  the  shaft;  nits  are  firmly  attached, 
while  seborrheic  scales  can  be  dislodged  by  light  brushing  or  shaking. 
In  women  and  girls,  pustular  eruptions  upon  the  scalp,  especially  pos- 
teriorly, should  always  arouse  a  suspicion  of  pediculosis.  There  is,  of 
course,  the  possibility  in  some  cases  of  the  pediculosis  being  secondary 
to  eczema  instead  of  being  the  primary  exciting  factor  of  the  eczematous 
irritation. 

Treatment. — The  applications  upon  which  reliance  is  usually 
placed  consist  of  crude  petroleum,  tincture  of  cocculus  indicus,  mercuric 
chlorid  lotion;  and  ointments  of  white  precipitate,  sulphur,  and  ?- 
naphthol,  from  20  to  60  grains  (1.3-4.)  to  the  ounce  (32.)  of  petrolatum. 
In  slight  cases  I  have  found  a  daily  shampooing  with  a  sulphur-naphthol 
soap  a  satisfactory  method;  the  lather  is  always  to  remain  on  five  to  ten 
minutes.  In  the  use  of  crude  petroleum  the  scalp  is  to  be  soaked  with  it, 
and  a  head-bandage  applied  or  a  suitable  cap  worn;  care  should  be  taken 
that  the  oil  does  not  run  down  over  the  forehead  or  down  the  neck,  as  it 
is  likely  to  be  irritating  to  these  parts.  To  lessen  its  inflammability  it 
may  be  mixed  with  half  its  quantity  or  even  an  equal  part  of  olive  oil 
or  liquid  petrolatum.  This  dressing  is  to  be  worn  for  twelve  hours,  and 
the  scalp  then  thoroughly  washed  with  soap  and  water.  As  a  rule,  this 
will  suffice  to  destroy  all  the  pediculi  and  the  attached  ova.  If  there  is 
any  doubt  in  regard  to  this,  the  dressing  is  to  be  renewed  for  another 
twelve  hours.  Owing  to  its  inflammability  it  is  not  a  good  plan  for 
practice  among  the  ignorant  or  careless.  Tincture  of  cocculus  indicus 
is  commonly  employed  diluted  with  one,  two,  or  three  parts  of  alcohol, 
and  sponged  on  the  scalp  twice  daily  for  a  few  days,  and  associated  and 
supplemented  with  soap-and-water  washings.  Mercuric  chlorid  lotion, 
in  the  strength  of  \  or  2  grains  (0.033-0.13)  to  the  ounce  (32.)  of  water, 
or  equal  parts  of  alcohol  and  water,  is  to  be  applied  for  two  or  three  days 
twice  daily ;  it  should  not  be  employed  if  there  is  much  irritation  or  a  raw 
surface.  If  the  parts  are  decidedly  eczematous,  one  of  the  several  oint- 
ments named  may  be  used  instead  of  the  lotions,  making  the  application 


PEDICULOSIS  1177 

freely  and  thickly  and  enveloping  the  head  in  a  bandage,  and  renewing 
the  dressing  twice  a  day  for  from  two  to  four  days.  Subsequently  to  the 
active  treatment,  or  in  association  with  it,  the  scalp  should  be  washed 
once  daily  with  soap  and  water  or  with  alkaline  lotions  or  dilute  acetic 
acid  (i  part  to  10  or  20  of  water)  in  order  to  free  the  hair-shafts  from  the 
ova  or  shells  that  may  be  attached;  frequent  combings  with  a  fine- toothed 
comb  will  be  of  service  both  for  this  purpose  and  also  for  the  removal  of 
the  pediculi.  In  the  management  of  pediculosis  capitis  close  cutting 
of  the  hair  will  facilitate  the  treatment,  but  it  is  not  essential. 

PEDICULOSIS   CORPORIS 

Synonyms. — Pediculosis  vestimenti  seu  vestimentorum;  Phthiriasis  corporis; 
Vagabond's  disease;  Fr.,  Phtiriase  du  corps. 

Pediculosis  corporis,  or  body-lousiness,  is  due  to  the  presence  of  the 
pediculus  corporis.  It  is  characterized  by  more  or  less  general  itching, 
excoriations,  together  with  various  inflammatory  lesions,  some  of  which 
may  be  primary  and  others  secondary.  In  sensitive  skin  wheals,  usually 
of  evanescent  character,  sometimes  arise  at  the  points  where  the  parasites 
have  inserted  their  sucking  apparatus,  or  haustellum.  This  act  also 
produces  a  peculiar  lesion,  which  may  be  said  to  be  characteristic, 
consisting  of  a  minute  hemorrhagic  punctum  on  a  level  with  the  surface 
and  practically  imperceptible  to  the  finger  passing  over  it— in  this  respect 
differing  from  the  red,  excoriated  points  resulting  from  scratched,  con- 
gested, or  irritated  follicles.  As  the  parasites  live  in  the  clothing,  in 
the  seams,  and  also  where  the  skin  is  most  conveniently  reached  for  pur- 
poses of  feeding,  the  various  lesions  and  excoriations  are,  therefore, 
to  be  found  most  abundantly  on  those  parts  with  which  the  clothing 
comes  closely  in  contact,  as,  for  instance,  around  the  neck,  across  the 
shoulders  and  upper  part  of  the  back,  around  the  waist,  over  the  sacrum, 
and  down  the  outside  of  the  thighs.  The  parasites,  if  numerous,  are 
readily  found,  but  if  in  scanty  number  are  to  be  hunted  for  in  the  seams 
of  the  collar-band;  the  ova  are  also  found  in  the  clothing,  and  sometimes 
attached  to  the  lanugo  hairs,  especially  of  the  upper  part  of  the  trunk. 
The  irritation  produced  is  often  sufficiently  intense  in  this  form  to  lead 
to  more  or  less  violent  scratching,  so  that  it  is  not  uncommon  to  see, 
here  and  there,  but  especially  upon  the  upper  part  of  the  back,  parallel 
linear  scratch-marks  made  by  several  or  more  of  the  finger-nails,  in  efforts 
to  gain  relief.  The  continued  irritation,  consequent  hyperemia,  and  the 
excoriations  occasionally  bring  about  in  places  a  slight  degree  of  eczema, 
and  also  in  persistent  cases  a  variable  degree  of  resulting  pigmentation, 
most  pronounced  on  the  upper  portion  of  the  trunk  posteriorly,  although 
in  extreme  instances  it  is  more  or  less  general  and  of  quite  a  dark  hue,  as 
to  suggest  the  possibility  of  Addison's  disease  (see  under  Chloasma).1 

1  The  observations  of  Besnier,  Greenhow,  and  Thibierge  (Thibierge,  Bull,  el  mem. 
de  la  Soc.  med.  des  hop.  de  Paris,  Dec.  18,  1891)  that  in  some  of  these  instances  pigmen- 
tation is  also  found  on  the  buccal  mucous  membrane,  and  also  on  the  glans  penis,  would 
seem  to  indicate  that  there  were  other  reasons  for  the  integumentary  discoloration  in 
addition  to  those  commonly  believed.  Thibi6rge  remarks  that  such  cases  reduce  the 
pathognomonic  significance  of  pigmentation  of  the  mucous  membranes  in  Addison's 
disease. 


Ii;8  PARASITIC  AFFECTIONS 

The  violence  with  which  the  skin  is  sometimes  scratched  is  such  that 
the  nails  not  only  penetrate  to  the  corium,  but  into  some  depth  of  the 
latter,  as  shown  here  and  there,  especially  on  the  back,  by  scattered, 
small,  irregular,  atrophic-looking,  or  cicatricial  spots.  These  are  also 
to  some  extent  possibly  due  to  the  secondary  ecthymatous  lesions  which 
are  occasionally  seen.  The  symptoms  vary  considerably,  however,  in 
different  individuals,  in  some  the  itching  being  extremely  slight  and  the 
effects  insignificant,  in  others  of  a  decided,  scarcely  bearable  character, 
the  patients  getting  but  little  rest,  and  the  skin  the  seat  of  papules,  small 
and  large  pustules,  and  excoriations.  Jamieson1  has  recorded  a  few 
instances  of  pyrexia,  apparently  of  reflex  nature,  due  to  the  presence  of 
body-lice,  and  hi  cases  in  which  the  cutaneous  lesions  were  insignificant. 
Pediculosis  corporis  is  commonly  seen  in  adults,  and  more  frequently 
in  those  of  advancing  years.  It  is  rather  rare  in  children.  It  is  observed 
quite  often  among  the  frequenters  of  lodging-houses  and  among  the  cach- 
ectic, poor,  and  uncared-for.  Certain  individuals  are  more  prone  to 
successful  invasion  than  others.  It  is  readily  communicated  by  trans- 
ference of  either  the  parasites  or  their  ova. 

The  diagnosis  of  pediculosis  corporis  in  well-marked  examples 
is  comparatively  easy,  as  the  distribution  of  the  excoriations  and  other 
lesions,  as  well  as  often  the  pigmentation  and  the  usually  intense  itchi- 
ness,  and  the  minute  hemorrhagic  puncta,  are  quite  suggestive.  Parallel 
linear  scratch-marks  are  also,  as  a  rule,  significant.  The  distribution 
and  absence  of  hand  involvement  are  generally  sufficient  to  prevent 
error  with  scabies  (see  the  latter  for  other  differential  points).  Careful 
search  will  almost  invariably  disclose  one  or  more  pediculi,  unless  the 
underwear  ha'd  been  changed  just  before  examination,  and  in  some  in- 
stances ova  can  be  found  attached  to  the  lanugo  and  other  body-hairs. 
In  some  cases  there  is  a  suggestion  of  urticaria,  the  wheals  arising  where 
the  pediculi  have  inserted  the  haustellum,  as  well  as  sometimes  elsewhere 
in  consequence  of  the  reflex  irritation.  The  distribution,  however,  as 
well  as  the  other  characters  mentioned,  will  generally  suffice  for  the  dif- 
ferentiation. In  ordinary  urticaria  the  hands  and  face  frequently  share 
in  the  eruption,  parts  not  involved  in  pediculosis.  The  malady  is  not 
to  be  confused  with  simple  pruritus  (q.  z>.). 

Treatment. — As  the  lice  only  go  to  the  skin  for  the  purpose  of 
feeding,  the  main  attention  in  the  treatment  of  pediculosis  corporis  is 
to  be  directed  to  the  infested  wearing  apparel  and  bed-linen,  which 
should  be  thoroughly  baked,  boiled,  or  gone  over  with  a  very  hot  iron 
in  order  to  destroy  the  pediculi  and  their  ova.  Inasmuch,  however,  as 
in  some  instances  the  ova  are  found  attached  to  the  lanugo  body-hairs, 
a  fact  to  which  Jamieson2  has  directed  notice,  the  surface,  therefore, 
requires  treatment  also,  otherwise  a  recurrence  naturally  soon  shows 
itself.  An  occasional  general  tub-bath  of  corrosive  sublimate  (oij-iij 
(4.-! 2.)  to  the  bath),  if  there  are  not  many  excoriations,  will  be  destruc- 
tive to  the  ova.  The  employment  of  a  naphthol-sulphur  soap  in  con- 

1  Jamieson,  "On  Some  of  the  Rarer  Effects  of  Pediculi,"  Brit.  Jour.  Derm.,  1889, 
p.  321. 

2  Jamieson,  ibid.,  1895,  p.  248. 


PEDICUL  OSIS  1 1 79 

nection  with  the  ordinary  bath  is  also  serviceable.  Jamieson  advises 
the  use  of  a  piece  of  roll  sulphur,  the  size  of  a  pigeon's  egg,  in  a  coarse 
muslin  or  canvas  bag,  and  worn  next  the  skin  day  and  night;  the  heat  of 
the  body  causes  gradual  oxidation  and  the  formation  of  sulphurous  acid. 
This  plan  can,  as  Jamieson  suggests,  also  be  employed  in  those  of  the 
careless  or  tramp  class,  who  cannot  give  proper  attention  to  the  apparel. 
In  these  instances,  too,  the  use  of  an  ointment  of  stavesacre,  2  drams 
(8.)  to  the  ounce  (32.),  of  sulphur,  30  to  60  grains  (2.~4.)  to  the  ounce 
(32.),  or  of  /3-naphthol,  20  to  60  grains  (1.33-4.)  to  the  ounce  (32.), 
will  serve  a  like  purpose.  These  ointments,  if  in  weaker  strengths,  also 
are  of  benefit  to  the  papular  and  pustular  lesions;  but  if  the  skin  is 
decidedly  eczematous,  a  weak  carbolized  zinc  ointment  or  a  saturated 
solution  of  boric  acid,  with  i  or  2  drams  (4--8.)  of  carbolic  acid  to  the 
pint  (500.),  is  to  be  preferred.  Carbolic  acid,  like  the  other  substances 
named,  is  likewise  distasteful  to  the  parasites. 

PEDICULOSIS  PUBIS 

Pediculosis  pubis,  or,  as  it  is  sometimes  designated,  "crab-lice,"  or 
"crabs,"  is  due  to  the  presence  of  the  pediculus  pubis  or  crab-louse,  and 
is  characterized  in  most  instances  by  more  or  less  itching  about  the 
genitalia,  together  with  excoriations,  papules,  pustules,  and  other  in- 
flammatory symptoms.  Cases  vary  very  widely  in  the  amount  of 
irritation:  it  may  be  extremely  slight  and  even  wanting,  more  espe- 
cially in  females,  and  even  when  the  parasites  are  present  in  great 
number;  or,  on  the  other  hand,  it  may  be  sufficiently  severe  to  exhibit 
a  decidedly  eczematous  aspect.  While  the  irritation  and  lesions  are 
practically  limited  to  the  pubic  region,  in  some  instances  the  excoria- 
tions and  other  lesions  are  seen  extending  up  on  to  the  lower  abdominal 
surface.  As  in  the  scalp  variety,  several  or  more  ova  can  often  be  found 
glued  to  a  single  hair-shaft.  The  parasite  may  be  discovered  upon  close 
examination  seated  near  the  root  of  the  hair,  clutching  the  hair,  its  head 
downward,  and  often  slightly  buried  in  the  follicle.  Sometimes,  in 
association  with  the  malady  involving  this  region,  and  occasionally  inde- 
pendently, the  crab-louse  is  found  upon  other  situations,  as  the  hairy 
part  of  the  breast,  axillae,  the  legs,  beard,  and  even  the  eyebrows  and  the 
eyelashes,  producing  on  these  regions  similar  but  variable  irritation. 

Involving  the  eyelashes  (phthiriasis  sen  pediculosis  palpebrarum)1 
the  appearances  are  roughly  suggestive  of  an  eczema  or  blepharitis. 
The  parasites,  looking  not  unlike  minute  scabs,  can  be  detected  upon 
close  inspection  on  the  edge  of  the  lid  clinging  to  the  hair,  and  often 
with  the  head  somewhat  hidden  in  the  follicle.  Ova  attached  to  the 
eyelashes  are  quite  easily  to  be  seen.  A  noticeable  feature,  and  one 
which  first  attracts  one's  attention,  is  the  presence  of  the  excrement — 

1  Both  de  Schweinitz  ( Univ.  Med.  Mag.,  March,  1889)  and  Jullien  (Annales,  1891, 
p.  1006)  describe  cases  and  show  that  it  was  much  more  common  on  this  region  in 
ancient  times,  citing  numerous  descriptive  accounts  by  older  writers.  Several  in- 
stances, of  which  the  first  was  reported  (Arch.  Derm.,  1881,  p.  301),  have  come  under 
my  notice.  Winfield  (Jour.  Cutan.  Dis.,  1889,  p.  331)  reported  4  cases  and  also  reviews 
the  subject. 


Il8o  PARASITIC  AFFECTIONS 

reddish  or  blackish  specks — on  and  beneath  the  lower  lids,  resembling 
specks  of  iron  rust. 

There  are  lesions  associated  with  pediculosis  pubis  known  as  macula 
ccertilecB  (laches  ombrees,  laches  bleuatres,  of  the  French).  They  are 
pea-  to  finger-nail-sized,  of  a  steel-gray  tint,  not  elevated,  with  no 
thickening,  and  not  disappearing  upon  pressure,  consisting,  in  fact, 
simply  of  stains.  They  are  seen  most  commonly  or  typically  in  those  of 
clear,  white,  transparent,  skins  usually,  therefore,  predominantly  in 
blondes;  and  are  found  scantily  or  somewhat  abundantly,  chiefly  on  the 
sides  of  the  thorax,  abdomen,  and  inner  aspects  of  the  thighs  and  upper 
arms.  Inasmuch  as  in  the  careful  hunt  for  rose-spots  in  typhoid  fever 
these  lesions  were  occasionally  observed,  it  was  at  one  time  thought  they 
were  peculiar  to  this  malady,  but  it  is  now  known  that  they  are  also 
found  in  association  with  other  diseases,  and  also  independently.1  They 
are  simply  pathognomonic  of  the  presence  of  the  crab-louse.2  The  view 
held  as  to  the  spots  being  hyperemias  or  hemorrhages  is  not  supported 
by  their  appearances  or  behavior.  According  to  Duguet's  successful 
inoculation  experiments  with  the  crushed  crab-louse,  they  result  from 
pigment  introduced  by  the  parasite  in  the  act  of  feeding;  and  which,  as 
PeUier's  investigations3  also  indicate,  is  secreted  directly  by  the  pedicu- 
lus.  There  is,  however,  a  certain  predisposition  necessary,  as  they  are 
by  no  means  observed  in  all  those  infested  with  the  pediculus.  Duguet 
was  able  to  produce  the  lesion  experimentally  in  all  instances  in  those 
who  already  had  them,  but  only  occasionally  in  others.  Both  Jamieson 
and  Payne4  have  noted  in  these  cases  a  remarkable  absence  of  the  signs 
of  scratching  or  any  complaint  of  irritation. 

Pediculosis  pubis,  as  to  be  readily  inferred,  occurs  chiefly  in  adults, 
although  also  seen  in  adolescents.  Its  contraction  is  generally  believed 
to  be  through  sexual  intercourse,  but  this  is  by  no  means  always  so,  for 
there  are  many  other  ways  in  which  the  parasite  might  gain  access. 
In  children  the  crab-louse  seems  to  have  as  its  special  field  the  eyebrows 
and  eyelashes. 

The  diagnosis  of  pediculosis  pubis  is  to  be  based  upon  the  region 
involved,  itching,  variable  amount  of  irritation,  papules,  excoriations, 
etc.,  and,  above  all,  by  the  presence  of  the  pediculi  and  their  ova.  The 
former  can  be  detected  upon  close  inspection  close  to  the  skin,  grasping 
a  hair-shaft,  with  the  head  usually  downward;  the  ova  are  easily  found 
attached  to  the  hairs.  It  is  to  be  noted  that  lesions  of  irritation  are 
quite  frequently  to  be  seen  beyond  the  actual  markedly  hairy  limits. 
The  fact,  too,  that  the  pubic  louse  may  not  confine  his  presence  or 

1  See  Jameson's  paper  (loc.  cit.)  and  that  by  Leviseur,  Jour.  Cutan.  Dis.,  1889,  p. 
414. 

2  The  reader  interested  in  the  important  earlier  literature  of  these  spots  is  referred 
to  the  papers  by  Moursou,  "Nouvelles  recherches  sur  1'origine  des  taches  ombrees," 
Annales,  1877-78,  vol.  ix,  p.  198,  and  Duguet,  "Sur  les  taches  bleues;  leur  production 
artificielle  et  leur  valeur  semeiologique,"  Gaz.  des  hdpitanx,  April  20,  1880,  and  An- 
nales, 1880,  p.  544;  and  by  Duguet  and  Gibier,  "Les  taches  bleues  et   le  phtirius," 
Compt.  rend.  d.  la  soc.  de  biol.,  1882.  p.  617,  and  Annales,  1881,  p.  357. 

3  Pellier,  Monatshefte,  1909,  vol.  xlviii,  p.  56;  Tieche,  Archiv,  1908,  xci,  p.  327, 
gives  good  review  of  the  subject  of  the  spots. 

4  Payne,  Brit.  Jour.  Derm.,  1890,  p.  209. 


BROWN-TAIL    MOTH  Il8l 

effects  to  the  pubic  region  alone  is  to  be  borne  in  mind.  The  features 
of  the  condition  elsewhere  are,  however,  practically  the  same — if  the 
possibility  of  such  is  remembered,  a  mistake  can  scarcely  occur;  the 
ova  and  pediculi  are  always  to  be  discovered,  whether  in  axillae,  on  the 
short  body  hair  regions,  on  eyelashes,  or  on  eyebrows. 

Treatment. — The  classic  treatment  by  blue  ointment,  while 
efficient,  is  nasty,  and  often  excites  a  dermatitis  or  veritable  eczema. 
The  cleanest  method  is  by  means  of  corrosive  sublimate  lotion,  \  to  2 
grains  (0.033-0.133)  to  the  ounce  (32.).  Fournier  commends  one  con- 
sisting of  i  part  of  corrosive  sublimate,  100  parts  alcohol,  and  400  parts 
water;  and  also  one  of  i  part  of  this  drug  to  300  parts  of  vinegar,  to  be 
applied  diluted  with  i  or  2  parts  water.  A  5  to  10  per  cent,  ammoni- 
ated  mercury  ointment  or  same  strength  /?-naphthol  ointment  will  also 
prove  useful.  Repeated  washings  with  vinegar  or  dilute  acetic  acid  or 
with  alkaline  lotions  will  free  the  hairs  of  the  ova;  a  daily  shampooing  of 
the  parts  will  accomplish  the  same  purpose.  In  cases  involving  many  of 
the  body  or  leg  hairs,  baths  of  corrosive  sublimate  can  be  employed. 
Such  cases  do  well  with  a  daily  washing  with  a  naphthol-sulphur  soap. 
In  pediculosis  palpebrarum  the  best  and  quickest  plan  is  to  remove  the 
parasites  and  ova  with  small  forceps.  A  weak  citrine  ointment  can  also 
be  carefully  applied  to  the  edge  of  the  lids. 

OTHER  ANIMAL  PARASITES,  OF  MINOR  IMPORTANCE,  ATTACK- 
ING OR  IRRITATING  THE  SKIN 

BROWN-TAIL  MOTH 

The  brown-tail  moth  (Euproctis  crysorrhcea)  is  a  comparatively  recent  acci- 
dental importation  into  Massachusetts  from  Holland,  it  is  said,  along  with  some 
roses,  destructive  to  fruit  trees  and  probably  other  vegetation.  It  has  now  already 
spread  over  New  England,  a  part  of  Canada,  and  westward,  and  has  received  the 
attention  of  those  interested  in  agriculture.1  At  about  or  shortly  after  the  time  of  its 
introduction  J.  C.  White2  reported  a  number  of  cases  of  dermatitis  due  to  a  caterpillar, 
to  which  first  Meek3  and  later  Towle,4  Spear,5  Tyzzer,6  Potter,7  and  others  have  added 
their  observations.  It  has  now  been  shown  that  the  "nettling"  hairs  of  the  brown- 
tail  moth,  its  cocoon,  and  caterpillar  are  responsible  for  a  considerable  number  of  cases 
of  cutaneous  irritation  (brown-tail  moth  dermatitis)  of  somewhat  variable  character  and 
degree. 

Symptoms. — The  first  symptom  is  usually  itching,  following  a  short  time  after 
exposure,  as  a  rule  within  a  half-hour;  and  the  appearance  of  discrete  erythematous 

1  Fernald  and  Kirkland,  "The  Brown-tail  Moth,"  Bull.  Mass.  State  Bd.  Agricul- 
turer,  1903;  Fifty-second  Ann.  Rep.  Sec'y  Mass.  State  Bd.  AgricuU.,  1904;  "Nature 
Leaflet,  No.  26,"  ibid.,  April  2,  1908;  Ann.  Rep.  Sec'y  AgricuU.,  Nova  Scotia,  1908. 

2  J.  C.  White,  "Dermatitis  Produced  by  a  Caterpillar,"  Boston  Med.  and  Surg.  Jour., 
IQOI,  vol.  cxliv,  p.  599. 

3  Meek,  "Further  Observations  on  the  Brown-tail  Moth,"  ibid.,  p.  657  (correspond- 
ence). 

4  Towle,  "The  Brown-tail  Moth  Eruption,"  ibid.,  1905,  vol.  clii,  p.  74. 

5  Spear,  "Brown-tail  Moth  Eruption,"  ibid.,  p.  121  (correspondence). 

'Tyzzer,  "The  Pathology  of  the  Brown-tail  Moth  Dermatitis,"  Jour.  Med.  Re- 
search, 1907,  N.  S.  xi,  p.  43  (with  plate);  and  Trans.  Internal.  Dermal.  Cong.,  1908,  vol. 
i,  p.  169. 

7  Potter,  "Brown-tail  Moth  Dermatitis,"  Jour.  Amer.  Med.  Assoc.,  1909,  vol.  liii, 
p.  1463- 


Il82 


PARASITIC  AFFECTIONS 


macules  which  rapidly  become  urticaria-like  efflorescences,  or  they  may  begin  as  the 
latter.  They  are  about  pea-sized,  raised,  rather  firm,  but  may  be  made  to  disappear 
momentarily  upon  pressure.  The  lesions  instead  of  being  discrete  may  be  irregularly 
grouped  or  crowded  together;  or  there  may  be,  in  more  severe  cases,  a  more  or  less  co- 
alescent  inflammatory  redness,  and  some  swelling,  with  an  accentuation  here  and  there, 
either  in  spots  or  patches.  Occasionally  the  dermatitis  is  eczematoid,  exceptionally 
with  even  associated  fissuring.  The  degree  of  the  reactionary  irritation  depends  largely 
upon  the  amount  of  the  irritating  material  as  well,  doubtless,  to  some  degree  upon  the 
character  and  vulnerability  of  the  individual  skin.  The  itching  is  always  more  or 
less  troublesome,  sometimes  quite  intense.  According  to  the  severity  of  the  case, 
the  eruption  may  last  from  a  few  days  to  several  weeks  or  longer.  The  face,  neck, 
arms,  and  upper  part  of  the  trunk  are  favorite  situations;  it  may  be  limited  to  several 
small  scattered  or  grouped  spots,  or  to  a  small  area,  or 
involve  one  or  more  of  these  regions;  exceptionally, 
from  infested  clothing,  it  may  be  somewhat  general. 
In  some  of  the  general  cases  systemic  symptoms  of  a 
mild  toxemia  may  develop. 


Fig.    316. — Brown-tail   moth,    female    (Fernald-     Fig.  317. — Brown-tail  moth  cater- 
Kirkland).  pillar  (Fernald- Kirkland). 

The  malady  is  most  frequently  seen  about  the  time  the  caterpillar  reaches  its 
full  growth — in  the  latter  part  of  May  and  June — but  it  may  be  met  with  before  or 
after  this  time;  in  fact,  at  any  period  of  the  year  from  wearing  clothing  in  which  the 
hairs  had  previously  become  lodged.  The  active  factor  in  the  production  of  the 
cutaneous  irritation  is  to  be  found  in  the  minute  nettling  barbed  hairs,  most  numerous 
on  the  caterpillar,  but  also  present  on  the  cocoon  and  on  the  moth;  usually  by  immediate 
contact,  but  also  by  handling  plants  or  vegetables  upon  which  hairs  have  become  lodged ; 
doubtless,  too,  these  hairs  occasionally  may  lodge  upon  the  skin  along  with  the  dust  of 
the  air.  The  epidermis  and  sometimes  the  upper  corium  are  pierced  by  the  barbs,  occa- 
sionally probably  going  more  deeply.  While  at  first  this  irritation  was  thought  to  be 
purely  mechanical,  Tyzzer's  experiments  indicate  that  it  is  largely  due  to  the  action  of 
some  irritative  substance  contained  in  the  penetrating  hairs;  Tyzzer  found  experi- 
mentally that  this  substance  produces  some  reactionary  changes  in  the  red  blood-cor- 
puscles. There  is  found  necrosis  of  the  epidermis  around  the  nettling  hair,  and  in  most 
instances  there  is  exudation  of  fluid  into  the  epidermis  (Tyzzer). 

Treatment  consists  in  the  use  of  soothing  and  antipruritic  lotions  and  ointments, 
such  as  prescribed  in  other  forms  of  dermatitis,  pruritus,  and  eezema — carbolized 
lotions  and  ointments  being  most  frequently  employed.  It  is  sometimes  quite  persist- 
ent and  rebellious,  due,  doubtless,  in  such  instances  to  the  fact  that  the  hairs  may  be 
somewhat  deeply  imbedded.  My  colleague,  Professor  Holland,  who  spends  the  sum- 
mer along  the  eastern  shore,  tells  me  that  the  treatment  found  most  successful  consists 
in  the  use  of  a  mercuric  chlorid  lotion  (i  :  1000  to  i  :  2000)  and  the  painting  of  each  spot 
with  flexible  collodion. 


PEDICULOIDES    VENTRICOSUS  1183 

PEDICULOIDES  VENTRICOSUS' 

(Producing  a  dermatitis  variously  described  or  named:  Grain-mile  dermatitis;  Straw 
itch  (Rawles);  Grain  itch,  acarodermatitis  urticarioides  (Schamberg);  Grain  derma- 
titis; Barley  itch  (Wills);  Mattress  itch;  Straw-packers'  itch;  Straw  dermatitis;  Derma- 
titis urticarioides  parasitica;  Prairie  itch,  etc.) 

For  some  years  occasional  reports  (Lagreze-Fossot  and  Montane,  Rouyer,  Geber, 
Roller,  Moniez,  Fleming,  Pascal,  Ducret,  Sberna,  and  others)  in  European  countries 
of  small  epidemics  of  an  eruption,  consisting  usually  of  discrete,  scanty  to  thickly  set 
erythematopapular  and  papulovesicular  lesions  of  micro-urticarial  and  micro  varicelli- 
form  characters,  have  appeared  from  time  to  time,  and  attributed  to  a  small  parasite — 
the  pediculoides  ventricosus — sometimes  found  infesting  straw  and  grain.  In  this 
country,  in  the  past  few  decades,2  groups,  usually  family  groups,  of  cases  of  similar 
eruption  have  also  been  noted  (first  by  Schamberg),  more  particularly  in  Philadelphia 

1  Important  literature  of  pediculoides  ventricosus  and  of  the  dermatitis  provoked 
by  it:  Newport,  "An  Account  of  a  New  Acarus  (Heteropus  ventricosus):  A  Parasite  in 
the  Nests  of  the  Anthophora  retusa,"  Trans.  Linnean  Soc'y  of  London  (read  March  5, 
1850),  1853,  vol.  xxi,  p.  95;  Lagreze-Fossot  and  Montane,  "Sur  la  mite  du  ble'," 
Registre  agronom.  de  la  Soc.  des  Sci.  d'agricult.  et  bell.  lett.  du  Tarnet-Garome,  1851,  xxxii, 
No.  2;  Rouyer  (through  Robin),  "Eruption  cutanee  due  a  1'acarus  du  ble',"  Compt. 
rend,  des  seances  de  la  Soc.  de  Biolog.,  4,  1867,  p.  178;  Geber,  "Eutziindliche  Prozesse  der 
Hant  durch  eine  bisher  nicht  bestimmte  Milbenart  verusacht,"  No.  43,  Oct.  26,  1879, 
pp.  1361,  1395,  and  1428;  "Observations  on  the  Angoumois  Grain-moth  and  its  Para- 
site," Report  of  State  Entomologist  of  Illinois,  Nov.  20,  1883;  Targionni-Tozzetti,  An- 
nali  di  Agricoltura,  Italy,  1878,  vol.  1;  Laboulbene  and  Megnin,  "M6moire  sur  le  Sphsero- 
gyna  ventricosa  (Newport),"  Jour,  de  I'Anat.  et  de  Physiol.,  1885,  xxi,  p.  i  (with  plate 
of  illustrations  of  parasite) ;  Flemming,  "Ueber  eine  geselechtsreife  Form  der  als  Tarso- 
nemus  beschriebenen  Thiere,"  Zeitschr.  fur  die  ges.  Naturwissenschaften  (4),  1884,  iii,  p. 
472,  Halle;  Roller,  "Neue  Falle  eines  durch  einen  Getreidschmarotzer  verusachten 
Hautausschlages,"  Pester  med.-chir.  Presse,  No.  32,  1882;  abs.  in  Archiv,  1882,  p.  511; 
and  Biolog.  Centralbl.,  1885,  iii,  p.  127;  Geber,  Ziemssen's  Handbook  of  Skin  Diseases, 
1885,  p.  555;  Rarpelles,  "Eine  auf  dem  Menchen  und  auf  Getreide  lebende  Milbe," 
Anzeiger  der  K.  K.  Akad.  der  Wissensch.  zu  Wien.,  1885,  xxii,  p.  160;  R.  Blanchard, 
Traite  de  Zoologie  medicale,  Paris,  1890,  vol.  ii,  p.  284;  Brucker,  "Sur  Pediculoides 
Ventricosus  (Newport),"  Compt.  rend,  de  la  Soc.  de  "Bid.,  1899,  p.  953,  and  Bull.  Sci. 
de  la  France  et  Belg.,  1901,  t.  35,  p.  365;  Pascal,  "Erythema  scarlatiniforme  desquamatif 
generalise  d'origine  parasitaire,"  Annales,  1900,  p.  947;  Moniez,  "Sur  1'habitat  normal 
dans  les  tiges  d.  cereales  d'un  parasite  accidentel  de  I'homme,"  Rev.  biolog.  du  Nord.  de 
la  France,  1895,  vii,  p.  148,  and  Traite  de  Parasitologie,  animale  et  vegetale,  applique  a 
la  Medicine,  Paris,  1906;  Cambillet,  "Epidemic  d'urticaire  provoquee  par  1'aleurobius 
farinae,"  Jour.  mal.  cutan.,  1908,  p.  546;  Ducrey,  "Acariasi  da  grano,  in  forma  epidemica, 
dovuta  al  Pediculoides  ventricosus,"  Processi  verballi.  Soc.  Ital.  di  Dermal,  e.  Sifil'.  (Dec. 
16-19,  1908,  in  Rome),  Milan,    1909,  pp.  93-122  (review,  with  references);  Sberna, 
"Dermatosi  accidentale  du  acari  della  tignola  del  grano  (pediculoides  ventricosus"), 
ibid.,  pp.  122-138  (review  and  bibliography);  Wills,  "Barley  Itch,"  Brit.  Jour.  Derm., 
Aug.,  1909;  Max  Braun,  "Animal  Parasites  of  Man,"  1906,  New  York. 

Schamberg,  "An  Epidemic  of  a  Peculiar  and  Unfamiliar  Disease  of  the  Skin,"  Phila. 
Med.  Jour.,  July  6,  1901  (with  several  case  illustrations);  and  "Grain  Itch  (Acaro- 
dermatitis Urticarioides):  A  Study  of  a  New  Disease  in  this  Country,"  Jour.  Cutan. 
Dis.,  Feb.,  1910  (a  complete  exposition  and  review,  with  excellent  illustrations  and  refer- 
ences); Goldberger  and  Schamberg,  "Epidemic  of  an  Urticaroid  Dermatitis  Due  to  a 
Small  Mite  (Pediculoides  ventricosus)  in  the  Straw  of  Mattresses,"  Public  Health 
Report,  No.  2<?,\Washington,  D.  C.,  July  9,  1909;  and  Rawles,  "Straw  Itch,"  Indiana 
State  Med.  Jour.,  Aug.,  1909. 

2  It  would  seem,  however,  that  the  malady  was  noted  some  years  earlier:  Harris, 
"The  Report  of  Insects  Injurious  to  Vegetation,"  Boston  edition  of  1852  (also  cited  by 
Schamberg),  curiously  shows  that  the  association  of  straw  (straw  mattresses)  and  an 
eruptive  condition  was  noted  in  1829  and  1830  in  Eastern  New  England,  as  indicated  by 
several  communications  regarding  the  matter  in  Fessenden's  New  England  Farmer. 
In  Philadelphia  the  first  cases  came  under  my  own  observation  in  the  autumn  of  1889, 
consisting  of  a  group  of  a  mother  and  two  children;  only  a  few  cases  yearly  were  after- 
ward seen  by  me  till  1900-02,  when  they  presented  in  moderate  numbers,  always  in 
family  groups;  since  that  time  it  has  been  less  uncommon,  and  especially  in  certain  years. 
Although  recognizing  them  as  unusual  cases,  and  probably  due  to  an  unknown  parasite, 
they  were  provisionally  classified  as  "vesicopapular  urticaria." 


1184 


PARASITIC  AFFECTIONS 


and  nearby  States  westward;  Goldberger  and  Schamberg,  and,  almost  simultaneously, 
Rawles,  were  the  first  to  associate  convincingly  cause  and  effect,  and  to  identify  the 
organism;  Schamberg's  investigations  being  extensive  and  conclusive.  An  examina- 
tion of  the  reports  made  from  the  West  and  South,  some  years  ago,  of  so-called  prairie 
itch,  swamp  itch,  Ohio  scratches,  Texas  mange,  lumbermen's  itch,  etc.,  leads  to  the 
conclusion  that  at  least  some  groups  of  these  cases1  were  examples  of  dermatitis  due  to 
this  same  cause. 

Symptoms. — The  eruption  usually  presents  itself  rapidly,  preceded  by  and  asso- 
ciated with  itching.  The  lesions  at  first  appear,  as  a  rule,  as  small  to  large  pea-sized 
erythematous  spots,  which  may  not  be  materially  elevated,  or  may  be  more  or  less 
typical  hives,  but  rarely  very  large  in  size;  within  a  short  time,  at  the  very  central 
point,  there  appears  a  papulovesicular  or  vesicular  formation,  which  in  the  course  of  a 
day  or  two  shows  some  milkiness  and  frequently  becomes  slightly  purulent,  occasionally 
distinctly  so.  These  vesicles  or  vesicopapules  remain,  for  the  most  part,  small,  scarcely 


Fig.  318. — Grain-mite  dermatitis  (courtesy  of  Dr.  J.  F.  Schamberg). 

larger  than  an  average  pin-head.  As  the  lesions  thus  advance,  the  urticarial  aspect 
measurably,  sometimes  almost  entirely,  subsides.  The  tops  of  some  of  the  scratched  or 
broken  lesions  are  apt  to  show  a  minute  blood  crust.  If  the  cause  has  ceased  to  act,  the 
eruption  soon  begins  to  dry  up,  the  lesions  becoming  surmounted  by  a  thin  crust  or 
scale,  which  finally  falls  off;  and  in  one  to  three  weeks  the  malady  is  usually  at  an  end. 
If  the  patient  continues,  however,  exposed  to  the  cause,  new  eruption  keeps  coming 
out,  and  it  may  so  persist  a  month  or  more.  The  foregoing  is  the  type  most  commonly 
seen,  simulating  somewhat  a  vesicopapular  urticaria  (lichen  urticatus);  and  if  there  are 
intermingled  distinct  pustules,  from  accidental  infection,  it  bears  some  resemblance, 
except  as  to  distribution,  to  scabies.  In  exceptional  instances  this  additional  pyogenic 

1  The  statement  made  by  one  writer  that  he  believes  it  "associated  with  decaying 
hay  and  straw,"  and  that  of  another,  that  "men  who  go  with  threshing  machines  seem 
to  have  it  generally,"  are  very  suggestive. 


PEDICULOIDES    VENTRICOSUS  1185 

element,  together  with  the  scratching,  may  result  in  giving  the  eruption,  in  one  or  more 
places,  an  eczematoid  or  even  an  impetiginous  aspect.  Occasionally  the  vesiculation  is 
more  pronounced  and  the  vesicles  somewhat  larger,  and  in  such  instances  it  offers  a 
distinct  suggestion  of  varicella — a  microvaricella — the  lesions  being  somewhat  smaller 
than  in  ordinary  varicella.  Only  exceptionally  are  cases  met  with  in  which  the  erup- 
tion consists  of  erythematous  spots  only — the  erythema  type — and  which  may  in  places 
be  so  close  together  as  to  seemingly  coalesce.  In  other  instances  the  lesions  do  not  get 
beyond  the  urticarial  development.  The  lesions  are,  however,  rarely  typical  wheals, 
but  are  usually  smaller,  and,  as  a  rule,  are  pinkish  or  reddish  in  their  entirety,  lacking 
the  whitish  central  portion  which  commonly  characterizes  the  true  wheal  of  urticaria. 
The  eruption  varies  in  amount — there  may  be  but  twenty  to  forty  lesions  in  some  cases 
and  uncountable  numbers  in  others;  it  is  moderately  abundant  in  the  average  case. 
There  is  no  tendency  to  actual  coalescence,  except  occasionally  as  the  result  of  scratch- 
ing and  additional  pyogenic  infection.  The  eruption  is  most  commonly  seen  upon  the 
trunk,  especially  the  upper  two-thirds,  on  upper  part  of  the  arms,  and  on  the  neck; 
but  it  may  involve,  in  addition  to  these  regions,  the  upper  part  of  the  thighs  and  face, 
and,  exceptionally,  is  practically  generalized.  Itching  is  often  a  troublesome  feature. 
In  well-developed  cases  there  is  not  infrequently,  in  the  first  few  days,  slight 
febrile  action,  with  other  mild  systemic  symptoms.  Rawles  and  Schamberg  noted 


Male.  Young  female.  Gravid  female. 

Fig.  319. — Pediculoides  ventricosus,  greatly  enlarged  (Laboulbene  and  Megnin). 

slight  albuminuria  in  a  small  proportion  of  their  cases,  and  the  latter  observed  a  moder- 
ate leukocytosis  in  most  patients  and  a  well-marked  eosinophilia  in  many. 

Etiology  and  Pathology. — All  ages  are  liable.  It  is  most  commonly  seen  during  the 
warm  months.  It  is  met  with  in  those  who  come  in  contact  with  infested  straw  or 
grain — either  by  sleeping  on  mattresses  containing  such  straw  or  by  handling  such  grain 
or  straw.  It  has  occurred  in  those  unloading  bags  of  grain  and  in  packers  who  use  straw 
packing.  It  may  thus  find  its  way  to  the  human  subject  by  direct  contact  with  these 
substances  or  through  accidentally  infested  apparel  or  other  articles.  The  irritating 
agent  is  a  small  mite,  first  clearly  identified  by  Newport  (1850)  and  since  by  others; 
and  is  now  known  by  the  accepted  name  of  "pediculoides  ventricosus,"  of  the  class 
Arachnida  and  of  the  order  Acarina  or  mites.  It  can  usually  be  detected  in  the  dust 
of  the  straw  or  grain  with  a  magnifying  glass  of  moderate  power.  Its  characteristics 
are  well  depicted  in  the  accompanying  cuts.1  Whether  it  is  always  the  same  species 

1  The  mite  has  four  pairs  of  legs.  The  male  is  oval  in  shape,  o.i  2  mm.  in  length,  and 
0.08  mm.  in  breadth,  is  flattened,  has  six  pairs  of  chitinous  hairs  on  the  dorsal  surface 
and  a  lyre-shaped  lamella  on  the  posterior  part.  The  non-gravid  female  is  cylindric  in 
form,  0.2  mm.  in  breadth,  and  0.07  mm.  in  length;  when  gravid  the  posterior  part  of 
the  body  becomes  ball-shaped  up  to  1.5  mm.  in  size.  They  reproduce  rapidly,  the 
young  being  sexually  mature  almost  as  soon  as  born. 
75 


1 1 86  PARASITIC  AFFECTIONS 

that  produce  the  trouble  is  not  definitely  known.  It  is  usually  only  found  where  there 
are  grain-destroying  insects,  being  predatory  and  parasitic  upon  them;  although  they 
doubtless  may  live  on  the  straw  and  grain  also.  They  do  not  burrow  in  the  skin,  as 
does  the  itch-mite,  but  probably  only  pierce  it  momentarily  for  the  purpose  of  nourish- 
ment, and  apparently  at  the  same  time  injecting  a  toxic  substance.  The  pathologic 
changes  in  the  skin  are  those  characteristic  of  the  lesions  of  urticaria  (Schamberg). 

Diagnosis. — The  suddenness  of  the  outbreak,  the  intense  itching,  and,  usually, 
its  appearance  in  seemingly  epidemic  or  group  form,  the  distribution,  and  the  uniformity 
of  the  lesions,  are  extremely  suggestive;  add  to  this  the  history  of  contact  with  straw  or 
gram,  and  the  inference  is  more  or  less  conclusive.  The  distribution  is  different  from 
that  in  scabies,  and  the  latter  begins  insignificantly,  insidiously,  in  fact,  and  is  only 
slowly  progressive;  in  grain-mite  dermatitis  the  eruption  develops  almost  at  once  and 
rapidly.  It  is  in  those  cases  that  persist  from  continued  exposure  to  the  cause  that  may 
at  times  give  rise  to  some  confusion  with  scabies.  The  vesicles  in  chicken-pox  are  much 
larger,  the  eruption  rarely  so  abundant,  and  itching  scarcely  present,  or  at  the  most 
slight;  the  scalp  is  quite  commonly  the  seat  of  some  lesions,  whereas  this  region  is 
rarely  attacked  in  grain-mite  dermatitis.  The  eruption  in  urticaria  of  small  papulo- 
vesicular  nature  is  comparatively  scanty  and  the  limbs  are  its  usual  site. 

Prognosis  and  Treatment. — Upon  removal  of  the  cause,  disinfection  of  the  mattress, 
bedding,  and  wearing-apparel,  frequent  baths,  and  the  application  of  mild  antipruritic 
lotions  or  ointments,  the  malady  comes  gradually  to  an  end,  usually  in  from  one  to  two 
weeks.  The  carbolized  calamin-zinc-oxid  lotion  and  a  carbolized  Lassar's  paste  (see 
Eczema)  are  both  useful.  Schamberg  speaks  well  of  an  ointment  of  betanaphthol  and 
sulphur,  of  about  one-half  the  strength  employed  in  scabies.  Repeated  exposure  to  the 
infested  mattress  or  other  infested  straw  or  grain  is  responsible  for  long-continued  cases; 
although,  even  when  disinfection  is  not  practised,  the  mites  apparently  finally  die  or 
become  innocuous,  and  the  patient  sooner  or  later  recovers. 

Cimex  lectularius  (acanthia  lectularia,  Fr.,  punaise  des  lits;  Ger.,  Bettwanze) ,  or, 
as  commonly  called,  the  bed-bug,  is  a  well-known  insect,  universal  in  its  distribution, 
which  can  produce  a  good  deal  of  cutaneous  mischief.  It  simply  goes  to  the  skin  for 
nourishment,  puncturing  it  and  sucking  blood;  it  is  said  to  inject  an  irritating  fluid  to 
increase  the  flux  of  blood  to  this  point.  An  inflammatory  papule  or  wheal-like  lesion 
most  commonly  results,  having  often  a  purpuric  tendency,  especially  at  and  about  the 
point  of  puncture.  This  purpuric  or  hemorrhagic  point  or  spot  remains  after  the  swell- 
ing subsides,  but  finally,  in  the  course  of  several  days  or  a  few  weeks,  disappears.  Very 
frequently  the  insect  makes  several  punctures  at  but  short  distance  apart,  so  that  the 
lesions  are  sometimes  seen  as  an  irregular  group  of  three,  four,  or  more,  and  are  often 
covered  over  with  a  blood-crust.  The  legs,  especially  in  the  neighborhood  of  the  ankles, 
are  a  favorite  point  of  attack,  probably  because  nearest  the  joints  or  crevices  of  the  bed. 
The  resulting  irritation  varies  considerably  in  different  individuals,  in  some  nil,  and 
in  others  extremely  severe  and  lasting.  The  hemorrhagic,  wheal-like  papules  may  be- 
come pustular  and  show  a  good  deal  of  underlying  and  surrounding  inflammation.  The 
condition  is  not  to  be  confused  with  urticaria,  to  which  it  bears  some  suggestion,  es- 
pecially if  the  lesions  are  somewhat  numerous  and  scattered.  The  hemorrhagic  tend- 
ency, central  puncture,  and  persistence  of  the  bed-bug  lesions  are  not  seen  in  urticaria. 

Treatment  consists  in  the  use  of  alkaline  and  carbolic  acid  lotions,  with  carbolized 
ointments  if  necessary.  The  various  other  lotions  employed  in  urticaria  are  also  ser- 
viceable. 

Pulei  irritans  (Fr.,  puce  commune;  Ger.,  gemeiner  Floh),  or  common  flea,  is  of 
somewhat  general  distribution,  but  more  common  in  some  regions,  especially  in  tropical 
climates;  it  is  capable  of  exciting  varying  degrees  of  irritation.  The  most  usual  lesion 
is  a  small,  ring-like,  erythematous  spot  with  a  minute,  central,  hemorrhagic  point, 
marking  the  place  of  attack.  In  exceptional  instances  the  purpuric  character  has  been 
sufficiently  pronounced  as  to  suggest  purpura  simplex.  In  some  people  the  lesion  is 


PEDICULOIDES    VENTRICOSUS  1 1 87 

scarcely  perceptible  and  gives  rise  to  no  discomfort.  In  others,  who  seem  to  be  espe- 
cially vulnerable  to  "flea-bites,"  the  resulting  lesion  is  urticarial  in  character,  and  more 
or  less  persistent,  markedly  itchy,  tender,  and  painful,  with  sometimes  a  fiery,  burning 
feeling.  Several  or  more  are  frequently  to  be  seen  close  together,  or  strung  out,  marking 
the  travels  of  a  single  parasite.  When  the  latter  are  present  in  any  number,  suscep- 
tible individuals  may  suffer  somewhat  intensely,  and  may  even  show  some  general  dis- 
turbance. Many  American  travelers  in  Europe  suffer  considerably  from  this  pest,  the 
"foreign  flea"  seeming  to  be  especially  damaging  to  the  American  skin,  although  such 
individuals  are  often  unaware  of  the  character  of  the  trouble,  believing  it  to  be  urticaria 
due  to  change  of  food,  etc.  The  lesions  in  those  of  sensitive  skin  resemble  those  of 
the  latter  malady,  but  the  recent  spots  usually  show  the  minute  central  hemorrhagic 
point. 

In  the  treatment  the  various  carbolized,  thymol,  and  alkaline  lotions  employed  in 
urticaria,  pruritus,  and  eczema  are  of  value  in  relieving  the  irritation,  and  their  use 
makes  the  skin  a  less  attractive  feeding-ground  for  the  parasites.  In  those  especially 
vulnerable  to  these  pests,  particularly  women,  whose  manner  of  dress  permits  easy 
access,  the  wearing  of  a  lump  of  camphor  enclosed  in  a  cheese-cloth  bag  under  the  cloth- 
ing will  sometimes  furnish  variable  protection;  in  extreme  instances  the  wearing  of 
several  small,  loosely  woven  bags  containing  pyrethrum  powder,  pinned  on  at  different 
parts  of  the  underwear,  will  often  keep  up  an  efficient  atmosphere  of  protection  against 
attacks. 

The  ixodes  (Fr.,  pou  de  bois;  tique;  Ger.,  Holzbock;  Zecke),  or  wood- tick,  is  a 
minute  parasite  which  is  sometimes  parasitic  on  man,  and  of  which  there  are  several 
species.  It  is  generally  found  on  bushes  or  trees,  and  occasionally  drops  on  an  oppor- 
tune subject  to  secure  blood.  In  its  attack  it  sticks  its  proboscis  in  the  skin  and  sucks 
blood  until  several  times  its  natural  size,  and  then  falls  off;  an  urticarial  lesion  marks  the 
site,  sometimes  more  or  less  persistent,  itchy,  and  painful.  If  the  parasite  is  caught 
in  the  act  of  attack,  it  should  not  be  forcibly  extracted,  as  its  proboscis  may  thus  be 
broken  off  and  remain  in  the  skin,  and  give  rise  to  considerable  pain  and  inflammation. 
It  may  be  made  to  relinquish  its  hold  by  placing  on  it  a  drop  of  an  essential  oil  or 
moist  tobacco.  A  thymol  or  carbolized  boric  acid  lotion  will  relieve  the  irritation. 

The  dermanyssus  avium  et  gallinse  (bird-mite;  fowl-mite;  chicken-louse;  Fr., 
dermanysse  des  oiseaux;  Ger.,  Vogelmilbe)  occasionally  attack  the  human  integument 
and  provoke  a  varying  degree  of  erythematous  and  papular  irritation,  which  is  often 
added  to  by  the  scratching  induced.  The  parasite  is  small,  about  the  size  of  a  grain  of 
sand,  grayish  white  in  color,  with  six  three-jointed  legs,  no  antennae,  but  strong  man- 
dibles. They  are  quite  a  pest  among  fowls,  and  sometimes  afflict  those  who  care  for 
them,  chiefly  attacking  the  hands  and  forearms.  The  treatment  is  that  of  similar  con- 
ditions just  described. 

Other  parasites  which  attack  the  human  skin  for  nourishment  are  the  mosquito 
(culex  anxifer),  gnat  (culex  pipiens),  and  certain  kinds  of  flies  and  other  insects,  and 
give  rise  to  erythematous  and  urticarial  lesions,  which  vary  considerably  in  different 
individuals,  in  some  having  but  little  effect,  in  others  quite  pronounced  irritation.  This 
may,  and  usually  does,  subside  quickly,  although  exceptionally  the  lesions  last  one  to 
several  days.  In  addition  to  these  insects  are  to  be  mentioned  those  which  sometimes 
attack  the  skin  to  inflict  injury  or  in  self-defence,  such  as  bees,  wasps,  spiders,  ants, 
caterpillars,  etc.  With  some  of  these,  especially  the  bees  and  wasps,  if  the  stings 
are  numerous,  the  effects  may  be  quite  serious,  in  extreme  instances  death  having 
resulted.  The  lesions  vary,  but  are  chiefly  urticarial  in  appearance.  Some  species 
of  spiders  can  also  produce  alarming  consequences,  a  poisoned  wound  developing 
at  the  point  of  attack,  and  followed  by  systemic  symptoms.  For  obvious  reasons  the 
exposed  parts  are  those  attacked,  and  this  fact  is  of  some  value  in  the  diagnosis.  The 
central  punctum  in  these  lesions,  together  with  the  parts  involved  and  history  of  ex- 
posure, are  generally  sufficient  to  prevent  error. 


1 1 88  PARASITIC  AFFECTIONS 

Treatment  is  with  the  various  applications  already  named.  Spirits  of  camphor, 
weakened  ammonia  water,  and  menthol  preparations  are  most  efficient  in  relieving  the 
sting.  A  2  or  3  per  cent,  solution  of  menthol,  oil  of  eucalyptus,  or  tar  oil  is  variously 
used  for  protection  where  these  parasites  are  numerous  and  troublesome.  For  wasp 
or  bee  stings  common  earth  or  clay  made  into  a  paste  with  water  and  applied  is  a  well- 
known  and  efficient  application. 

SCABIES 

Synonyms. — Itch;  Fr.,  Gale;  Ger.,  Kratze. 

Definition. — A  contagious  disease  due  to  the  invasion  of  the  skin 
by  the  acarus  scabiei,  characterized  by  itching  and  lesions  of  a  papular, 
vesicular,  and  pustular  type,  predominantly  upon  the  fingers,  hands, 
wrists,  axillary  folds,  lower  abdomen,  and  genital  and  anal  regions. 

Symptoms. — The  first  evidence  of  the  disease  is  itchiness,  caused 
by  the  presence  of  the  itch-mite  within  the  cutaneous  tissue,  at  first 
being  limited  to  the  region  where  the  parasites  have  gained  access. 
On  examination  a  few  papules  or  vesicles  may  be  discovered.  The 
malady  is  one  of  steady  progression,  getting,  unless  held  in  check  by 
daily  washings,  worse  and  worse  as  regards  itching  and  the  amount  of 
eruption.  As  a  rule,  when  the  patient  seeks  advice,  the  affection  has 
lasted  for  several  weeks;  the  itching  is  more  or  less  general,  but  more 
pronounced  on  certain  situations.  Inspection  discloses  the  presence 
of  papules,  vesicles,  and  often  pustules,  in  scant  or  great  number  upon 
the  hands,  especially  the  fingers,  the  wrist,  about  the  region  of  the 
elbow,  at  the  axillae,  the  lower  abdomen,  the  genitalia,  cleft  of  the  nates, 
inside  of  the  thighs,  and  frequently  about  the  ankles  and  feet.  The 
region  of  the  nipple  in  women  is  also  a  favorite  situation.  Scattered 
excoriations  are  to  be  seen  here  and  there.  Other  parts  of  the  body  in 
well-marked  cases  likewise  show  lesions,  but  they  are  always  predomi- 
nantly present  on  the  situations  just  named.  The  head,  except  in  infants 
and  very  young  children,  rarely  shares  in  the  eruption.  In  addition  to 
these  various  lesions  the  burrow,  or  cuniculus,  is  usually  to  be  found, 
the  common  situations  for  it  being  the  interdigital  spaces,  the  flexor 
surface  of  the  wrist,  about  the  mammas  in  the  female,  and  on  the  shaft 
and  glans  of  the  penis  in  the  male.  It  consists  of  a  tortuous,  straight,  or 
zigzag,  dotted,  slightly  elevated,  dark-gray  or  blackish,  thread-like,  linear 
formation,  varying  in  length  from  |  to  \  inch;  at  one  end  slightly  more 
elevated,  and  appearing  as  a  minute  whitish  or  dark  grayish  dot  is  the 
contained  female  mite. 

The  eruptive  phenomena  may  be  quite  pronounced,  especially  in  the 
careless  and  uncleanly;  and  in  such  there  may  be  an  abundance  of 
variously  sized  blebs  and  pustules,  in  addition  to  vesicles,  papules,  ex- 
coriations, and  burrows.  The  inflammatory  lesions  are  also  always  most 
marked  as  regards  development  in  those  of  irritable  skin,  and  in  such 
individuals  the  burrows,  except  evidences  on  the  vesicle,  pustule,  or 
bleb- wall,  are  usually  scanty  in  number  and  hard  to  find;  the  reactive 
irritation  of  the  tissue  giving  rise  to  a  papule,  vesicle,  or  bleb,  the 
mite  thus  being  so  soon  disturbed  the  burrow  cannot  be  formed  or  is 
soon  interfered  with  and  uplifted.  In  some  cases,  if  of  long  continuance 


SCABIES  1189 

and  neglected,  and  particularly  in  those  predisposed  to  true  eczema,  in 
addition  to  the  multiform  eruption  of  scabies,  an  eczematous  aspect  is 
presented,  especially  about  the  hands,  forearms,  and  axillary  folds. 
Impetiginous  lesions  and  crusts  are  also  often  interspersed.  Among  the 
lepers  in  Norway  and  in  others,  from  neglect  and  long  duration,  more  or 
less  massive  crusting  and  calloused  formations  are  sometimes  noted — 
Norwegian  itch.  In  other  instances,  in  those  who  are  bathing  daily,  the 
eruption  is  always  scanty,  and  generally  consists  of  scarcely  more  than 
several  or  more  insignificant  papules  or  vesicles  upon  the  various  favorite 
regions,  with,  as  a  rule,  burrows  likewise  sparse.  The  itching  of  scabies, 
as  may  be  inferred  from  the  common  name,  "the  itch,"  is  usually  of  an 
intense  character.  It  is  not  so  marked  or  violent  during  the  day-time 
as  when  the  patient  gets  in  bed  and  the  skin  becomes  thus  warmed  up, 
the  parasites  being  apparently  more  active  under  such  influence.  In  some 
cases  there  is  but  little,  if  any,  suffering  during  the  day.  The  degree  of 
pruritus  varies  somewhat,  too,  in  different  cases. 


Fig.  320. — Acarus  scabiei  (ventral  surface):  i,  Female;  2,  male  (X  100)  courtesy  of 

Dr.  L.  A.  Duhring). 

The  course  of  the  disease,  as  already  stated,  is,  as  a  rule,  steadily 
progressive,  but  in  many  instances,  owing  to  frequent  baths  or  soap- 
and-water  washings,  the  development  is  only  of  moderate  character. 
In  fact,  in  many  patients  as  met  with  in  our  dispensaries,  and  in  the 
majority  in  private  practice,  the  malady  never  reaches  the  extent  and 
severity  of  the  cases  so  common  in  the  European  clinics.  Nor  with  most 
of  our  patients  are  the  hands  ordinarily  so  predominantly  involved  as  in 
those  seen  in  the  latter  countries.  In  those  of  certain  occupations, 
such  as  stone-cutters,  bricklayers,  polishers,  pasters,  etc.,  the  hands, 
from  the  character  of  the  work  and  the  frequent  washing  necessitated, 
are,  as  a  rule,  the  seat  of  but  sparsely  scattered  lesions.  With  private 
patients,  many  of  whom  as  soon  as  they  first  notice  itching  begin  to  wash 
diligently  and  frequently,  the  eruption  is  almost  always  scanty,  consist- 
ing of  but  a  few  lesions  on  wrists,  axillary  folds,  lower  abdomen,  and 
penis,  and  possibly  between  the  fingers. 


I  I  go  PARASITIC  AFFECTIONS 

Except  as  to  the  depression  consequent  upon  the  distress  and  wake- 
fulness  produced  by  the  itching,  the  general  health  does  not  seem  affected, 
although  albumin  has  been  occasionally  found  in  the  urine  of  patients 
while  subjects  of  the  disease;1  sometimes,  possibly,  due  to  the  remedies 
applied.  Kolmer,2  Schamberg3  and  Strickler  found  an  increase  in  the 
eosinophiles. 

Animal  Scabies  (of  domestic  animals)  may  be  conveyed  to  man, 
usually  by  more  or  less  intimate  contact,  and  provoke  lesions  similar 
to  those  in  the  human  variety ;  burrows  are,  however,  seldom  seen ;  and 
apparently  in  the  eruption  produced  by  scabies  of  the  cat4  the  lesions 
are  mostly  papular,  later  with  apex  vesiculation,  papular  excoriations 
with  crusting,  and  accidental  coccic  infection  lesions.  The  distribution, 
especially  from  cat  scabies,  is  more  largely  truncal,  rarely  affecting,  to 
any  great  extent,  the  lower  parts  of  the  extremities. 

Htiology  and  Pathology. — The  disease  is  due  to  an  animal 
parasite,  the  acarus  scabiei,  sarcoptes  scabiei,  sarcoptes  hominis,  be- 
longing to  the  class  arachnidae,  in  the  subdivision  acarinae,  and  family 
sarcoptidae.  It  is  contagious  to  a  marked  degree.  It  is  most  commonly 
contracted  by  sleeping  with  those  affected,  or  by  occupying  a  bed  with 
unchanged  linen  in  which  an  affected  person  has  slept.  It  may,  doubtless, 
be  also  contracted  in  many  other  ways,  which  will  readily  suggest  them- 
selves. Its  contraction  is  possible,  although  not  so  probable,  from  the 
use  of  common  towels  and  other  toilet  articles,  tools,  etc.,  and  even  from 
shaking  hands.  For  obvious  reasons  it  occurs  usually  among  the  poor, 
although  it  is  occasionally  met  with  among  the  better  classes.  It  is  seen 
at  all  ages  and  in  both  sexes.  It  is  much  more  common  in  Europe  and 
other  countries  than  with  us,  but  of  late  our  dispensary  and  private 
practice  records  show  a  marked  increase  over  former  years.5  It  is  not 
infrequent  in  our  own  country  to  see  many  cases  among  the  foreign- 
born  laborers,  especially  the  Italians,  Hungarians,  and  Poles,  who,  from 
the  natural  flocking  together  and  intimate  contact,  are  soon,  as  the  result 
of  the  introduction  of  one  or  two  fellows  with  the  disease,  largely  affected 
— hence  the  names  sometimes  heard,  of  "Italian  itch,"  "Hungarian  itch," 
"Polish  itch."  There  are  the  same  opportunities  for  its  spread  in 
closely  quartered  armies,  hence  the  term  "army  itch."  Some  of  the  cases 
reported  as  "prairie  itch,"  "swamp  itch,"  "lumberman's  itch,"  etc.,  were 

1  Nicolas  and  Jambon,  "L'albuminurie  chez  les  galeux,"  Annales,  1908,  p.  65,  con- 
tribute the  latest  paper  on  this  point,  also  fully  reviewing  the  subject  (with  references). 

2  Kolmer,  Jour.  Cutan.  Dis.,  1911,  p.  339,  found  in  a  series  of  cases  (18)  the  disease 
accompanied  by  a  mild  leukocytosis;  the  eosinophilia  varied  from  3  to  u  per  cent.,  and 
two-thirds  of  the  cases  were  over  5  per  cent.,  an  average  of  5.9  per  cent. 

3  Schamberg  and  Strickler,  "Report  of  Eosinophilia  in  Scabies  with  a  Discussion  of 
Eosinophilia  in  Various  Diseases  of  the  Skin,"  ibid.,  1912,  p.  53,  found  in  an  examination 
of  47  cases  of  scabies,  38,  or  more  than  80  per  cent.,  showed  5  or  more  per  cent,  of  eosino- 
philes; the  maximum  was  19  per  cent.,  and  the  average  7  per  cent.,  the  patients  exhibit- 
ing no  increase  were  for  the  most  part  those  with  scant  eruption;  this  paper  contains 
a  valuable  review,  with  tabulations,  of  the  important  papers  on  eosinophilia  and  blood- 
counts  in  the  various  skin  diseases,  with  bibliography. 

4  Thibierge,  "Sur  Peruption  provoquee  chez  1'homme  par  la  gale  du  chat,"  Gaz. 
des  Hdpitaux,  Jan.  31,  1911. 

5  See  following  papers  bearing  on  this  point:  Greenough,  Boston  Med.  and  Surg. 
Jour.,  Sept.  23,  1886;  J.  C.  White,  ibid.,  Feb.  14,  1889;  Stelwagon,  Med    News,  Sept. 
23,  1893- 


SCABIES 

cases  of  scabies,  and  some,  doubtless,  of  pruritus  hiemalis,  although  most 
of  them  were  probably  examples  of  grain-mite  dermatitis. 

The  eruptive  lesions  are  the  result  of  the  irritation  produced  by 
the  presence  and  products  of  the  parasite  in  the  cutaneous  tissue,  reaction- 
ary inflammation  invoked,  papules  and  vesicles  and  blebs  resulting. 
Purulent  lesions  are  also  produced,  doubtless  due  to  secondary  inoculation 
of  pus  cocci.  The  constant  scratching  gives  rise  to  favorable  opportuni- 
ties for  integumentary  coccus  infection. 

The  female  mite  is  the  one  which  invades  the  integument,  the  male 
never  being  found  in  the  cutaneous  tissue,  but  in  excavations  in  the  skin, 
and  apparently  takes  no  direct  part  in  the  production  of  the  symp- 
toms. The  general  appearances  and  characters  of  both  are  shown  in  the 


Fig.  321. — Scabies,  section  of  skin  showing:  B,B,B,  Burrow;  C,  C,  corneous  layer;  R, 
rete  mucosum;  Cm,  corium  (courtesy  of  Dr.  M.  B.  Hartzell). 

annexed  cuts.  It  is  observed  that  the  male  is  much  smaller  than  the 
female;  the  latter  is  about  ^  inch  long,  and  f  less  in  width.  They  have 
an  oval  body,  the  upper  surface  convex  and  transversely  corrugated, 
with  some  spinous  projections;  the  lower  or  ventral  surface  is  flat,  with 
four  anterior  and  four  posterior  claws,  the  former  being  each  provided 
with  a  sucker  and  several  hairs,  the  latter  with  long  bristles.  There  is 
a  short,  projecting  head.  The  male  differs  from  the  female  only  in  having 
suckers  also  in  the  two  inner  posterior  claws;  it  is  provided  with  rather 
conspicuous  genital  organs.  The  parasite  does  not  invade  the  rete, 
as  has  been  commonly  believed,  but,  as  both  Torok1  and  Schischa2 

1  Torok,  "Zur  Anatomic  der  Scabies,"  Monatshefte,  1889,  vol.  viii,  p.  360. 

2  Schischa,  "Zur  Anatomic  der  Scabies,  nebst  Beitrag  zur  Histologie  der  Horn- 
schicht,"  Archiv,  1900,  vol.  liii,  p.  313  (with  3  plates  and  n  cuts;  with  review  of  the 
opinions  of  others). 


1192  PARASITIC  AFFECTIONS 

have  shown,  as  previously  indicated  by  Riehl,  it  penetrates  the  corneous 
layer  and  traverses  the  middle  or  lower  part  of  it.  This  is  also  well 
shown  in  the  annexed  cut  (Hartzell).  As  the  mite  burrows  it  deposits 
ova,  in  variable  number,  finally  perishing  in  the  skin.  The  burrow  or 
cuniculus  contains  therefore  the  female  parasite,  ova,  and  excrementi- 
tious  matter;  by  snipping  off  this  formation  and  placing  under  a  magnify- 
ing-glass  or  microscope  with  low  power,  the  mite,  ova,  and  products  can 
be  readily  seen.  The  mite  can,  if  one  is  expert  and  has  good  sight,  be 
caught  in  the  blind  end  of  the  burrow,  where  it  reposes  as  a  grayish  or 
grayish-black  dot,  by  quickly  transfixing  it  with  a  pin  or  needle.  The 
ova  gradually  hatch  out,  and  thus  the  malady  is  continued  and  its  extent 
increased.  It  takes,  on  an  average,  about  five  or  six  days  for  the  larva 
to  develop  from  the  egg,  and  about  twelve  to  fourteen  days  more  to  reach 
full  adult  growth;  at  first  the  larva  has  only  six  legs. 

Diagnosis.— But  little  difficulty  need  be  experienced  in  the  diag- 
nosis of  this  disease  if  its  characters  are  borne  in  mind:  these  are  the 
distribution,  the  multiformity  of  the  eruption  (papules,  vesicles,  excoria- 
tions, and  often  blebs  and  pustules) ,  the  itching,  usually  marked  at  night 
when  the  patient  warms  up  in  bed,  and  quite  frequently  a  history  of  con- 
tagion. The  burrow,  if  carefully  looked  for  between  the  fingers,  in  the 
palms,  on  the  wrist,  and  on  the  penis,  can  usually  be  found,  and  when 
present  is  diagnostic.  The  peculiar  distribution  is  likewise  commonly 
sufficient  to  lead  to  a  correct  conclusion.  The  history  of  an  itching  mal- 
ady, of  progressive  character,  with  eruptive  evidences,  such  as  described, 
between  the  fingers  and  other  parts  of  the  hand,  on  the  wrist,  about  the 
elbow- joint,  axillae,  lower  abdomen,  genitalia,  buttocks,  and  in  women 
also  about  the  nipples,  is  always  strongly  suggestive,  and  generally  con- 
clusive. As  the  hands  share  in  the  eruption  this  factor,  as  well  as  the 
other  distribution,  will  serve  to  differentiate  it  from  pediculosis  corporis. 
In  this  latter  the  irritation  and  consequent  lesions  are  found  upon  cov- 
ered parts  only,  especially  those  regions  with  which  the  clothing  comes 
closely  in  contact,  as  around  the  neck,  across  the  upper  part  of  the  back 
and  shoulders,  about  the  waist,  and  down  the  outside  of  the  thighs — a  dis- 
tribution quite  different  from  that  in  scabies.  Moreover,  in  pediculosis 
the  parasite  can  generally  be  easily  found  in  the  clothing,  especially  in  or 
about  the  seam  of  the  neck-band.  Scabies  bears  some  resemblance 
to  eczema,  but  with  care  can  usually  be  readily  distinguished  from  it 
(see  Eczema  for  differentiation),  as  well  as  from  other  itchy  diseases.1 

1  Luck  has  reported  (Med.  Record,  Aug.  5,  1899)  a  curious  mucor  dermatosis, 
with  some  resemblance  to  scabies,  affecting  chiefly  the  fingers,  arms,  and  axillas.  The 
eruption  was  of  itchy  character,  was  made  up  of  small  elevations  connected  by  channels 
running  under  the  horny  layer  of  the  epidermis,  and  some  small,  dark-red  pustules  and 
crusted  spots.  Small  filaments  protruded  from  some  of  the  pustules,  which  on  examina- 
tion were  found  to  consist  of  fragments  of  mycelia  of  a  species  of  mucor,  probably  the 
mucor  corymbifer.  Mercurial,  chrysarobin,  and  ichthyol  applications  were  unsuccess- 
ful, but  a  3  per  cent,  ointment  of  menthol  and  salol  proved  curative. 

Castellani  (Brit.  Jour.  Derm.,  Jan.,  1913,  p.  19)  describes  under  the  name  of  copra 
itch  an  eruption  very  similar  to  that  of  scabies,  both  in  character  and  distribution,  ex- 
cept that  no  burrows  or  cuniculi  are  present;  it  is  observed  in  those  working  in  copra 
mills  in  Ceylon  (copra  being  derived  from  cocoanuts) ;  he  found  acari-like  parasites  in 
the  copra  dust;  Hirst  (ibid.,  p.  21)  found  the  parasite  to  be  an  acarus,  belonging  to  the 
genus  Tyroglyphus,  resembling  and  probably  a  variety  of  Tyroglyphus  longior  Gerv. — 


SCABIES  1193 

Prognosis. — The  disease  is  readily  and  usually  promptly  cured 
if  the  treatment  is  thoroughly  and  vigorously  carried  out.  There  is 
no  tendency  to  spontaneous  disappearance.  As  soon  as  the  parasites 
and  their  ova  are  destroyed,  the  itching  and  the  eczematoid  or  secondary 
eruptive  lesions  as  a  rule  rapidly  disappear.  In  those  predisposed  to  true 
eczema  this  latter,  which  may  have  been  provoked  by  the  parasites  and 
scratching,  may  occasionally  tend  to  persist  even  after  the  scabies  proper 
has  been  cured.  Generally,  however,  such  cases  yield  to  continued  sooth- 
ing applications. 

Treatment. — The  treatment  of  scabies  is  purely  external.  There 
are  three  remedies  which  have  a  special  reputation  in  promptly  curing 
it.  These  are  sulphur,  balsam  of  Peru,  and  /5-naphthol.  The  first  is 
the  one  upon  which  chief  reliance  is  placed,  or  at  least  that  most  fre- 
quently prescribed,  although  either  of  the  others  is  likewise  sufficient 
to  destroy  the  parasites.  Ointments  containing  two  or  all  these  ingre- 
dients are  commonly  found  the  most  satisfactory.  For  children  and 
those  of  delicate  skin  the  following  may  be  used: 

]$.     Sulphur  sublimat., 

Bals.  Peruv.,  aa  5ij-vj  (8-24.); 

Adipis  benzoinat., 

Petrolati,  aa.  q.  s.  ad  5iv  (128.). 

In  those  of  the  average  dispensary  or  hospital  class,  this  same  com- 
bination of  full  strength  can  also  be  satisfactorily  employed,  or  one  con- 
taining /3-naphthol,  as  in  the  following: 

!$.     Sulphur,  sublimat.,  3ij-vj  (16-24.); 

Bals.  Peruv.,  3iv  (16.); 

/3-naphthol,  3HJ  (4--8.); 

Adipis  benzoinat., 

Petrolati,  aa  q.s.  ad  5iv  (128.). 

Before  the  ointment  is  applied  the  patient  takes  a  hot  bath,  using  plenty 
of  soap,  and  if  the  skin  is  not  oversensitive,  sapo  viridis.  All  parts 
should  be  thoroughly  washed  with  a  coarse  wash-cloth,  or  in  those  of 
rather  tough  skin  with  a  brush;  in  this  way  the  horny  layer  is  softened 
and  the  burrows  and  other  lesions  opened  up  for  full  action  of  the  reme- 
dial application.  The  ointment  is  then  rubbed  in  vigorously  over  the 
entire  surface,  below  the  chin  line,  rubbing  in  particularly  well  in  those 
situations  where  the  eruption  is  most  marked.  In  infants  and  very 
young  children  in  whom  the  face  and  possibly  other  parts  of  the  head 
may  share  in  the  parasitic  invasion,  these  places  must  also  receive  atten- 
tion. The  ointment  is  rubbed  in  night  and  morning  for  two  to  four  days, 
the  patient  wearing  the  same  underwear  continuously.  Ten  or  twelve 
hours  after  the  last  application  the  patient  takes  a  bath,  changes  his  un- 
derwear, and  also  the  bed-linen.  Thoroughly  done,  one  such  course 
will  suffice.  Itching  usually  lessens  or  wholly  abates  after  the  first 

the  latter  being  of  rather  wide  distribution  and  found  on  dried  or  preserved  animal  and 
vegetable  matter;  Castellani  states  if  the  patient  abstains  from  his  work  for  some  time 
the  condition  disappears  spontaneously;  he  found  a  5  to  10  per  cent.  /3-naphthol  oint- 
ment useful. 


1 194  PARASITIC  AFFECTIONS 

application.  Toward  the  last  rubbing,  slight  itching  may  have  again 
appeared,  due  to  the  irritation  excited  by  the  sulphur,  but  this  quickly 
subsides  as  soon  as  treatment  is  discontinued.  Not  infrequently  the 
eczematoid  eruption  provoked  by  the  malady  or  by  the  sulphur  applica- 
tions requires  soothing  remedies,  such  as  named  under  Eczema.  Some- 
times the  irritation  excited  by  the  sulphur  is  mistaken  by  the  overzealous 
for  a  continuance  of  the  scabies,  and  the  irritating  application  still 
further,  but  unnecessarily,  continued,  the  dermatitis  or  eczema  being 
thus  kept  up. 

In  exceptional  instances  of  tough  skin  and  marked  development  of 
the  malady  the  Helmerich  ointment,  as  modified  by  Hardy,  and  in  com- 
mon use  in  Saint  Louis  Hospital  in  Paris,  can  be  resorted  to.  It  consists 
of  2  parts  of  sublimed  sulphur,  i  part  of  potassium  carbonate,  and  12 
parts  of  lard.  It  is  preceded  by  a  prolonged  washing  or  bath  with  hot 
water  and  sapo  viridis.  Sulphur  treatment  is  sometimes  given  in  the 
form  of  a  bath,  using  3  to  6  ounces  (96.-! 92.)  of  potassium  sulphuret 
to  30  gallons  of  water,  the  patient  soaking  in  this  for  from  fifteen  to  thirty 
minutes,  rubbing  himself  thoroughly  with  a  coarse  wash-cloth  or  a  scrub- 
brush;  one  to  three  baths  are  usually  necessary.  The  bath  may  also 
be  made  with  liquor  calcis  sulphuratae;  or  this,  weakened  or  full  strength, 
can  be  rubbed  in  the  skin  after  an  ordinary  soap-and-water  washing. 
Sherwell1  strongly  lauds  a  plan  of  treatment  with  sulphur  used  as  a  pow- 
der as  being  efficacious  and  much  more  cleanly  than  the  ointment  method, 
although  somewhat  slower.  After  a  bath  the  powdered  sulphur,  in  small 
quantity,  is  lightly  rubbed  in  over  the  surface;  a  small  quantity  is  also 
sprinkled  between  the  bed-sheets.  This  is  repeated  every  two  or  three 
nights,  the  bed-linen  and  underwear  changed  each  time.  Cure  is  effected, 
it  is  stated,  in  a  week  or  ten  days. 

The  balsam  of  Peru  itself,  as  already  remarked,  is  sufficient,  and 
might  be  employed  in  those  exceptional  instances  in  which  the  skin 
is  extremely  sensitive  or  predisposed  to  eczema.  It  is  a  routine  method 
in  certain  foreign  centers,  and  has  been  warmly  commended  by  Peters, 
Burckhardt,  Nothnagel,  Jullien  and  Descouleurs,2  and  others.  Ex- 
perimentally it  has  been  shown  to  be  much  more  rapidly  fatal  to  the  itch- 
mite  than  sulphur.  It  is  brushed  over  the  entire  surface,  and  allowed  to 
remain  on  over  night;  in  extreme  examples  somewhat  longer,  and,  if 
necessary,  a  fresh  application  made. 

An  important  point  in  the  management  of  scabies  is  the  care  of 
the  clothing,  otherwise  the  patient  is  reinfected  over  and  over  again. 
The  underwear,  as  well  as  the  bed-linen,  should  be  boiled,  or,  if  the 
former  is  woolen,  in  order  to  avoid  shrinking,  a  thorough  baking  can 
be  given  instead.  The  outer  clothing  and  any  other  wearing  apparel 
that  has  had  a  chance  at  harboring  the  parasites  must  also  be  baked 
or  ironed  with  a  very  hot  iron.  Moreover,  as  there  are  often  several 
members  of  a  family  affected  before  the  nature  of  the  malady  has  been 
ascertained,  it  is  a  matter  of  course  that  all  should  receive  attention, 

1  Sherwell,  Jour.  Culan.  Dis.,  1899,  p.  494. 

*  Jullien  and  Descouleurs,  "Trois  cents  cas  de  gale  traites  par  le  baume  de  Perou," 
Annales,  1896,  p.  577. 


DRA  CUNCUL  US  1195 

otherwise  the  disease,  through  constant  reinfection,  may  continue  in 
such  a  household  indefinitely. 

The  treatment  of  animal  scabies  in  man  is  to  be  much  less  vigorous. 
The  human  skin  is  not  a  favorite  habitat  for  the  animal  sarcoptes,  and 
often  the  removal  of  the  infecting  animal,  along  with  soothing  anti- 
pruritic  applications,  such  as  a  i  to  2  per  cent,  carbolated  Lassar  paste, 
with  i  to  3  grains  of  menthol  incorporated,  will  suffice.  A  weak  sul- 
phur ointment  may  be  used  in  some  cases,  but  as  Thibierge  points  out 
in  cases  in  which  the  parasites  do  not  get  into  the  human  tissues,  as 
apparently  hi  scabies  from  the  cat,  sulphur  preparations  are  apt  to 
irritate. 


OTHER   ANIMAL   PARASITES,   OF  MINOR    IMPORTANCE,   PENE- 
TRATING THE  SKIN 

Leptus  (harvest  bug;  mower's  mite;  Fr.,  Rouget;  Ger.,  Erntemilbe),  of  which 
several  varieties  (leptus  autumnalis,  leptus  Americanus,  leptus  irritans),  with  but 
slight  minor  differences,  are  encountered,  is  a  minute,  barely  macroscopically  visible 
parasite,  elongate,  pyriform,  or  ovalish  in  shape,  of  an  orange-red  or  brick-red  color, 
and  with  six  long  legs.  It  is  found  in  summer  in  harvest-fields,  in  grass,  bushes,  in 
swampy  regions,  and  along  the  river-banks.  It  buries  itself  partly  or  more  or  less  com- 
pletely in  the  skin,  and  gives  rise  to  a  good  deal  of  irritation,  which  may  be  of  an  ery- 
thematous,  urticarial,  papular,  vesicular,  or  pustular  aspect,  and  when  several  or  more 
are  close  together,  may  present  an  eczematous  appearance.  The  lower  extremities, 
especially  about  the  ankles  and  feet,  are  the  favorite  parts,  although  other  regions,  such 
as  the  hands  and  arms,  are  sometimes  invaded.  One  variety  (leptus  Americanus), 
according  to  Duhring,  is  found  in  the  axilla?  and  scalp,  as  well  as  other  parts  of  the 
body,  and  more  frequently  in  children. 

Treatment  consists  in  the  application  of  weak  ointments  of  sulphur,  balsam  of 
Peru,  and  other  parasiticides.  A  carbolized  boric  acid  lotion  is  also  useful. 

Pulex  penetrans  (rhinochoprion;  chigoe;  chigger;  jigger;  sand-flea;  Fr.,  puce  de 
sable;  chique;  Ger.,  Sandfloh)  is  an  almost  microscopic  parasite,  especially  of  warm  and 
tropical  climates,  which  in  its  general  features  resembles  the  common  flea,  except  that 
it  is  furnished  with  a  long  proboscis.  The  impregnated  female,  which  alone  is  the  inva- 
der, penetrates  and  burrows  into  the  skin,  producing  an  inflammatory  swelling,  vesicle, 
pustule,  abscess,  or  even  ulceration.  The  feet,  especially  the  toes,  are  the  favorite 
sites  of  attack,  particularly  alongside  or  just  under  the  nail.  Other  parts  are  some- 
times invaded,  as  the  knee,  scrotum,  back,  etc.  The  parasite  sometimes  gives  rise  to 
considerable  disturbance,  with  adenitis. 

Treatment  consists  in  the  removal  of  the  parasite  and  applications  to  relieve  the 
irritation.  The  former  is  accomplished  by  careful  extraction,  usually  with  a  blunt 
needle,  and  the  latter  by  means  of  carbolized  boric  acid  or  alkaline  lotions.  If  the 
more  severe  conditions  are  provoked,  these  are  treated  upon  general  principles.  Essen- 
tial oils  are  commonly  used  as  a  protection  against  the  parasites. 

Dracunculus1  (dracunculus  medinensis;  guinea-worm;  guinea-worm  disease; 
dracontiasis;  filaria  medinensis;  Fr.,  ver  de  Guin6e;  dragonneau;  filaire  de  M6dine;  Ger., 
Peitschenwurm;  Medinawurm). — This  parasitic  nematode  worm  is  found  in  tropical 
countries,  especially  in  upper  Egypt,  Persia,  India,  west  coast  of  Africa,  Senega,  Guinea, 

1  Some  important  general  literature:  Horton,  Guinea-worm  or  Dracunculus,  London, 
1868;  Leuckart,  Die  Menschlichen  Parasiten,  1876,  vol.  ii;  Manson,  "On  the  Guinea 
Worm,"  Brit.  Med.  Jour.,  1895,  ii,  p.  1350;  Dubreuilh  and  Beille,  "La  filaire  de  Medine," 
Arch,  clinique  de  Bordeaux,  1897,  p.  425  (with  resume  and  references). 


1 196  PARASITIC  AFFECTIONS 

etc.  When  matured,  the  female,  which  is  the  invader,  attains  from  one  to  several  feet 
in  length,  averaging  about  25  inches,  and  is  about  ^  to  TV  inch  in  thickness,  being  some- 
what flattened.  It  has  a  slightly  convex  head  and  a  curved  and  pointed  tail,  and  is  of  a 
milky  color.  It  was  formerly  thought  that  it  gained  entrance  in  various  ways,  but  it  is 
now  known  (Fedschenko,  Stambolski,  Forbes)  that  the  embryos  which  enter  the  water 
gain  access  to  a  minute  crustacean  (cyclops)  and  undergo  larval  development,  the 
crustaceans  finding  their  way  to  man  through  the  drinking-water.  The  larvae  escape, 
develop,  and  the  female  begins  to  migrate  into  the  tissues,  where  it  remains,  giving 
rise  to  no  trouble  until  fully  developed.  Its  migrations  may  then  continue  for  some 
months,  and  even  after  its  appearance  near  the  surface  is  noted  may  sometimes  continue 
its  travels  before  it  finally  seeks  exit.  At  the  point  where  it  appears  it  may  present  a 
cord-like  appearance  under  the  skin,  and  in  other  instances  it  can  be  felt  as  a  worm  or 
cord-like  mass.  Usually,  however,  the  first  sign  is  a  local  inflammation,  developing  into 
a  vesicopustular,  nodular,  or  boil-like  formation,  attended  with  more  or  less  pain  and 
swelling.  This  breaks,  and  at  the  bottom  of  the  cavity  the  head  of  the  worm  is  seen. 
Through  this  opening  the  worm  may,  with  its  contained  young,  gradually  be  extruded; 
or  it  may,  if  disturbed,  or  voluntarily,  be  withdrawn,  the  opening  close  up,  and  a  new 
formation  appear  elsewhere,  usually  near  by,  where  it  again  attempts  to  find  exit. 
The  rupture  of  the  worm,  the  escape  of  the  embryos  into  the  tissues,  and  the  severance 
of  the  head  in  attempts  to  dislodge  the  parasite,  leaving  the  worm  in  the  tissues,  are 
variously  stated  to  be  fraught  with  some  danger,  such  as  the  development  of  lymphan- 
gitis, gangrene,  septicemic  symptoms,  and  death.  Sometimes  the  parasite  is  destroyed 
by  the  suppurative  inflammation  which  may  be  excited,  and  with  possible  untoward 
consequences.  The  part  at  which  the  worm  is  commonly  seen  is  the  foot,  not  infre- 
quently on  the  thigh,  occasionally  on  the  hands  and  elsewhere.  In  most  instances 
there  is  but  one  worm,  although  two  are  sometimes  present,  and  exceptionally  they 
may  exist  in  numbers. 

In  regions  where  the  malady  is  endemic  the  appearance  of  a  local  inflammatory, 
boil-like  swelling  might  be  suggestive,  but  no  positive  diagnosis  can  be  made  until  the 
worm  can  be  felt  or  seen. 

Treatment  practised  by  the  natives  in  endemic  regions  consists  in  securing  the 
protruding  head  part,  and  gradually,  day  by  day,  winding  the  worm  with  gentle  trac- 
tion around  some  substance  until  it  is  all  withdrawn,  ceasing  traction  each  time  that 
the  parasite  makes  opposition.  Perrin1  states  that  plunging  the  part  into  cold  water 
hastens  this  process,  the  parasite  temporarily  relaxing  its  hold.  This  method  is,  how- 
ever, unscientific,  slow,  not  without  danger,  and  takes  many  days.  According  to 
Forbes,  if  the  worm  is  let  alone  it  emerges  spontaneously  in  from  fifteen  to  twenty  days 
from  her  first  appearance.  The  plan  which  promises  well  is  that  by  Emily,2  of  injecting 
into  the  forming  tumor  a  solution  of  corrosive  sublimate  (i  :  1000);  if  the  head  has  al- 
ready protruded,  he  injects  the  solution  into  the  body  of  the  worm.  This  method  has 
since  been  successfully  used  by  Davoren,3  Blin,4  Manson  and  Boyd.5  As  Manson  suc- 
cinctly states,  a  "dead  aseptic  guinea-worm  does  not  act  as  an  irritant  to  the  tissues, 
and  it  can  be  got  rid  of  by  absorption  like  any  aseptic  animal  ligature."  The  method 
advocated  by  Horton  has  been  effective,  consisting  of  the  administration  of  moderate 
to  large  doses  of  asafetida.  Tilbury  Fox  and  others  reported  success  with  this  plan,  the 
parasite,  which  the  remedy  seems  to  destroy,  either  being  gradually  discharged  or  re- 
maining in  the  tissues,  becoming  encysted  or  slowly  absorbed.  Forbes  states  that  sul- 
phur internally  is  likewise  efficient. 


1  Perrin,  Annales,  1896,  p.  1315. 

2  Emily,  Arch,  de  med.  navale,  1894,  No.  6,  vol.  Ixi,  p.  460. 

3  Davoren,  Brit.  Med.  Jour.,  Oct.  17,  1894. 

4  Blin,  Arch,  de  med.  navale,  Nov.,  1895,  No.  5,  vol.  Ixiv,  p.  368. 
6  Manson  and  Boyd,  Brit.  Jour.  Derm.,  1896,  p.  37. 


DEMODEX  FOLL1CULORUM  Up/ 

Cysticercus  Celluloses. — Our  first  knowledge  of  the  presence  of  the  cysticercus  of 
taenia  solium  in  the  subcutaneous  tissues  we  owe  to  Rokitansky.1  According  to 
Kiichenmeister  and  Zurn,  the  proportion  of  integumental  infection  compared  to  that 
of  other  organs  is  about  5  per  cent.,  which  Geber2  considers  a  rather  low  estimate. 
The  malady  is  most  frequently  encountered  in  North  Germany,  where  raw  or  half- 
cooked  pork  is  a  favorite  article  of  diet.  The  tumor  caused  by  its  presence  is  situated 
under  rather  than  in  the  skin,  and  varies  in  size  from  a  large  pea  to  that  of  a  walnut, 
the  larger  formation  dependent  upon  the  reactive  inflammation  excited.  There  may 
be  several  or  many.  They  are  ordinarily  not  sensitive  to  pressure  unless  from  reac- 
tionary inflammation,  although  at  times  they  may  be  spontaneously  painful.  The 
integumental  covering  rarely  shows  any  change.  In  shape  they  are  rounded  or  ovalish, 
smooth  and  elastic,  or  even  firm  and  hard,  and,  as  a  rule,  more  or  less  movable.  After 
reaching  a  variable  size  they  may  remain  stationary  somewhat  indefinitely,  although 
after  death  of  the  parasite  they  become  smaller  and  exhibit  a  tendency  to  calcification. 
The  trunk  is  a  favorite  locality,  likewise  the  extremities,  and  occasionally  they  are  seen 
on  other  parts.3 

Their  chief  interest  lies  in  the  diagnosis,  as  the  tumors  bear  some  resemblance  to 
other  growths,  and,  in  fact,  a  positive  conclusion  is,  as  a  rule,  possible  only  by  micro- 
scopic examination,  which  reveals  the  presence  of  the  cysticerci.  Examination  of  the 
contents,  obtained  by  puncturing,  usually  suffices,  as  the  hooklets  are  easily  found  in 
the  discharge. 

Demodex  folliculorum  (acarus  folliculorum;  steatozoon  folliculorum;  entozoon 
folliculorum;  Fr.,  acare  des  follicules;  Ger.,  Haarbalgmilbe)  is  a  minute,  microscopic 


Fig.  322. — Demodex  folliculorum  (ventral  surface;  X  3°o)  (after  Simon). 

parasite,  found  in  the  sebaceous  glands  and  hair-follicles,  the  first  knowledge  of  which 
we  owe  to  Henle  (1841)  and  Simon  (1842).  It  has  most  commonly  an  elongated,  worm- 
like  form,  made  up  of  a  head,  thorax,  and  long  abdomen,  with  eight  short  stout  legs 
coming  off  from  the  thorax;  the  larva  has  but  six  legs.  The  parasite  varies  in  length 
considerably,  some  being  quite  short.  It  is  present  most  abundantly  in  the  sebaceous 
glands  and  hair- follicles  of  the  nose,  forehead,  and  cheeks,  and  is  easily  found  in  the 
pressed-out  sebaceous  matter.  It  seldom  occurs  in  infants  (Duhring)  nor  in  all  adults, 
but  is  most  frequently  to  be  seen  in  greatest  numbers  in  those  of  thick,  greasy  skin.4 

1  G.  Lewin,  "Ueber  Cysticercus  cellulosae  in  der  Haut  des  Menschen,"  Archiv,  1894, 
vol.  xxvi,  pp.  70  and  217  (gives  complete  exposition  with  review  of  the  literature  and 
references). 

2  Geber,  Ziemssen's  Handbook  of  Skin  Diseases,  p.  549. 

3  Pye-Smith,  Brit.  Jour.  Derm.,  1892,  p.  366,  had  a  case  under  observation  with 
more  than  50  tumors  scattered  over  face,  neck,  trunk,  and  limbs;  they  were  quite  pain- 
less; their  true  nature  was  not  suspected  until  the  microscope  cleared  the  matter  up. 

4  Gmeiner,  Archiv,  1908.  vol.  xcii,  p.  25  (with  several  plates),  gives  a  good  historical 
summary  and  description  of  the  morphology  of  the  demodex  folliculorum;  investigation 
was  made  with  200  corpses,  and  with  the  exception  of  infants  the  parasite  could  be 
found  on  the  face  of  every  individual;  DuBois  ("Recherches  sur  Demodex  follirulorum 
hominis  dans  la  peausaine,"  Annales,  1910,  p.  188),  in  a  large  series  of  examinations  on 
living  subjects  found  it  absent  in  those  under  the  age  of  five;  it  or  its  larva  present  in 
50  per  cent,  of  the  subjects,  between  five  and  ten.  and  present  in  all  above  ten;  eggs  of 
the  parasite  develop  into  hexapod  larval  forms. 


PARASITIC  AFFECTIONS 

It  has  been  thought  to  be  harmless,  but  recently  De  Amicis,1  Majocchi2  (2  cases), 
and  Dubreuilh3  have  reported  instances  of  pigmentation  involving  parts  of  the  face  due 
to  its  presence,  the  pigmentation  being  of  a  fawn  or  brownish  tint,  similar  to  that  of 
tinea  versicolor.  In  Dubreuilh's  patient  the  neck  was  also  the  seat  of  the  discoloration, 
and  some  spots  were  found  on  the  breast.  The  chin  and  lip  regions  are  apparently  favor- 
ite situations.  There  was  slight,  but  scarcely  perceptible,  follicular  prominence,  due 
to  minute  corneous  projections  from  the  orifices,  associated  with,  in  one  or  two  instances, 
trifling  scurfiness.  Dubreuilh  noted  that  the  pigmentation  started  and  was  most 
pronounced  about  the  follicular  outlet.  The  clinical  appearances  suggested  tinea  versi- 
color to  these  observers,  but  upon  microscopic  examination  the  fungus  of  this  disease 
was  not  found,  but  the  demodex  was  discovered  in  numbers,  and  this  was  noticeable  only 
in  the  pigmented  parts.  It  is  well  known,  of  course,  that  other  or  allied  varieties  of  this 
parasite  are  found  in  some  of  the  lower  animals,  and  in  which  it  may  be  productive  of 
considerable  mischief. 

The  treatment  in  De  Amicis'  case,  which  was  successful,  was  by  washings  with  soft 
soap.  Dubreuilh  tried  a  stimulating  parasiticide  application,  but  without  any  result- 
ing benefit. 

CEstrus  (Gad-fly;  Bot-fly). — The  larvae  of  both  the  families  of  the  muscidae  and 
cestridae4  are  occasionally  found  invading  the  human  skin,  although  there  is  none  pecu- 
liar to  man.  Such  invasion,  especially  by  the  latter,  is  not  uncommon  in  Central  and 
South  America,  and  is  also  met  with  exceptionally  elsewhere.  The  ova  of  the  former 
are  deposited  usually  in  open  wounds  and  ulcers,  sometimes  creating  serious  trouble, 
and  naturally  come  more  under  the  surgeon's  observation.  The  ova  of  the  cestridae 
are  deposited  in  the  skin  in  the  puncture  made  by  the  insect,  most  frequently  on  ex- 
posed parts,  the  larvae  developing  and  giving  rise  to  furuncle-like  tumors.  These  for- 
mations generally  have  a  central  aperture  through  which  a  sanious,  seropurulent,  or 
sanguinopurulent  fluid  exudes.  In  some  instances,  as  the  result  of  burrowing  of  the 
worm,  irregular  lines  resembling  inflamed  lymphatics,  of  a  purplish  or  purplish-red 
color,  are  produced.  In  rare  cases  considerable  surf  ace  may  be  traversed  by  the  larva 
before  final  suppurative  action  is  excited,  an  abscess-like  tumor  formed,  and  the  worm 
can  be  pressed  out  or  extracted.5 

The  treatment  of  the  formation  produced  by  the  cestrus  consists  in  the  removal 
of  the  parasite  by  free  excision  and  pressure,  and  application  of  antiseptics  to  the 

1  De  Amicis,  "Demodex  folliculorum  e  ipecromia  cutanea,"  Giorn.  ital.,  1898,  p. 
205 — brief  abs.  in  Brit.  Jour.  Derm.,  1899.  p.  42. 

2  Majocchi,  ibid. 

3  Dubreuilh,  "Pigmentation  cutanee  cause"e  par  le  demodex  folliculorum,"  Jour,  de 
med.  de  Bordeaux,  No.  4,  Jan.  27,  1901. 

4  See  exhaustive  paper  by  G.  Joseph,  "Ueber  Myiasis  externa  dermatosa,"  Monats- 
hefte,  1877,  pp.  49,  106,  and  158,  with  review  of  the  whole  subject  and  literature  refer- 
ences.    Joseph  places  the  cutaneous  malady  variously  produced  by  the  different  species 
under  the  above  name;  subdividing  the  cases  into  two  classes:  those  due  to  the  family 
muscidae,  myiasis  dermatosa  muscosa,  and  those  due  to  the  cestridae,  myiasis  dermatosa 
astrosa;  also  that  by  Strauch,  "Myiasis  Dermatosa,"  Jour.  Cutan.  Dis.,  1906,  p.  524 
(with  some  references) ;  Yount  and  Sudler,  "Human  Myiasis  from  the  Screw-worm  Fly," 
Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlix,  p.  1912,  chiefly  intranasal.  and  in  the  south 
and  southwest;  Gilbert,  Archives  Int.  Med.,  1908,  vol.  ii,  p.  226;  Miller,  Jour.  Amer. 
Med.  Assoc.,  Dec.  3,  1910,  gives  notes  of  a  case  of  "Myiasis  Dermatosa  due  to  the  Ox- 
warble  Flies";  it  occurred  in  a  white  boy  aged  eleven,  and  presented  itself  as  a  traveling 
"lump."     The  lumps  were  occasionally  stationary,  but  generally  migrated  3  to  4 
inches  a  day.     The  larva,  according  to  examination  by  C.  W.  Stiles,  was  identified  as 
"the  larva  of  hypoderma  lineata  in  the  second  stage";  a  somewhat  similar  case  is  referred 
to:  Kane,  "Insect  Life,"  ii,  238,  traveling  lump,  finally  breaking  down,  and  found  due  to 
the  larva  of  the  hypoderma  bovis. 

5McCalman,  Brit.  Med.  Jour.,  1879,  vol.  ii,  p.  92,  and  Arch.  Derm.,  1880,  p.  174; 
W.  G.  Smith,  Trans.  Internal.  Cong.,  London,  i88i,vol.  iii,  p.  181,  and  abs.  in  Arch. 
Derm.,  1882,  p.  45;  and  Walker,  Brit.  Med.  Jour.,  1870,  vol.  i,  p.  151,  report  interesting 
examples. 


CREEPING  ERUPTION  1199 

lesion  and  wound  thus  made.  In  the  more  conspicuous  serpiginous  cases  the  larva 
can  sometimes  be  secured  by  excision  of  an  area  around  or  just  beyond  the  advancing 
part.1 

Creeping  eruption  (Lee),2  also  named  larva  migrans  (Crocker),  hyponomoderma 

1  Foster  ("Gastrophilus  Epilepsalis  Larvae  in  the  Skin  of  an  Infant,"  St.  Paul  Med. 
Jour.,  Oct.,  1903)  records  a  case  of  an  infant  three  weeks  old,  with  a  papular  and  pustu- 
lar eruption  on  the  neck,  a  pustule  on  the  palm,  and  one  between  the  great  and  second 
toes  of  right  foot,  of  a  few  days'  duration;  from  three  lesions  of  which  (the  one  between 
the  toes,  the  one  on  the  back  of  the  neck — somewhat  nodular  or  furunculoid — and  the 
one  in  the  palm)  a  small  living  worm  came  out.     The  worms  were  about  ^  inch  in  length, 
and  evidently  the  larvae  of  some  species  of  fly — later  identified  by  Coquillet  as  gas- 
trophilus  epilepsalis,  a  species  somewhat  closely  allied  to  gastrophilus  equi  or  bot-fly. 

Vignolo-Lutati  (Archiv,  1907,  vol.  Ixxxvii,  p.  81)  described,  under  the  title  "Oxy- 
uriasis  cutanes,"  a  case  of  acute  seropurulent  dermatitis  of  the  peri-anal  and  genitocrural 
regions  in  a  man  aged  twenty-four,  the  most  inflamed  skin  being  dotted  over  with 
vesicopustules,  due  to  the  presence  and  colonization  of  the  oxyuris  vermicularis  in  the 
skin  of  the  peri-anal  region;  the  worms  were  detected  in  large  numbers  in  the  discharge. 
He  refers  to  several  similar  cases  (Szerlecky,  1874;  Michelson,  1877;  and  Majocchi, 

1893). 

Spoor  ("Infection  with  Fly  Larvae,"  Jour.  Amer.  Med.  Assoc.,  1907,  vol.  xlix,  p. 
1775)  saw  in  an  infant  four  weeks  old  several  lesions  about  the  neck  and  face,  forearms, 
and  hands;  some  slightly  raised,  with  a  red  areola  around  a  whitish  center  of  seropuru- 
lent material  about  the  size  of  a  pin-head,  from  which  a  "worm"  escaped  when  the  lesion 
was  pressed  between  the  fingers,  as  one  would  extract  a  comedo— afterward  healing 
taking  place  rapidly.  There  were  also  larger  lesions  (one  as  large  as  a  plum) ,  represent- 
ing a  more  severe  type  of  inflammation,  and  contained  larger  larvae.  The  larvae  varied 
in  size,  and  microscopically  resembled  somewhat  the  small  worm  found  in  apples. 

Stiles  ("The  Occurrence  of  a  Proliferating  Cestode  Larva  (Sparganum  proliferum) 
in  Man  in  Florida,"  Jour.  Cutan.  Dis.,  1908,  p.  345,  with  illustrations)  records  (Gates' 
patient)  a  case  where  numerous  cystic  nodules  in  the  skin  and  in  the  fascia  between  the 
skin  and  muscles  were  scattered  over  the  trunk,  and  of  long  duration.  When  opened 
the  lesions  were  found  to  contain  one  to  three  worms  about  T^  inch  wide  and  f  inch 
long;  the  most  striking  feature  of  the  worm  being  its  irregular  shape,  with  tendency  to 
proliferation  by  forming  supernumerary  heads.  Stiles  also  reviews  an  apparently  simi- 
lar case  (Ijima's  Japanese  case). 

Costa  ("Two  Important  Parasites  of  the  Skin,"  Jour.  Cutan.  Dis.,  Jan.,  1910)  re- 
cords a  case  in  a  child  where  several  rather  large  tumefactions  on  the  head  were  due  to 
the  presence  of  a  worm,  probably  the  larva  of  an  cestride,  the  dermatobia  noxialis.  The 
other  parasite  to  which  he  calls  attention  is  the  sarcopsylla  penetrans,  which  penetrates 
the  skin  of  the  feet,  producing  a  variable  degree  and  type  of  inflammation. 

2  Lee,  "Creeping  Eruption,"  London  Clin.  Soc'y  Trans.,  1874,  vol.  viii,  p.  44,  and 
ibid.,  1884,  vol.  xvii,  p.  74;  Crocker,  "Larva  migrans,"  Diseases  of  the  Skin,  second 
edit.,  p.  926;  Neumann,  "Ueber  eine  neue  Hautaffection,"  Vcrhandl.  des  V.  Cong.  d. 
Deutschen  dermal.  GeseUsch.,  1895  (1896),  p.  95;  Sokolow,  "Ueber  eine  Wurmchen, 
welches  in  der  epidermoidalen  Schichte  der  menschlichen  Haut  Gange  bildet" — abs.  in 
Archiv,  1897,  vol.  xxxviii,  p.  153;  Samson-Himmelstjerna,  "Ein  Hautmaulwurf,"  ibid., 
1897,  vol.  xli,  p.   367;  Kumberg,   "Ein  Fall  von  Dermatomycosis  linearis  migrans 
oestrosa" — abs.  in  Dermalolog.  Centralbl.,  1897-98,  vol.  i,  p.  283;  Kaposi,  Wiener  klin. 
Wochenschr.,  1898,  p.  399   (case  demonstration);   Van  Harlingen,  "Report  of  Three 
Cases  of  Creeping  Larvae  in  the  Human  Skin"  (Hyponomoderma,  Kaposi),  Amer.  Jour. 
Med.  Sci.,  September,  1902;  Stelwagon,  "A  Case  of  Creeping  Eruption,"  Trans.  Section 
of  Cutaneous  Medicine  and  Surgery  of  the  A.  M.  A.  for  1903,  and  Jour.  Cutan.  Dis., 
1903,  p.  502;  "A  Second  Case  of  Creeping  Eruption,"  Jour.  Cutan.  Dis.,  1904,  pp.  359, 
381  (each  with  illustration) ;  Hamburger,  "Creeping  Eruption;  Its  Relations  to  Myiasis," 
Jour.  Cutan.  Dis.,  1904,  p.  217;  Shelmire,  "Creeping  Eruption;  Report  of  a  Case," 
ibid.,  June,  1905  (on  a  finger  of  a  physician);  Hutchins,  ibid.,  1906,  p.  270  (2  cases; 
successful  treatment  by  injection  of  a  drop  or  two  of  chloroform) ;  Moorhead,  Texas  Med. 
News,  February,  1906  (cure  in  5  cases  by  freezing  the  advancing  end  with  ethyl  chlorid) ; 
Kengsep,  Dermaiolog.  Centralbl.,  April,  1906,  p.  194  (i  case,  with  resume);  Hutchins 
(third  case),  Jour.  Cutan.  Dis.,  1908,  p.  521;  Wosstrikow  and  Bogrow  ("Zur  ^tiologie 
der  'Creeping  Disease,'  "  Archiv,  1908,  vol.  xc,  p.  323,  plate  illustrations)  have  met  with 
2  or  3  cases  yearly  for  the  past  twenty  years,  but  never  able  to  discover  the  parasite  till 
in  a  recent  case;  it  consisted  of  a  minute  (i  mm.)  worm  with  blackish  head  and  white 
body,  with  active  wave-like  movements,  and,  according  to  Prof.  Koschewnikow,  it  is 
an  immature  gastrophilus  larva,  probably  of  the  gastrophilus  hasmorrhoidalis  of  the 
horse;  Gosman,  Jour.  Amer.  Med.  Assoc.,  Jan.  i,  1910,  p.  38  (2  cases;  i  with  two  sepa- 


I2OO 


PARASITIC  AFFECTIONS 


(Kaposi),  and  dermamyiasis  lincaris  migrans  oestrosa  (Kumberg),  is  a  curious  malady, 
first  described  by  Lee,  Crocker,  and  subsequently  by  others,  and  has  the  peculiar  fea- 
ture of  traversing  the  surface,  as  the  name  signifies.  The  burrow  made  by  the  parasite 
is  5  to  |  inch  in  diameter,  and,  at  least  in  its  extending  part,  just  perceptibly  raised, 
and  of  a  pale  rose-pink  or  reddish  color.  In  the  part  less  recently  traversed  the  line  is 
sometimes  a  thin,  elevated,  more  or  less  continuous,  broken  or  bead-like  linear  vesicle 
(as  in  the  appended  illustration);  this  in  the  still  older  part  dries  into  a  thin  crust. 
Sometimes  the  whole  line  is  merely  a  slightly  raised  erythematous  thread-like  formation, 
most  pronounced  at  its  extending  part,  and  fading  away  at  the  older  traversed  part. 

The  parasite  travels  at  the  rate  of  a  fraction 
of  an  inch  to  several  inches  daily  and  seems 
more  active  during  the  night — in  Haase's 
case  it  was  noted  only  at  this  time.  It  may 
take  a  tortuous,  irregular,  or  erratic  course, 
and  even  traverse  a  great  part  of  the  body. 
Exceptionally,  there  is  more  than  one  parasite 
present  (rarely  more  than  two),  as  in  one  of 
my  cases,  giving  rise,  to  a  similar  correspond- 
ing extending  burrow.  The  formation  is  due 
to  a  minute  migrating  larva,  which  Sokolow, 
Samson-Himmelstjerna,  and  Rudell  have 
found.  According  to  Samson  it  is  more 
readily  detected  by  pressing  the  blood  out  of 
the  part  by  means  of  a  flat  piece  of  glass, 
through  which,  with  the  aid  of  a  magnifying 
lens,  the  parasite  can  be  seen  as  a  black 
speck.  In  one  of  my  cases  I  was  able — and 
Rudell  also — to  corroborate  this,  but  I  did 
not  succeed  in  getting  possession  of  the  para- 
site. Rudell  succeeded  by  making  a  small 
flap-like  incision,  with  a  small  cataract  knife, 
directly  in  front  of  the  dark  speck;  on  lifting 
the  flap  the  larva  emerged  from  its  burrow. 
This  malady  is  met  with  most  commonly 
hi  Southern  Russia;  it  is  rare  with  us,  but 
during  the  last  several  years  cases  have  been 
recorded,  in  the  order  named,  by  Van  Har- 
lingen,  myself,  Hamburger,  Shelmire,  and 
others.  In  almost  all  cases  the  starting-point 

of  the  lesion  is  on  those  parts  most  exposed  to  inoculation  and  invasion — hands  or 
lower  part  of  the  forearm,  the  feet  or  lower  part  of  the  leg,  and  the  buttocks  or  adjacent 
part  of  the  back.  In  all  of  my  4  cases,  and  also  in  some  instances  reported  by  others, 
the  malady  began  at  or  after  a  visit  to  the  sea  or  seashore.  According  to  Sokolow,  the 
parasite,  resembling  the  larva  of  a  fly,  is  i  mm.  in  length,  with  ten  segments,  and  hook- 
lets,  with,  at  the  head-end  apparently,  two  suckers;  he  considered  it  the  larva  of  a 
bot-fly,  or  cestreus,  of  the  genus  Gastrophilus,  probably  of  the  species  haemorrhoidal. 
It  was  also  stated  by  this  observer  that  black  nits  could  be  found  adherent  to  the  hairs 
in  the  neighborhood  of  the  burrow. 

Treatment  usually  advised  consisted  in  excising  or  cauterizing  an  area  around  or 
just  beyond  the  advancing  part.     In  my  cases  I  applied  cataphoretically  a  solution  of 

rate  burrows);  Haase,  Jour.  Cutan.  Dis.,  1910,  p.  393  (i  case,  two  burrows,  dorsum  of 
both  feet;  progress  noted  only  during  night;  good  case  illustration) ;  Rudell,  Jour.  Amer. 
Med.  Assoc.,  July  26,  1913  (2  cases,  i  with  two  burrows,  one  of  which  going  over  the 
eyelid,  crossing  from  the  upper  to  the  lower  lid  during  the  night;  good  illustration). 


Fig.  323. — Creeping  eruption  (larva 
migrans)  in  a  youth  aged  eleven;  there 
was  also  an  active  extending  burrow 
on  the  back. 


GROUND   ITCH  I2OI 

mercuric  chlorid  2  grains  to  the  ounce  (0.13 : 32.)  to  a  i^-inch  area  around  the  advancing 
end  of  the  burrow,  and  applied  a  minute  quantity  of  nitric  acid  to  the  suspected  site 
of  the  parasite,  just  beyond  the  extreme  end  of  the  line;  a  magnifying  glass  should  be 
employed  to  discover  this  point,  as  it  is  slightly  in  advance  of  where  it  appears  to  be  by 
unaided  vision.  These  cases  were  all  cured  within  a  week  by  this  method,  more 
probably  by  the  nitric  acid  than  by  the  cataphoresis.  Hutchins  had  marked  success 
with  the  injection  of  a  few  drops  of  chloroform. 

Craw-craw  is  a  malady  observed  chiefly  on  the  west  coast  of  Africa,  having  to 
some  extent  the  aspects  of  scabies,  which  is  caused  by  nematodes,  according  to  Nielly,1 
a  species  of  the  genus  Leptodera  and  family  anguillulidae,  and  in  Corre's  and  O'Neill's2 
opinion  to  a  kind  of  filaria.  The  fingers  and  forearms  are  always  predominantly,  and 
sometimes  exclusively,  affected.  The  eruption,  as  to  be  inferred  from  its  resemblance 
to  scabies,  consists  of  papules,  vesicles,  and  pustules,  discrete  or  crowded,  and  frequently 
with  considerable  crusting,  and  is  exceedingly  itchy.  There  are  no  cuniculi,  however, 
as  in  scabies,  nor  the  same  peculiar  distribution.  The  parasites  in  craw-craw  can  be 
found  in  the  scrapings  and  in  the  seropurulent  liquid. 

The  disease  is  rebellious  to  treatment,  consisting  of  thorough  cleanliness,  baths, 
removal  of  the  crusts,  and  sometimes  the  curetting-out  of  the  underlying  soft  tissue, 
together  with  the  use  of  parasiticides. 

The  echinococcus  larva,  while  usually  found  affecting  the  internal  organs,  excep- 
tionally gives  rise  (echinococcus  cutis)  to  a  softish,  fluctuating,  semitranslucent,  pro- 
jecting tumor,  somewhat  larger  than  those  of  the  cysticercus.  It  is  seated  in  the  sub- 
cutaneous tissue,  and  has  been  found  more  frequently  in  women.  The  covering  in- 
tegument is  unchanged.  Encapsulation  of  the  parasite  takes  place;  it  perishes  in  one 
or  two  years,  the  tumor  undergoing  calcification.  There  are  no  subjective  symptoms 
except  a  sensation  of  tension  and  heaviness.  According  to  Geber,  the  semitranslucent 
character  of  the  tumor,  its  superficial  seat  and  projection  without  alteration  of  the  skin, 
and  the  fluctuation  are  the  features  of  diagnostic  value;  supplemented  by  exploratory 
incision  and  finding  the  booklets  of  the  parasite.  Treatment  consists  of  extirpation. 

The  distoma  hepaticum,  or  liver-fluke,  has,  according  to  Kiichenmeister,  been 
found  in  the  subcutaneous  tissues  of  human  beings  in  three  instances — one  woman 
and  two  men— giving  rise  to  a  tumor-like  formation.  In  one  the  site  was  the  region 
of  the  ear,  another  the  lower  extremities,  and  the  third  the  trunk.  The  subjective 
symptoms  varied,  being  practically  nil,  in  one  instance  painful,  suggestive  of  the  pain 
of  a  developing  abscess.  Diagnosis  was  possible  only -by  finding  the  distoma. 

Ground  itch3  or  uncinarial  dermatitis,  observed  in  certain  tropical  countries  (also 
called  water-itch,  water-pox,  water-sores,  sore  feet  of  coolies,  panighao;  and  in  Porto 
Rico,  also,  "mazamorro") ,  consists  primarily  of  an  erythematous  or  an  erythemato- 
papular  and  papulo-vesicular  eruption  of  the  feet  due  to  the  irritation  of  these  parts 
by  the  larvae  of  the  hookworm.  Uncinariasis,  ankylostomiasis,  or  hookworm  disease 
(also  known  as  dochmiasis,  tropical  chlorosis),  is,  as  known,  a  serious,  and  when  un- 
treated, often  fatal,  constitutional  malady  characterized  by  depression  of  the  vital 
forces,  profound  anemia  and  inertia.  It  is  due  to  the  intestinal  parasite  (probably  of 
several  varieties)  known  variously  as  uncinaria  duodenalis,  ankylostoma  duodenalis, 

1  Neilly,  Bull,  de  I'acad.  de  med.  de  Paris,  1882,  p.  395. 

2  O'Neill,  Lancet,  1875,  i,  p.  265. 

3  Recent  literature  of  Ground  itch:  Stiles,  "The  Significance  of  the  Hookworm 
Disease  for  the  Texas  Practitioner,"  Trans.  State  Med.  Assoc.  of  Texas,  1903,  p.  353 
(an  excellent,  clear,  and  complete  exposition  and  review);  C.  A.  Smith,  "Remarks  on 
the  Mode  of  Infection  in  Uncinariasis,"  Jour.  Amer.  Med.  Assoc.,  1905,  vol.  xlv,  p.  1142, 
and  ibid.,  1906,  vol.  xlvii,  p.  1693;  Leonard,  "Ankylostomiasis  or  Uncinariasis,"  Jour. 
Amer.  Med.  Assoc.,  1905,  vol.  xlv,  p.  588;  Dubreuilh,  "L'Ankylostomiase  Cutan£e,"  La 
Presse  Med.,  April  15,  1905;  Ashford,  "The  Problem  of  Epidemic  Uncinariasis  in  Porto 
Rico,"  Jour.  Assoc.  of  Military  Surgeons,  Jan.,  1907,  p.  40.     These  various  papers  refer 
to  the  observations  of  Looss,  Sandwith,  Bently,  and  others.     Cole,  "Necator  Ameri- 
canus  in  Natives  of  the  Philippines,"  Philippine  Jour,  of  Sci.,  Manila,  Aug.,  1907. 

76 


1202  PARASITIC  AFFECTIONS 

dochmius  duodenalis,  uncinaria  americana,  necator  americanus,  and  belonging  to  the 
nematode  family  Strongylidae  (Stiles).  It  was  formerly  thought  that  the  larvae  of  the 
uncinaria  found  entrance  by  the  mouth  in  food  or  water,  but  it  is  now  known,  through 
the  observations  and  experiments  of  Looss,  Schaudinn,  Sandwith  and  Smith,  and  others 
that  a  common  mode  of  entrance  is  by  way  of  the  skin  of  the  lower  extremities  in  those 
going  barefooted  in  moist  or  wet,  muddy  and  sandy  soil,  the  eggs  of  the  parasites  finding 
their  way  here  in  the  alvine  discharges  from  affected  persons.  The  cutaneous  disturb- 
ance begins  commonly  as  reddish  spots  or  macules  which  soon  show  papulation  or 
vesicles;  the  latter  may  coalesce  and  form  small  and  large  blebs,  which  rupture  and 
expose  raw,  oozing  surface,  and  often  with  considerable  underlying  swelling  of  the 
parts.  In  some  instances  there  is  a  tendency  to  pustulation,  and  even  sometimes  to  the 
development  of  ulceration.  The  eruption,  which  is  usually  intensely  itchy,  is  frequently 
first  observed  between  the  toes.  It  may  be  limited  to  a  part  of  one  foot  or  may  involve 
both  extensively;  the  toes  and  lateral  parts  are  the  favorite  localities.  With  good  man- 
agement the  cutaneous  disturbance  subsides  in  a  few  weeks,  but  in  those  cases  in  which 
scratching  and  secondary  coccic  infection  occur,  the  eruption  lasts  much  longer  and 
may  extend  somewhat  beyond  its  usual  regional  limit,  and  occasionally  lead  to  obstinate 
ulcerations,  and  exceptionally  to  gangrene.  It  is  not  uncommon  for  a  person  to  have 
several  attacks,  each  due  to  exposure  to  a  fresh  invasion  of  the  larvae. 

The  treatment  of  the  cutaneous  irritation  consists  in  cleanliness,  the  use  of  mild 
antiseptic  lotions  and  ointments,  such  as  are  used  in  the  acute  types  of  eczema  and 
other  types  of  acute  dermatitis;  the  opening  of  vesicles,  blebs,  and  pustules,  and  their 
cleansing  and  disinfection.  Long  soaking  of  the  parts  in  antiseptic  solution,  such  as 
boric  acid  solution  and  weak  corrosive  sublimate  lotions,  is  commended.  The  avoid- 
ance of  going  barefooted  in  the  warm,  rainy  season  is  a  positive  preventive  measure. 
It  is  thought  by  some  observers  that  in  some  of  the  cases  of  so-called  ground  itch  the 
malady  may  be  due  to  bacterial  infection  other  than  that  of  the  hookworm  larva?. 

Trypanosomiasis,1  in  its  advanced  stages  known  as  "sleeping  sickness ,"  results 
from  the  invasion  of  the  body  by  a  minute  flagellate  parasite  through  the  intermediary 
of  a  certain  insect,  belonging  probably  to  the  species  glossina  palpalis.  There  is 
usually  a  variable  irritation  at  the  points  of  cutaneous  puncture  made  by  the  insect, 
through  which  the  trypanosome  gains  entrance  to  the  body;  and  later  at  the  point  or 
points  of  irritation  there  may  arise  a  red  or  violaceous,  furunculoid,  slightly  elevated 
swelling.  After  several  days  these  formations  may  have  disappeared,  leaving  behind 
pigmented  spots  which  gradually  fade  away.  In  other  instances  the  reaction  may  be 
more  intense,  sometimes  with  markedly  inflammatory  symptoms  and  edema.  Appar- 
ently suppuration  does  not  occur.  In  these  more  violent  cases  there  is  considerable 
constitutional  disturbance,  with  lymphangitis  and  adenitis.  The  nucha,  limbs,  knees, 
flanks,  and  axillary  regions  are  the  favorite  sites.  Later,  when  the  systemic  malady  is 
developed,  the  eruptive  phenomena  may  consist  of  itchy  vesicopapular  lesions,  poly- 
morphous urticarial  erythemas,  and  the  more  or  less  diagnostic  polymorphic  erythemas, 
which  assume  the  type  of  erythema  circinata,  the  ring-like  patches  being  sc  metimes 
several  inches  or  more  in  diameter.  The  constitutional  involvement  gradually  be- 
comes severe,  anemia,  nervous,  and  other  like  symptoms  present,  with  mental  and  phys- 
ical lassitude,  and  the  patient  may  succumb.  The  malady  was  for  a  time  thought  to 
be  more  or  less  limited  to  the  dark  race  in  portions  of  Africa,  but  is  now  known  to  occur 
elsewhere,  and  also  among  the  whites. 

In  the  treatment  much  stress  has  been  placed  on  arsenic.  Prophylaxis  is,  however, 
the  important  part  in  the  control  of  the  malady,  protection  from  insects,  etc.  For  the 
cutaneous  symptoms,  antiparasitic  and  mildly  antiseptic  lotions  may  be  employed  when 
required. 

1  Some  recent  literature:  Manson,  "Tropical  Diseases";  Rogers,  "Fevers  in  the 
Tropics,"  1908;  and  Darre,  "Les  symptomes  cutanes  de  la  trypanosomiase  humaine," 
Annales,  1908,  p.  673  (review,  with  many  references). 


SUPPLEMENTARY  SECTION 

FOR  PRESENTATION  OF  A  FEW  DISEASES  OF  THE  ADJOINING 
MUCOUS  MEMBRANES  NOT  ELSEWHERE  CONSIDERED 

THE  mucous  membranes  in  proximity  to  and  adjoining  the  skin  are  quite  frequently 
the  subject  of  diseases  corresponding  to,  and  existing  conjointly  with,  those  of  the 
latter.  These  have,  to  a  great  extent,  been  already  referred  to  in  connection  with  the 
individual  cutaneous  maladies,  such  as  eczema,  lichen  planus,  pemphigus,  erythema 
multiforme,  lupus  vulgaris,  syphilis,  and  others.  It  is  the  purpose  to  describe  here 
briefly  several  other  affections  of  the  tongue,  vermilion  of  the  lips,  and  contiguous 
mucous  membrane  which  come  from  time  to  time  under  dermatologic  inspection.1 
For  other  diseases  of  the  tongue  and  oral  cavity  the  reader  is  referred  to  special  works  on 
the  subject.2 

LEUKOPLAKIA 

Synonyms. — Leukoplakia  buccalis;  Leukokeratosis  buccalis;  Leukoma;  Leuko- 
plasia;  Ichthyosis  linguae;  Tylosis  linguae;  Psoriasis  of  the  tongue;  Smokers'  patches; 
Chronic  superficial  glossitis;  Fr.,  Leucoplasie;  Plaques  opalines;  Plaques  blanches  des 
fumeurs;  Plaques  blanches  de  la  bouche. 

Definition. — A  disease  of  the  mucous  membrane  of  the  buccal  cavity,  commonly 
of  the  tongue,  characterized  by  one,  several,  or  more  rounded,  irregularly  shaped  or 
diffused,  whitish  patches,  often  more  or  less  thickened,  with  sometimes  a  tendency  to 
fissure.  Although  this  not  infrequent  malady  was  occasionally  alluded  to  in  older 
writings,  Bazin  (1866)  and  his  pupil  Debove  were  the  first  to  give  a  clear  description, 
followed  by  the  classic  presentation  by  Schwimmer,3  Vidal,4  Leloir,8  Besnier  and  Doyon.6 
These  and  other  contributions  have  firmly  established  the  individuality  of  the  affection, 
and  demonstrated  that  it  is  not  a  manifestation  of  psoriasis  or  a  symptom  or  conse- 
quence of  syphilis,  but  that  it  may  often  arise  and  exist  independently  of  these  and 
other  maladies. 

Symptoms. — The  earliest  evidence  of  a  leukoplakia  patch  is  a  slightly  increased 
redness,  sometimes  with  a  bluish  tinge,  which  is  often  so  trifling  as  to  be  recognizable 
only  on  close  inspection.  Sometimes  it  has  a  somewhat  thinned  or  abraded  look.  Oc- 
casionally there  is  also  a  scarcely  perceptible  accentuation  of  the  papillae,  peripherally 
as  well  as  less  commonly  on  the  surface  of  the  spot  itself.  At  this  time  there  is  often 
some  sensitiveness  to  hot  and  acid  foods.  This  stage  of  the  malady,  which  lasts  a 
variable  time  of  weeks  or  months,  frequently  escapes  observation,  the  first  sign  recog- 

1  Fordyce,  "Some  Affections  of  the  Oral  and  Nasal  Cavities  which  Are  Related  to 
Skin  Diseases,"  New  YorkMed.  Jour.,  March  6,  1909,  p.  465,  gives  a  serial  review  of 
these  and  other  various  conditions  showing  mucous  membrane  involvement. 

2  See  the  admirable  and  largely  illustrated  monographs  by  Butlin  and  Spencer,  Dis- 
eases of  the  Tongue,  Cassell  and  Company;  Mikulicz  and  Kiimmel,  Die  Krankheiten 
des  Mundes,  Jena;  and  Zinsser,  Diseases  of  the  Mouth  (translated  and  edited  by  J.  B. 
Stein,  Rebman  Co.,  New  York). 

3  Schwimmer,  Archiv,  1877,  p.  511  (with  review  of  the  subject,  references,  and  4 
colored  case  illustrations). 

4  Vidal,  Union  med.,  1883,  vol.  xxxv,  pp.  i  and  37. 

6  Leloir,  Arch,  de  Physiolog.,  1887,  vol.  x,  p.  86  (with  6  colored  histologic  illustra- 
tions) . 

6  Besnier  and  Doyon's  French  translation  of  Kaposi's  treatise. 

1203 


I2O4  SUPPLEMENTARY  SECTION 

nized  being  the  white  or  opaline  spot  into  which  it  slowly  evolves.  This  consists  of  a 
rounded,  ovalish,  or  irregularly  shaped  patch  of  a  faint  pearly,  bluish-white,  or  pale 
milk  color,  usually  on  a  level  with  the  surrounding  surface,  from  which  it  is  sometimes 
bounded  by  a  narrow  line  of  hyperemia.  Instead  of  a  well-defined  area,  it  quite  often 
first  presents  as  one,  several,  or  more  short  or  long,  straight  or  crooked,  pale  white 
lines,  which  may  be  close  together  and  more  or  less  parallel,  of  the  same  or  different 
lengths;  or  instead  of  lines  there  may  be  scattered  or  grouped  pin-head-  to  small  pea- 
sized  white  spots.  Contiguous  lines,  points,  or  spots  may  gradually  coalesce  and  form 
larger  areas.  There  may  also  be  slight  papillary  hypertrophy.  This  stage  of  the 
malady  mav  continue  for  some  time  or  almost  indefinitely,  generally  with  a  tendency  to 
trifling  thickening  of  the  affected  membrane.  There  may  be  a  tendency  to  trifling 
exfoliation.  It  is  not  uncommon,  moreover,  to  find  the  affected  surface,  as  well  as 
other  parts  of  the  tongue,  traversed  to  a  variable  degree  with  superficial  or  deep  trans- 


Fig.  324. — Leukoplakia,  of  slight  development,  chiefly  short  streaks  and  small  spots, 
in  a  man  aged  fifty,  of  several  years'  duration;  also  a  pale,  somewhat  diffused,  milky 
color  of  the  main  portion  of  the  tongue,  and  some  furrowing;  contracted  syphilis  when 
aged  thirty-five,  but  has  had  no  manifestations  for  years. 

verse  and  longitudinal  grooves.  These  are  the  so-called  "smoker's  patches,"  although 
this  term  is  likewise  applied  to  the  more  advanced  types  also.  The  extent  involved 
may  be  small,  but  one  or  several  patches  being  seen,  or  a  greater  part  of  the  tongue,  or 
of  the  inside  of  the  cheeks  or  other  parts  of  the  oral  cavity,  may  be  involved.  In  ad- 
vancing cases  the  symptoms  become,  in  the  course  of  months  or  several  years,  slowly 
more  pronounced,  the  submucosa  variably,  often  considerably,  thickened,  the  surface 
rough,  rugous,  and  desquamating,  with  often  a  tendency  to  superficial  cracks  through 
the  dry,  hardened  white  epithelial  coating.  The  affected  area  is  stiff  and  less  elastic 
than  the  unaffected  parts.  New  spots  usually  present  after  variable  periods,  going 
through  the  various  phases  already  outlined.  In  many  instances  after  a  certain  stage 
or  extent  is  reached  the  malady  continues  at  a  stand,  or  progresses  so  slowly  that  prac- 
tically but  little  change  is  noted  from  month  to  month  or  even  year  to  year.  The  corni- 
fied,  somewhat  firmly  adherent  epithelium  is  rough,  exfoliates,  usually  in  small  frag- 


LEUKOPLAKIA 


I2O5 


ments,  from  time  to  time;  it  can  be  partly  removed  only  with  great  difficulty.     In  other 
cases  the  plaques  spread,  become  much  thicker,  rougher,  and  even  nodular,  with  short 


Fig.  325. — Leukoplakia  of  extensive  development,  in  a  man  aged  forty-five,  and  of 
eight  years'  duration;  has  been  subject  of  psoriasis  for  twelve  years;  never  had  syphilis 
(Schwimmer). 

or  long  cracks,  extending  more  or  less  deeply,  and  in  places  amounting  almost  to  super- 
ficial ulceration,  giving  rise  sometimes  to  considerable  pain  and  discomfort.  Slight 
bleeding  may  occur  now  and  then.  The  disease  may  occupy  considerable  surface.  In 


Fig.  326. — Leukoplakia,  with  development  of  epitheliomatous  changes;     patient  aged 

sixty-five. 

still  less  favorable  instances  the  deep  fissures  change  to  ulcerations,  show  considerable 
infiltration,  and  gradually,  sometimes  rapidly,  develop  into  epithelioma,  which  in  the 


1206  SUPPLEMENTARY  SECTION 

graver  cases  sooner  or  later  passes  rapidly  into  a  malignant  type,  with  fatal  termfna- 
tion.  As  in  the  earlier  stages,  there  is  in  most  instances  in  the  well-developed  malady 
sensitiveness  to  hot  and  irritating  substances.  The  region  most  commonly  the  seat  of 
leukoplakia  is  the  tongue,  especially  the  dorsal  surface,  anteriorly  and  laterally,  but  it 
may  occur  on  any  or  all  sections  of  this  organ,  and  involve  a  portion  or  the  greater  part 
of  it.  The  inside  of  the  cheek  is  another  favorite,  but  less  frequent,  situation,  and  the 
inner  aspect  of  the  lips,  and  even  the  vermilion  border,  especially  at  the  commissures, 
may  likewise  be  occasionally  its  site.  Other  mucous  surfaces,  as  of  the  vulva,  and  even 
the  glans  penis  (Krauss,  Planz),1  are  exceptionally  the  seat  of  similar  formation.  I 
have  met  with  one  instance  in  which  it  was  limited  to  the  urethral  orifice,  verging  \  inch 
on  to  the  glans,  and  one  involving  chiefly  the  prepuce,  with  hardening  and  contraction 
(kraurosis). 

Etiology  and  Pathology. — The  causes  of  leukoplakia  are  not  clearly  established. 
It  is  very  rare  in  women,  and  is  with  some  exceptions  a  development  of  middle  life. 
Syphilis  has  always  been  considered  of  etiologic  import,  but  it  occurs  frequently  enough 


Fig.  327. — Leukoplakia — well  marked  on  lower  lip,  slight  on  tongue. 

in  non-syphilitics  to  call  this  in  question.  Most  of  one's  patients  with  leukoplakia,  it  is 
true,  have  had  syphilis,  but  such  subjects  naturally  suspect  any  manifestations,  and 
immediately  seek  advice,  while  those  free  from  guilt  in  this  direction  are  much  less 
solicitous.  Both  Debove  and  Schwimmer  met  with  instances  of  the  disease  in  those 
who  subsequently  acquired  syphilis.  It  is  not  improbable  the  mercurial  treatment  of 
syphilis  may,  by  its  invoking  a  mild,  and  though  often  scarcely  perceptible,  stomatitis, 
be  a  factor  of  some  influence.  There  is  no  doubt  about  the  aggravating  influence 
of  smoking,  and  so  evident  is  this  that  this  practice  has  been  considered  etiologic. 
While  its  damaging,  and  probably,  under  some  circumstances,  its  causative,  action 
cannot  be  denied,  yet  the  fact  remains  that  the  malady  is  also  seen  in  those  not  addicted 

1  Krauss,  Archiv,  1907,  vol.  Ixxxv,  p.  137;  Planz,  "Ueber  idiopathische  Schleim- 
hauteleukoplakien  mit  besonderer  Beriicksichtigung  der  Leukoplakia  Penis,"  Dermato- 
log.Zeitschr.,  1909,  pp.  619,  710  (2  cases;  review,  and  full  bibliography);  Bohac,  "Ueber 
Leukoplakia  und  Kraurosis  der  Schleimkaut  und  der  Haut,"  Archiv,  Jan.,  1911,  cv,  p. 
1 79  (3  cases  involving  glands  and  prepuce;  i  case  in  woman,  involving  mucous  mem- 
brane of  the  lip,  with  extension  to  the  skin;  general  survey  and  review). 


I2O/ 

to  this  habit.  It  has  often  been  looked  upon  as  a  psoriasis  and  is  sometimes  seen  as- 
sociated with  this  malady,  but  it  is  also  seen  in  association  with  similar  scaly  and  other 
skin  eruptions,  attended  with  increased  cornification;  Schiitz1  observed  leukoplakia  in 
2  cases  of  tylosis  and  in  5  of  scaly  eczema.  Whatever  may  be  the  essential  initiative 
cause,  there  is  no  difference  of  opinion  as  to  the  aggravating  and  contributory  influence 
of  smoking,  strong  alcoholic  drinks,  hot,  highly  seasoned,  irritating,  and  acid  foods. 
Sharp,  rough,  and  decaying  teeth  are  also  to  be  considered  contributory.  A  factor  of 
considerable  import  in  my  experience  is  gastric  or  gastro-intestinal  catarrh.2 

The  anatomic  changes  have  been  studied  by  most  of  the  various  observers  already 
named,  and  by  Fordyce,  Pollitzer,  Heidingsfeld,  and  others.  There  is,  as  is  to  be  ex- 
pected, but  little  divergence  in  the  findings,  although  it  is  held  by  some  that  the  earliest 
changes  are  in  the  superficial  epithelium,  and  by  others  that  these  are  secondary  to  an 
inflammatory  process  in  the  papillary  region.  There  is  found  keratosis,  with  marked 


Fig.  328. — Leukoplakia,  showing  keratosis  of  the  superficial  layers  of  epithelium, 
and  marked  inflammatory  changes  in  the  subepithelial  tissues  (courtesy  of  Dr.  J.  A. 
Fordyce). 

thickening  of  the  superficial  layers,  thickening  of  the  deeper  strata,  and  down-growth 
of  the  epithelial  processes,  and  in  places  there  may  be  more  or  less  obliteration  of  the 
papillae,  with  the  subepithelial  tissue  showing  inflammatory  changes  and  infiltration 
of  round  cells.  Finally,  sclerotic  changes  may  ensue  in  the  submucous  and  deeper 
layers.  Leloir  found  that  the  epitheliomatous  changes  started  from  the  ulcerations 
and  not  from  the  unbroken  hyperkeratotic  parts.  Fordyce's3  examinations  in  instances 
of  epitheliomatous  development  showed  the  new  growth  to  belong  to  the  tubular  epi- 

1  Schiitz,  "Ueber  Leukoplakia  oris  bei  Psoriasis  und  anderen  Dermatosen,"  Archiv, 
1898,  vol.  xlvi,  p.  433  (a  good  review  with  pertinent  bibliography);  Filaretopoulo,  Jour, 
mal.  Cutan.,  1905,  p.  81,  also  refers  to  the  varied  causes  or  associations. 

2  Hertzka,  Deutsche  med.  Wochenschr.,  1880,  vol.  vi,  p.  154,  met  with  the  disease 
in  several  women  in  whom  gastro-intestinal  catarrh  seemed  etiologic. 

3  Fordyce,  Morrow's  System,  vol.  iii,  (Dermatology),  p.  626. 


I2O8  SUPPLEMENTARY  SECTION 

theliomata,  with  but  little,  if  any,  disposition  to  the  formation  of  horny  tissue.  Heid- 
ingsfeld,1  in  a  case  of  long  duration,  showing  as  yet  apparently  no  degenerative  changes, 
found  the  leukoplakic  condition  to  be  distinctly  pre-epitheliomatous  in  character — 
marked  proliferation  and  down-growth  of  the  epidermis  and  areas  of  degeneration,  with 
a  nest-like  arrangement  of  the  epithelium;  a  good  wall  of  connective  tissue  separated  it 
from  underlying  structures. 

Diagnosis. — The  beginning  features,  the  history,  and  slow  persistent  course  are 
characteristic.  Leukoplakia  of  the  tongue  is  readily  recognized.  It  might  possibly 
be  confused  with  the  mucous  patch  of  early  syphilis,  but  there  is  in  the  latter  no  tend- 
ency to  epithelial  hardening,  but,  on  the  contrary,  it  is  usually  soft,  with  the  surface 
film  generally  easily  removed  and  a  disposition  to  superficial  abrasion,  and  not  infre- 
quently to  more  or  less  ulcerative  action.  The  mucous  patch  is,  moreover,  of  rapid 
formation,  with  commonly,  therefore,  even  though  well  developed,  a  history  of  short 
duration.  Other  symptoms  of  syphilis  will,  as  a  rule,  be  found.  Lichen  planus 
patches  on  the  inside  of  the  cheeks,  a  somewhat  rare  occurrence,  may  bear  a  suggestive 
resemblance,  but  they  tend  to  present  in  irregular  streaks  or  peculiar  shape,  especially 
on  other  parts  of  the  mouth;  in  addition,  lichen  planus  is  rarely,  if  ever,  for  any  length 
of  time  at  least,  limited  to  this  region,  but  when  occurring  there,  it  is  almost  invariably 
with  the  eruption  on  some  part  of  the  cutaneous  surface. 

Prognosis  and  Treatment. — When  well  developed,  the  malady  is  persistent  and 
rebellious.  In  the  early  stage  of  some  cases  abstention  from  smoking  and  irritating 
foods  and  drinks  will  halt  its  advance  and  sometimes  promote  its  disappearance.  The 
possibility  of  malignant  development  is  to  be  kept  in  mind.  In  the  treatment  of  the 
disease  in  its  earliest  existence  the  prevention  of  irritation  from  food,  drink,  or  sharp  or 
decayed  teeth,  together  with  the  maintenance  of  good  digestion  and  free  action  of  the 
bowels,  will  often  accomplish  much,  or  at  all  events  not  infrequently  stay  its  progress. 
The  occasional  use  of  mildly  astringent  and  antiseptic  mouth- washes  is  found  of  service. 
At  this  period  application  every  day  or  two  with  glycerite  of  tannic  acid,  and  every  two 
or  three  weeks  with  silver  nitrate  stick,  will  sometimes  prove  beneficial.  When  epi- 
thelial thickening  has  taken  place,  the  same  general  plan  can  be  advised,  but,  as  a  rule, 
no  decided  betterment  is  possible  except  from  active  cauterizing  applications.  These, 
if  employed,  however,  should  be  used  boldly  and  thoroughly,  otherwise  there  is  likely 
to  result  more  harm  than  good.  There  seems  to  be  considerable  unanimity  as  to  the 
value  of  thermocauterization,  preferably  with  the  galvanocautery.  The  latter  has 
been  in  my  hands  of  decided  value  in  several  instances.  Vidal's  favorite  application 
was  a  20  per  cent,  solution  of  chemically  pure  chromic  acid,  and  this  is  also  employed 
by  others.  Sherwell2  strongly  commends  the  thorough  and  prolonged  application  of 
liquor  hydrargyri  nitratis,  the  surrounding  parts  being  protected  by  absorbent  cotton. 
Unna,  Leistikow,  and  Schiff3  speak  well  of  the  application  of  a  resorcin  peeling  paste, 
such  as  is  used  in  acne,  a  thin  coating  being  smeared  over  daily  until  exfoliation  occurs, 
and  the  treatment  repeated  at  intervals  of  a  week  or  so. 

Bockhardt4  states  that  if  patients  will  abstain  from  smoking  he  can  bring  about 
a  cure  with  an  application,  daily  or  every  other  day,  of  balsam  of  Peru,  and  frequently 
repeated  (6  to  12  times  daily)  washing  out  of  the  mouth  with  a  \  to  3  per  cent,  salt 
solution;  cure  takes  three  months  to  two  years,  according  to  the  case. 

As  to  constitutional  treatment,  there  is  a  difference  of  opinion  as  to  the  value  of 
antisyphilitic  remedies  in  those  cases  with  a  previous  syphilitic  history,  and  most 
observers  are  inclined  to  consider  it  of  but  little,  if  any,  value,  and  that  it  may  be  even 
detrimental.  With  a  few  exceptions  they  have  proved  valueless  in  my  experience.  In 
such  instances,  however,  when  the  disease  has  developed  but  a  few  years  after  the  con- 

1  Heidingsfeld,  "Trans.  Cincinnati  Acad.  Med.,"  Amer.  Medicine,  March  23,  1901, 
P-  834-  2  Sherwell,  Jour.  Culan.  Dis.,  1899,  p.  185. 

3  Schiff,  Wien.  klin.  Rundshau,  1895,  p.  113. 

4  Bockhardt,  Monatshefte,  1902,  vol.  xxxiv,  p.  164. 


TRANSITORY  BENIGN  PLAQUES- OF  THE    TONGUE      I2OQ 


traction  of  syphilis,  and  is  of  rapid  development,  and  especially  in  those  in  which  jthere 
is  a  suspicion  that  some  of  the  infiltration  maybe  of  a  gummatous  nature,  these  remedies, 
especially  potassium  or  sodium  iodid,  should  be  tried.  In  the  aggregate  of  cases  I 
believe  much  more  is  to  be  accomplished  by  remedies  directed  toward  any  digestive 
or  catarrhal  gastro-intestinal  disturbance  that  may,  and  frequently  does,  exist. 

FURROWED  TONGUE 

Synonyms. — Grooved  tongue;  Wrinkled  tongue;  Sulcated  tongue;  Cleft  tongue; 
Fluted  tongue;  Ribbed  tongue;  Scrotal  tongue;  Lingua  plicata;  Fr.,  Langue  plissee; 
Langue  montagneuse;  Langue  scrotale;  Ger.,  Gelappte  Zunge. 

Furrowed  tongue  is,  in  most  instances,  a  condition  to  which  some  families  seem 
especially  prone.  It  is  seen  on  the  dorsal  surface,  and  may  consist  simply  of  the  deep- 
ening of  the  central  furrow,  common  to  many  persons,  with  one  or  several  less  distinct 
parallel  linear  depressions,  or  they  may  be  so  numerous  and  deep  as  to  present  a  verita- 
ble network  of  lines,  depressions,  and  correspond- 
ing elevations.  When  there  is  a  natural  or  ac- 
quired enlargement  (macroglossia)  of  this  organ, 
and  the  furrows  are  irregularly  longitudinal, 
transverse,  curved,  and  forked,  the  general 
aspect  may  be  suggestive  of  a  miniature  of 
crowded  valleys  and  mountains  or  sometimes  of 
the  convolutions  of  the  brain.  The  surface  of 
the  depressions  or  clefts  is  usually  smooth  and 
free  from  fur.  When  deep,  there  is  a  tendency 
from  time  to  time  for  minute  particles  of  food  to 
collect  in  them,  undergo  change,  and  produce 
irritation. 

The  condition,  especially  in  its  milder  phases, 
is  not  very  rare.  It  is  in  some  cases  congenital, 
with  a  family  tendency,  but  is  rarely  of  marked 
development  in  infancy  or  early  childhood.  In 
others  it  appears  later  in  life,  spontaneously  or  as 
the  result  of  irritating  influences  and  of  various 
forms  of  glossitis  and  other  diseases,  some  of 
which  may  be  due  to  syphilis,  hereditary  or  ac- 
quired. Their  formation  is  sometimes  partly  owing  to,  and  made  more  pronounced 
by,  oversize  of  the  tongue,  the  organ  kept  somewhat  crowded  in  its  natural  bed. 

Excepting  the  appearances  and  the  occasional  irritation  due  to  the  collection  of 
food-particles  in  the  crevices,  and  the  possibility  of  the  irritation  thus  repeatedly  pro- 
duced being  the  starting-point  of  epithelioma,  the  affection  has  no  significance.  Treat- 
ment is  rarely  sought,  but  in  order  to  guard  against  the  possible  consequences  men- 
tioned, it  is  important  that  the  mouth  and  tongue  should  be  kept  clean,  using  water 
freely,  and  from  time  to  time  mild  antiseptic  solutions,  such  as  one  of  boric  acid  and 
myrrh,  the  furrows  and  crevices  being  separated  so  as  to  permit  of  thorough  cleansing. 

TRANSITORY  BENIGN  PLAQUES  OF  THE  TONGUE 

Synonyms. — Exfoliatio  areata  linguae;  Pityriasis  lingua-;  Annulus  migrans; 
Glossitis  areata  exfoliativa;  Erythema  migrans;  Wandering  rash;  Ringworm-like 
patches  of  the  tongue;  Circinate  eruption  of  the  tongue;  Fr.,  Desquamation  aberrant 
en  aires  de  la  langue;  Desquamation  epitheliale  de  la  langue  (Gautier);  Glossite  exfoli- 
atrice  marginee  (Fournier,  Lemonnier);  Lichenoide  lingual  (Gubler,  Vanlair);  Eczema 
en  aires  de  la  langue  (Besnier);  Eczema  margine'e  desquamitif  de  la  langue;  Ger., 
Fliichtige,  gutartige  Plaques  der  Zungenschleimhaut  (Caspary);  Landkartenzunge. 

Brief  mention  or  account  of  this  rare  and  strange  affection  is  to  be  found  some 
years  back,  but  it  was  not  until  the  more  recent  clear  and  fuller  descriptions  by  Bridou, 


Fig.  329. — Furrowed  tongue, 
with  a  moderate  degree  of  macro- 
glossia. 


1210  SUPPLEMENTARY  SECTION 

Gubler,  Caspary,  Vanlair,  Barker,  Gautier,  Unna,  Colcott  Fox,  and  others  that  the 
matter  excited  much  attention.  In  our  own  country  there  is  scant  literature,  cases 
having  been  reported  by  Kinnier,  Hartzell,  and  Allen.1 

Symptoms. — The  malady  shows  itself  as  one  or  several  small,  pin-head-sized, 
grayish,  well-defined,  slightly  elevated  spots,  of  vesicular  aspect,  on  the  dorsum  of  the 
tongue  and  most  commonly  laterally  and  toward  the  tip.  Exceptionally,  as  in  one  of 
Caspary's  cases  here  pictured,  the  under  surface  is  also  the  seat  of  lesions.  The  patches 
spread  peripherally,  the  central  part  tending  to  superficial  exfoliation  or  desquamation, 
and  becoming  moderately  or  markedly  reddened,  often  glossy,  and  sometimes  present- 
ing the  appearance  of  a  slight  abrasion,  and  with  apparently  trifling  depression.  The 
patch  is  frequently  of  a  brighter  red  toward  the  border.  The  peripheral  spreading 
portion  exhibits  the  grayish,  pseudovesicular  aspect  of  the  beginning  central  point. 
Sometimes  there  is  a  yellowish  hue  to  the  border,  and  sometimes  bluish,  but  generally  it 
is  grayish,  and  even  silvery  white.  Exceptionally,  the  spot  is  without  the  yellowish 
or  whitish  border.  A  patch  ordinarily  reaches  the  diameter  of  |  inch,  frequently 
greater,  and  then  begins  to  disappear,  the  central  portion  first  resuming  the  natural 
appearance.  From  one  or  two  to  ten  days  or  more  is  commonly  required  for  a  patch 
to  present,  run  its  course,  and  disappear,  and  marked  development  and  changes  can 
occur  in  several  hours.  In  many  instances  but  one  or  two  such  areas  are  present  at  one 
time,  new  ones  appearing  from  week  to  week  or  month  to  month  as  the  old  spots  fade, 
and  thus  the  malady  may  continue  indefinitely.  There  are,  however,  generally  periods 
of  variable  duration  when  the  tongue  remains  entirely  free  from  manifestations. 
When  several  are  to  be  seen,  from  enlargement,  coalescence  may  result,  and  a  peculiar 
appearance  be  presented,  giving  rise  to  the  term  "geographic  tongue"  (lingua  geograph- 
ica). 

The  plaques  are  usually  well  rounded,  occasionally  being  somewhat  irregular,  the 
irregularity  being  doubtless  due,  as  suggested  by  Unna,  to  the  fusing  of  closely  contigu- 
ous beginning  points  at  various  parts  of  the  border.  Guinon  saw  i  instance  in  which  a 
plaque  was  more  or  less  diffused  along  the  median  line.  Spots  near  the  side  of  the 
tongue  sometimes  finally  become  segmental  or  half-moon  shaped,  extension  ceasing 
at  the  edge  of  the  organ,  although  they  may  go  beyond  on  to  the  under  surface.  As  a 
rule,  the  areas  are  not  sore  or  painful,  and  give  rise  to  no  discomfort.  Occasionally,  as 
a  ring  becomes  large,  a  new  one  forms  at  the  central  parts,  and  in  exceptional  cases  a 
patch  may  show  two  or  three  concentric  rings.  The  filiform  papillae  are  sometimes 
shed,  but  the  f ungiform  papilla?  may  remain  and  even  appear  more  prominent  by  reason 

1  Literature:  Bridou,  "Sur  une  affection  innominee  de  la  muqueuse  linguale  (etat 
lichSnoide  de  M.  Gubler),"  These  de  Paris,  1872;  Gubler,  Diet,  encycl.  d.  Sci.  med., 
Paris,  1869,  vol.  i,  p.  211,  and  ibid.,  1876,  vol.  x,  p.  234;  Alibert,  Gaz.  des  hop.,  1875,  p. 
806;  Caspary,  Archiv,  1880,  p.  183  (with  colored  plate) ;  Vanlair,  Revue  men.  de  med.  et  de 
Chirurg.,  1880,  vol.  iv,  pp.  51  and  227  (with  review  and  some  references);  Barker, 
London  Path.  Soc'y  Trans.,  1880,  vol.  xxxi,  p.  353,  and  Holmes  and  Hulke's  Syst.  of 
Surg.,  third  edit.,  1883,  ii,  p.  560;  Gautier,  Revue  med.  de  la  stiisse  romand.,  1881,  p.  589 
(with  review  and  references);  Parrot,  Progres  med.,  1881,  p.  191  (31  cases);  Unna, 
Archiv,  1881,  p.  295  (12  cases);  Lemonnier,  "De  la  glossite  exfoliatrice  marginee," 
These  de  Paris,  1883  (with  bibliography  to  date);  Colcott  Fox,  Lancet,  1884,  i,  p.  842 
(10  cases;  gives  the  earliest  literature);  Butlin,  Diseases  of  the  Tongue,  1885;  Kaposi, 
Wien.  med.  Presse,  1885,  p.  361;  Guinon,  Rev.  mens.  de  mal.  de  I'enfance,  1887,  p.  385 
(6  cases);  Kinnier,  Jour.  Cutan.  Dis.,  1887,  p.  56;  Hartzell,  Med.  News,  1887,  vol.  Ii, 
p.  502;  Mibelli,  Giorn.  ital.,  1888,  p.  383;  Molenes,  Arch,  de  laryngol.,  1889,  vol.  ii, 
p.  326  (full  review  with  bibliography);  Bayet,  Clinique,  Brussels,  1889,  vol.  iii,  p.  657; 
Besnier,  Annales,  1889,  p.  320  (case  demonstration);  Hutchinson,  Arch,  of  Surg., 
1892-93,  vol.  iv,  p.  156;  Allen,  Jour.  Cutan.  Dis.,  1897,  p.  159  (case  demonstration); 
Du  Castel,  Annales,  1897,  p.  482  (case  demonstration);  Colleville,  Gaz.  hebdom.,  1898, 
p.  277;  Mikulicz  and  Kiimmel,  Die  Krankheiten  des  Mundes,  Jena.  1898,  p.  120  (a  good 
illustration);  Bohm,  Sammlung.  klin.  Vortrage,  Leipzig,  1899,  No.  249  (innere  Medicin, 
No.  75),  p.  1467  (a  clear  and  exhaustive  review);  Butlin  and  Spencer,  Diseases  of  the 
Tongue,  1900,  p.  94  (with  colored  plate). 


TRANSITORY  BENIGN  PLAQUES   OF  THE    TONGUE      1 21 1 


of  their  isolation  (Butlin  and  Spencer).  In  most  instances  there  have  been  practically 
no  subjective  symptoms,  but  itching  is  occasionally  noted,  and  in  Barker's  2  cases  it 
was  quite  marked,  and  associated  with  increased  salivary  flow. 

Etiology  and  Pathology. — The  malady  is  rare.  It  is  most  frequent  in  children 
under  the  age  of  two  years;  Parrot's  31  cases  were  under  six,  Guinon's  6  under  four,  Col- 
cott  Fox's  10  under  five.  The  2  cases  under  my  own  observation  were  under  four. 
It  is,  however,  seen  in  older  children  and  also  in  adults  (Vanlair,  Lailler,  Unna,  Hartzell, 
Besnier,  Molenes,  Allen,  Paget),  in  the  latter  much  more  frequently  than  formerly 
thought.  Of  Unna's  14  cases,  12  were  adults.  Hartzell's  patient  was  aged  forty-two, 
and  i  of  Vanlair's  sixty-six.  It  is  met 
with  in  both  sexes. 

The  cause  of  the  disease  is  not 
known.  Parrot  looked  upon  it  as  syphilis, 
but  his  experience  was  with  foundlings, 
and  he  was  inclined  to  look  upon  most 
obscure  affections  as  of  suspicious  nature. 
Fournier  is  disposed  to  class  it  among  the 
indirect  consequences  of  syphilis — among 
his  parasyphilides.  Almost  all  others 
(Vanlair,  Lemonnier,  Vidal,  Caspary, 
Besnier,  Unna,  Du  Castel,  Molenes, 
Hartzell,  Butlin  and  Spencer,  and  others) 
hold,  and  properly,  I  believe,  that  it  is 
in  no  way  related  to  syphilis.  In  my 
own  cases  there  was  not  a  suspicion  of 
such  cause.  Moreover,  both  Unna  and 
Du  Castel  met  with  patients  who  con- 
tracted syphilis  after  the  spots  had  pre- 
sented. Gastro-intestinal  disturbance  is 
looked  upon  (Gubler,  Bergeron,  Vanlair, 
Colcott  Fox,  Molenes,  Hartzell,  and 
others)  by  most  observers  as  of  etiologic 
influence,  and  such  appeared  to  be  of 
import  in  my  patients.  Others,  especially 
Unna,  consider  it  a  malady  of  tropho- 
neurotic  origin.  Unna,  Barker,  and  Cas- 
pary have  seen  it  in  delicate  children. 
Spencer's  case  developed  after  scarlet 
fever,  and  in  Bergeron's  hospital  intern 
during  convalescence  from  typhoid. 
Besnier  views  it  as  a  form  of  eczema, 
having  seen  it  associated  with  seborrheic 
eczema  of  the  integument.  The  appear- 
ance and  manner  of  spread  have  sug- 
gested ringworm,  and  Barker  found  a 
fungus  in  i  case  which  both  he  and 
Hutchinson  thought  resembled  the  trichophyton,  but  this  is  the  only  instance,  all 
others  having  failed  to  find  any  special  organism.  Kinnier  saw  these  tongue  spots  as- 
sociated with  ringworm  patches  on  the  skin.  The  evanescence  and  behavior  of  the 
areas,  as  well  as  their  persistent  recurrence  and  the  failure  to  find  fungus  elements,  seem 
conclusive  against  this  view.  A  hereditary  or  family  tendency  has  sometimes  been 
noted;  the  mother  of  one  of  Bridou's  patients  had  it  in  childhood;  Colcott  Fox  saw 
it  in  a  brother  and  sister;  Caspary  observed  it  in  2  instances  in  two  children  in  the 
same  family;  Gubler  has  seen  a  whole  family  affected.  In  one  of  Hutchinson's 


Fig.  330. — Transitory  benign  plaques  of 
the  tongue  (Caspary). 


1 2 12  SUPPLEMENTARY  SECTION 

patients  the  other  members  of  the  family  had  a  tendency  to  sores  on  the  lips  and  in 
the  mouth. 

According  to  Parrot,  the  epithelium  is  found  tumefied  and  thickened,  and  the  cells 
of  the  horny  and  Malpighian  layers  augmented,  those  of  the  latter  showing  signs  of 
proliferation;  lymphoid  cells  were  found  in  the  papillae  and  about  the  vessels  in  the 
subjacent  derma.  Unna  states  it  to  be  an  epithelial  disease,  with  its  seat  quite  super- 
ficial in  the  horny  layer. 

Diagnosis. — This  is  a  matter  of  no  difficulty,  as  the  superficial  character,  their 
well-defined  outline,  with  the  reddish,  sometimes  desquamating,  central  portion,  and 
the  usually  grayish  or  yellowish  border,  when  taken  together  with  the  history,  the 
rapidity  of  their  formation,  capriciousness,  and  recurrence,  will  serve  to  differentiate 
from  syphilitic  mucous  patches,  aphthae,  and  leukoplakia. 

Prognosis  and  Treatment. — The  malady,  while  benign,  is  generally  persistent, 
although  in  children  it  seems,  in  most  instances,  to  tend  to  spontaneous  disappearance 
as  they  grow  older.  It  is  ordinarily  rebellious  to  treatment,  although  a  careful  super- 
vision of  the  dietary  and  the  maintenance  of  good  digestion  and  free  action  of  the 
bowels  will  often  have  a  material  influence.  In  feeble  subjects  tonics  and  cod-liver  oil 
may  be  of  service.  Hartzell  found  in  his  case  arsenic,  also  commended  by  Vanlair  and 
Brocq,  lengthened  the  intervals  between  the  attacks.  Mildly  astringent  and  antiseptic 
mouth-washes  are  commonly  prescribed.  Besnier  advises  applications  of  boric  acid 
ointment  made  with  vaselin  and  with  the  addition  of  balsam  of  Peru.  Unna  states 
that  he  has  had  most  satisfaction  from  sulphur  applications.  The  most  convenient 
for  this  purpose  is,  as  Benard  suggests,  the  natural  sulphur  water,  although  Unna 
employs  emulsive  liquids  containing  washed  sulphur.  In  my  2  cases  the  most  benefit 
seemed  derived  from  attention  to  digestion  and  the  occasional  administration  of  a  laxa- 
tive of  antacid,  such  as  calcined  magnesia,  together  with  a  myrrh  and  boric  acid  mouth- 
wash. 

BLACK  TONGUE1 

Synonyms. — Hairy  tongue;  Lingua  nigra;  Hyperkeratosis  linguae;  Fr.,  Langue  noire; 
Nigritie  de  la  langue;  Hypertrophie  epitheliale  filiforme;  Langue  noire  pileuse;  Ger., 
Haarzunge;  Schwarze  Haarzunge. 

This  curious  malady  is  rare,  although  probably  not  so  much  so  as  commonly  be- 
lieved, inasmuch  as  it  practically  gives  rise  to  no  trouble,  and  sooner  or  later  passes 
away  spontaneously.  The  usual  situation  is  immediately  in  front  of  the  circumvallate 
papillae,  although  exceptionally  on  other  parts  of  the  tongue;  in  Curtis'  patient  the 
patch  was  behind  these  papillae,  and  in  Lediard's  and  Eve's  near  the  end,  and  in  Lake's 
at  the  left  side,  middle  third.  The  color  is  generally  black,  but  in  an  instance  observed 

literature:  Dessois,  De  la  langue  noire  (Glossophytie),  Paris,  1878;  Hutchinson, 
Med.  Press  and  Circular,  1883,  ii,  p.  20;  Stokes,  London  Path.  Soc'y  Trans.,  1884,  vol. 
xxxv,  p.  157;  Lediard,  ibid.,  1886,  vol.  xxxvii,  p.  222  (brief  note);  Roth,  Wien.  med. 
Presse,  1887,  pp.  935  and  987  (2  cases);  Brosin,  "Ueber  die  schwarze  Zunge,"  Ham- 
burg and  Leipzig,  1888,  Erganzungsheft,  Monatshefte,  1888  (with  illustration,  review, 
and  analytic  table  of  cases  (23)  to  date,  with  references);  Curtis,  New  York  Med. 
Jour.,  1889,  vol.  1,  p.  216  (case  demonstration);  Leviseur,  ibid.,  1889,  vol.  xlix,  p.  42; 
Lake,  Brit.  Med.  Jour.,  1891,  ii,  p.  946;  Smith,  ibid.,  p.  1043  (letter  communication — 2 
cases);  Masters,  ibid.;  Rydygier,  Arch,  fiir  klin.  Chirurg.,  1891,  vol.  xli,  p.  767  (with 
illustration);  Ciaglinski  and  Hewelke,  Zeitschr.  fur  klin.  Med.,  1893,  vol.  xxii,  p.  626 
(with  review  and  bibliography);  Mourek,  Archiv,  1894,  vol.  xxix,  p.  369;  Sendziak, 
Rev.  de  laryng.,  otol.,  et  de  rhinol.,  1894,  vol.  xiv,  p.  228,  and  (same  paper)  Monats- 
hefle  fur  Ohrenheilk.,  1894,  vol.  xxviii,  p.  112  (with  review  and  references);  Goodale, 
Jour.  Boston  Soc.  Med.  Sci.,  1897-98,  ii,  p.  204  (histology);  Vollmer,  Archiv,  1898, 
vol.  xlvi,  p.  12  (histology,  with  illustrations);  Gottheil,  Arch.  Pediat.,  1899,  p.  255 
(with  illustration  of  case  and  fungus  found);  Heidingsfeld,  Jour.  Amer.  Med.  Assoc., 
Dec.  17,  1910,  p.  2117  (report  of  2  cases;  histology  with  illustrations,  review,  and  bib- 
liography). 


BLACK  TONGUE 


1213 


by  Dinkier  it  was  yellow,  and  one  by  Mourek,  blue.  The  area  forms  gradually,  as  a 
rule,  centrally,  and  extends  peripherally;  the  reverse  takes  place  in  its  disappearance. 
In  some  instances  (Curtis,  Ciaglinski  and  Hewelke,  Masters,  Lake),  however,  it  de- 
velops rapidly,  occupying  considerable  area  in  from  several  days  to  one  or  two  weeks. 
The  condition  may  consist  simply  of  discoloration  (Stokes,  Ciaglinski  and  Hewelke, 
Sendziak,  Gottheil),  or,  as  usually  observed,  beset  with  thin,  filiform  projections,  also 
dark  colored  or  black,  which  may  be  likened  in  appearance  to  long  tendrils,  lashes,  sea- 
weed (Curtis),  or  hairs;  so  much  like  the  last  in  many  instances  that  they  were  suspected 
of  being  true  hairy  growths,  hence  the  term  "hairy  tongue."  In  some  cases,  as  Raynaud 
(cited  by  Lake)  expressed  it,  the  area  looks  like  "a  field  of  corn  laid  by  wind  and  storm." 
These  filiform  projections  can  reach  considerable  length.  With  the  exception  some- 
times of  a  mawkish  taste  when  the  patch  is  well  developed,  there  are  practically  no 
troublesome  subjective  symptoms;  rarely  slight 
pain,  although  in  Curtis'  case  this  was  quite  pro- 
nounced. 

The  causes  are  not  known.  Syphilis  has  been 
suggested  as  possibly  causative,  but  beyond  the 
fact  that  it  has  occasionally  been  seen  (Leviseur, 
Vollmer)  in  those  who  have  had  this  disease  there 
is  nothing  to  support  this  view.  It  is  not  impos- 
sible that  the  resulting  stomatitis  from  mercurial 
treatment,  the  use  of  irritating  mouth-washes,  ex- 
cessive smoking,  etc.,  may  have  some  influence  in 
its  production.  The  malady  is  seen  in  children 
and  adults,  in  the  former  with  usually  but  little, 
and  frequently  no,  filiform  projections.  In  adults 
it  may  also  sometimes  consist  practically  of  pig- 
mentation alone,  but  commonly  shows  variable 
filiform  or  hair-like  formations  also.  Its  occur- 
rence in  one  instance  observed  by  Rostowjew1  in 
man  and  wife  suggested  to  this  observer  the  possi- 
bility of  contagiousness.  It  occurs  in  both  sexes, 
but  reaches  its  greatest  "hairy"  development  in 
male  adults.  The  projecting  filaments  consist  of 

enormously  lengthened  filiform  papillae  produced  by  a  hyperkeratosis  or  overgrowth  of 
the  epidermis  of  these  papillae;  the  edges  are  usually  serrated  from  imbrication  of  their 
investing  epithelium.  Sometimes  these  elongated,  soft,  and  wavy  or  stiff  hair-like 
formations  show  lateral  projections,  so  strikingly,  as  in  Goodale's  patient,  as  to  suggest 
the  comparison  to  a  feather  with  stem  and  lateral  webs.  A  reason  for  this  excessive 
hyperkeratosis  is  hard  to  find.  Heidingsfeld  found  that  "the  fundamental  abnormality 
is  the  presence  of  abnormal  papillae  and  interpapillary  processes  or  filament  founts, 
situated  within  the  epidermis  from  which  the  abnormally  elongated,  stratified,  and  kera- 
tosed  filaments  trace  their  direct  origin."  The  malady  has  been  thought  probably  due 
to  parasitic  influence,  and  various  observers  have  discovered  organisms,  but  several, 
and  sometimes  numbers,  are  to  be  found  on  the  tongue,  even  when  this  organ  is  free 
from  disease.  The  spore-like  bodies  which  Gottheil  and  Heidingsfeld  detected  were 
probably  similar  to  those  reported  by  Dessois,  Laveau,  Lancereaux,  Schech,  Gubler, 
and  others.  That  which  Ciaglinski  and  Hewelke  and  Sendziak  found  and  cultivated 
was  a  black  mold  consisting  of  a  stalk-like  formation  having  spheric  capsules  on  the  end 
containing  black  spores;  a  mushroom-shaped  columella  developed  from  the  burst 
spore  capsule.  Many  investigators,  however,  have  failed  to  corroborate  these  and 
other  findings  reported.  It  is  probable  that  the  color  is  due  to  chroma togenous  organ- 
isms, although  this  is  by  no  means  proved.  Goodale  attributed  the  color  in  his  case 
1  Rostowjew,  abs.  in  Monatshefte,  1899,  vol.  xxiv,  p.  41. 


Fig.  331. — Black  tongue,  show- 
ing the  filamentous  or  hair-like 
development. 


1 2 14  SUPPLEMENTARY  SECTION 

to  highly  refractile,  yellowish-brown  granules.     Hutchinson  was  inclined  to  believe 
that  in  his  patient  (pigmentation  only)  the  color  was  purposely  produced. 

Prognosis  and  Treatment. — The  malady  is  somewhat  variable  in  its  behavior  in 
different  cases.  It  may  persist  for  several  weeks,  months,  or  years,  and  then  gradu- 
ally or  quickly  spontaneously  disappear;  or,  as  in  Stokes'  patient,  practically  of  pig- 
mentation only,  the  blackness  fluctuates  in  degree  and  extent.  Treatment  seems  to  be 
of  little  avail.  Shaving  and  scraping,  sometimes  practised,  will  remove  the  filiform 
formations,  but  regrowth  usually  occurs.  Exfoliation  can,  if  thought  advisable,  be  pro- 
duced by  the  resorcin  peeling  paste,  by  solutions  of  salicylic  acid  and  weakened  lactic 
acid.  Upon  the  whole,  except  as  to  the  maintenance  of  cleanliness,  the  applications  of 
mild  antiseptics  and  astringents,  such  as  glycerite  of  tannic  acid,  the  malady  is  best  let 
alone.  It  generally  disappears  spontaneously  sooner  or  later. 

CHEILITIS  GLANDULARIS 

Synonyms. — Cheilitis  glandularis  apostematosa  (Volkmann);  Myxadenitis  labialis. 

Volkmann1  was  the  first  to  describe  this  rare  malady,  his  cases  being  character- 
ized by  chronic  inflammation  of  the  lower  lip,  chiefly  of  the  vermilion  part,  but  extend- 
ing on  to  the  mucous  membrane  proper,  as  well  as  occasionally  involving  the  adjacent 
skin;  the  latter  was  erythematous  in  appearance.  The  lip  becomes  somewhat  tense  and 
swollen,  and  the  mucous  glands  prominent,  being  the  size  of  a  hemp-seed  or  larger,  with 
follicular  openings  much  dilated,  sufficiently  marked  in  some  instances  to  permit  the 
introduction  of  a  fine  probe.  An  opaque  mucous  or  mucopurulent  secretion  readily 


Fig.  332. — Cheilitis  glandularis  (courtesy  of  Dr.  Richard  L.  Sutton). 

exuded  upon  slight  pressure,  and  there  was  variable  spontaneous  oozing,  which  tended 
now  and  then  to  form  more  or  less  crusting.  It  is  not  uncommon  for  the  lips  to  be 
glued  together  in  the  morning.  Some  of  the  openings  were  of  a  fistulous  character, 
in  i  case  as  many  as  10  to  15  being  found  in  the  inside  of  the  lip,  admitting  a  large  probe, 
and  forming  irregular,  fistulous  tracts.  Furuncle-  and  abscess-like  inflammatory  for- 
mations sometimes  developed  in  the  fleshy  part  of  the  lip,  but  actual  ulcerative  action, 
Volkmann  states,  did  not  occur. 

Purdon2  has  met  with  4  examples  of  the  same  malady,  all  adults — 3  males  and  i 
female.  The  disease  was  confined  in  3  patients  to  the  lower  lip  and  its  mucous  lining, 
beginning  gradually,  and  spreading  over  the  entire  surface  of  the  lip.  The  mucous 
glands  of  the  lip  were  swollen,  and  could  be  felt  with  the  finger,  often  as  nodular  masses. 
These  conditions  were  most  pronounced  during  exacerbations,  at  such  times  the  lip 
becoming  tense,  swollen,  and  hard,  and,  as  in  Volkmann's  cases,  with  mobility  more  or 
less  impaired.  A  turbid  and  mucopurulent  secretion  was  pressed  out  of  these  glands, 
the  ducts  of  which  were  dilated.  In  fact,  there  seemed,  Purdon  states,  to  be  also  an 

1  Volkmann,  Virchow's  Archiv,  1870,  vol.  1,  p.  142  (5  cases). 

2  Purdon,  Brit.  Jour.  Derm.,  1803,  p.  23  (4  cases). 


FORDYCE'S  DISEASE  1 21 5 

active  catarrhal  condition  of  the  lining  membrane  of  the  cheeks  and  gums.  There 
were  no  fistulous  tracts  as  in  some  of  Volkmann's  patients.  In  i  patient  both  lips  were 
affected,  and  frequently  found  glued  together  in  the  morning.  In  i  case  the  skin  of 
the  chin  became  erythematous.  Sutton1  has  reported  3  American  cases  more  or  less 
typical. 

The  cause  of  the  malady  is  not  known.  It  is  entirely  distinct  from  cheilitis  ex- 
foliativa,  a  more  common  affection,  with  constant  and  persistent  exfoliation  and  crust 
accumulation  as  its  chief  feature.  The  patients  seemed  otherwise  in  good  health. 
The  etiologic  factor  is  to  be  sought  for  in  the  catarrhal  condition  of  the  mouth  and 
pharynx,  the  mucous  glands  of  the  lip  becoming  subsequently  involved.  It  is  not 
syphilitic.  It  usually  begins  in  early  or  middle  adult  life.  Button's  histologic  study 
indicates  that  the  disease  is  an  adenomatous  condition  of  the  mucous  glands  of  the  lip 
characterized  by  enormous  dilatation  and  hypertrophy  of  ducts,  usually  accompanied 
by  a  great  increase  in  the  amount  of  glandular  tissue. 

Prognosis  and  Treatment. — The  malady  is  persistent  and  rebellious  to  treatment.2 
Volkmann  cured  3  of  his  cases  in  one  to  two  months  with  potassium  iodid  internally, 
gargles  of  potassium  chlorate,  and  mild  cauterization  of  the  parts  with  silver  nitrate. 
Purdon  was  not  so  successful,  the  disease  seeming  obstinate  to  all  remedies.  What 
gave  most  benefit  was  the  local  application  of  lotio  nigra  and  glycerin,  with  occasional 
penciling  with  silver  nitrate  solution;  x-ray  treatment  was  found  promising  in  Sutton's 
cases. 

FORDYCE'S  DISEASE 

Synonym. — Fordyce's  disease  of  the  lips  and  oral  mucous  membrane. 

The  first  description  of  this  peculiar  affection,  involving  the  vermilion  of  lips  and 
mucous  membrane  of  the  mouth,  we  owe  to  Fordyce  (i8g6).3  Since  then  the  same 
condition  has  been  observed  by  Montgomery  and  Hay,  Audry,  Delbanco,  Heuss, 
Allen,  White,  and  others.4  It  is  characterized  by  the  appearance  of  whitish  or  yellowish, 
scanty  or  abundant,  discrete,  aggregated,  and  often  practically  coalescent,  milium- 

1  Sutton,  Jour.  Cutan.  Dis.,  1909,  p.  151   (with  case  illustration,  case  report  and 
review  of  the  literature,  with  references),  and  Unna-Festschrift,  Band  i,  p.  611;  2  addi- 
tional American  cases  (with  case  and  histologic  illustrations;  review  and  references) ; 
Howard  Fox,  Jour.  Cutan.  Dis.,  1909,  p.  229  (case  presentation — patient  born  in  Ire- 
land); Schamberg,  Jour.  Cutan.  Dis.,  1911,  p.  449  (case  demonstration;  man  aged 
forty-four,  involving  lower  lip,  of  two  years'  duration). 

2  Unna,  "Ueber  Erkrankungen  der  Schleimdriisen  des  Mundes,"  Monatshefte,  1890, 
vol.  xi,  p.  317,  reports  several  cases  of  a  malady  (Baelz's  disease)  in  many  respects 
apparently  similar,  and  to  which  his  attention  had  been  previously  called  by  Baelz; 
the  lip,  usually  the  under  lip  only,  was  involved,  and  with  the  early  symptoms  above 
described,  but  the  mucous  glandular  swelling  went  on  to  pronounced  suppuration,  crust- 
ing, and  ulceration,  and  then  cicatrization;  he  found  that  local  treatment  with  tinc- 
ture of  iodin,  a  plan  pointed  out  to  him  by  Baelz,  acted  as  a  specific,  improvement 
ensuing  immediately;  Jamieson  (Brit.  Med.  Jour.,  Dec.  7, 1895  (cited  by  Fordyce))  has 
reported  a  case  apparently  similar  to  those  described  by  Unna. 

3  Fordyce,  "A  Peculiar  Affection  of  the  Mucous  Membrane  of  the  Lips  and  Oral 
Cavity,"  Jour.  Cutan.  Dis.,  1896,  p.  413  (with  colored  plate,  case  illustration,  and 
histologic  cuts). 

4  D.  W.  Montgomery  and  Hay,  "Sebaceous  Glands  in  the  Mucous  Membrane  of 
the  Mouth,"  Proceedings  of  the  Tenth  Annual  Sessions  of  the  Assoc.  Amer.  Anatomists, 

1897,  p.   76;  Audry,  "Ueber  eine  Veranderung  der  Lippen-  und  Mundschleimhaut 
bestehend  in  der  Entwickelung  atrophischer  Talgdriisen,"  Monatshefte,  1899,  vol.  xxix, 
p.  101  (with  histologic  plate);  Delbanco,  "Ueber  die  Entwichelung  von  Talgdriisen  in 
der  Schleimhaut  des  Mundes,"  ibid.,  pp.  104  and  353,  and  Munch,  med.  Wochenschr., 

1898,  p.  1510  (case  demonstration),  and  ibid.,  1899,  p.  459  (case  demonstration) ;  Heuss, 
"Ueber  postembryonale  Entwickelung  von  Talgdriisen  in  der  Schleimhaut  der  mensch- 
lichen  Mundhohle,"  ibid.,  1900,  vol.  xxxi,  p.  501  (with  review);  Allen,  Jour.  Cutan. 
Dis.,  1897,  p.  29  (case  demonstration);  Suchannek,  "Ueber  gehauftes  Vorkommen  von 
Talgdriisen  in  der  menschlichen  Mundschleimhaut,"  Munch,  med.  Wochenschr.,  1900,  i, 
P-  575- 


I2l6 


SUPPLEMENTARY  SECTION 


like  bodies,  occurring  more  especially  on  the  inside  of  the  mouth,  laterally  along  the 
line  of  the  teeth  as  far  back  as  the  last  molar,  and  possibly  somewhat  less  frequently  on 
the  vermilion  or  mucous  and  inner  surface  of  the  lips.  There  is  but  slight  elevation, 
but  they  are  more  projecting  on  the  oral  membrane  than  on  the  lips.  The  color  of  the 
formations  in  the  mouth  are  also  more  of  the  white,  with  the  yellow  or  yellowish  aspect 
less  pronounced  than  observed  in  the  lip  lesions.  When  numerous  and  closely  crowded, 


Fig.  333. — Fordyce's  disease;  lesions  are  closely  crowded  (courtesy  of  Dr.  J.  A.  Fordyce). 

the  appearance  of  a  solid,  yellowish  patch  is  presented,  but  the  constituent,  milium-like 
bodies  can  be  readily  discovered  or  rendered  much  more  conspicuous  by  putting  the 
tissues  on  the  stretch.  As  a  rule  there  are  no  subjective  symptoms,  although  occasion- 
ally in  some  instances  a  feeling  of  slight  burning  and  itching,  accompanied  by  some  stiff- 
ness as  though  the  lip  were  swollen  (Fordyce) . 


Fig.  334. — Fordyce's  disease,  showing  lesions  in  the  mouth  (Delbanco). 

Etiology  and  Pathology. — The  condition  is  not,  as  at  first  thought,  very  rare,  but, 
owing  to  its  comparatively  insignificant  character,  relatively  few  individuals  af- 
fected seek  advice.  It  is  seen  most  frequently  in  male  adults.  In  12  cases  investi- 
gated by  Heuss,  in  a  number  of  which  the  lesions  were  in  the  oral  cavity  and  scanty, 
the  patients  were  aged  between  twenty-five  and  fifty,  and  there  were  only  3  women. 
Montgomery  and  Hay  and  Audry  saw  the  development  in  i  instance  in  an  infant. 
Fordyce's  patient  (a  physician)  found  the  lesions  in  all  other  members  of  his  family, 
but  they  appeared  after  puberty;  he  also  found  them  in  "half  of  the  negroes  examined." 


LA   PERLECHE  12 I  / 

The  formations  have  been  histologically  investigated  by  Fordyce,  Montgomery  and 
Hay,  Delbanco,  Heuss,  and  White.  Fordyce  first  thought  they  were  due  to  a  granu- 
lar change  in  the  protoplasm  of  the  cells  of  the  affected  mucous  membrane,  but 
subsequently  agreed  with  the  observations  by  the  others  named  that  they  are  in 
reality  slightly  or  moderately,  sometimes  markedly,  developed  sebaceous  glands. 
Montgomery  and  Hay  were,  by  their  investigations  of  these  peculiar  bodies,  the  first  to 
show  that  these  glandular  structures  are  sometimes  to  be  found  in  the  mucous  membrane 
of  the  oral  cavity.  C.  J.  White,1  in  still  later  investigations,  claims  that  Fordyce's 
original  opinion  is  the  correct  one,  as  he  found  that  the  sebaceous  element,  though 
abundantly  present,  lies  beyond  the  diseased  tissue  proper. 

There  is  some  difference  of  opinion  as  to  whether  these  glands  are  simply  a  late 
development  of  pre-existing  embryonic  elements  (Audry) ,  or  whether  they  are  purely 
postnatal  in  origin  (Heuss).  This  latter  observer  believes  their  growth  and  develop- 
ment are  favored  by  catarrhal  conditions,  stomatitis,  etc.,  and  thinks  that  their  appar- 
ent greater  prevalence  in  those  who  have  had  syphilis  is  due  to  the  stomatitis  which  the 
mercurial  treatment  sometimes  causes.  They  have,  of  course,  as  all  observers  agree, 
no  direct  connection  with  syphilis,  and  it  is  more  than  probable  that  in  the  cases  in- 
vestigated (Montgomery  and  Hay,  Delbanco,  Heuss),  in  which  syphilis  had  previously 
existed,  their  presence  was  purely  a  matter  of  coincidence. 

Prognosis  and  Treatment. — The  condition,  while  benign,  is  persistent,  and  shows 
but  little,  if  any,  tendency  toward  retrogressive  changes,  although  in  a  few  instances 
the  lesions  became,  in  course  of  time,  smaller  and  less  conspicuous.  Treatment  has 
not  been  satisfactory.  Fordyce  found  that  when  the  superficial  layer  of  the  epithelium 
was  scraped  away,  some  of  the  bodies  could  be  pressed  out,  and  the  discoloration  thus 
somewhat  lessened;  the  effect  was,  however,  only  temporary. 

LA  PERLECHE 

Synonyms. — Bridou;  Parasitic  disease  of  the  lips. 

This  is  a  peculiar  affection  of  the  lips,  especially  of  the  commissures,  observed 
chiefly  in  certain  districts  of  France,  and  first  clearly  described  by  Lemaistre,2  and 
since  by  Raymond,3  Guibert,4  Planche,5  and  a  few  others.  It  occurs  almost  exclusively 
in  infants  and  young  children.  It  begins,  as  a  rule,  in  the  angles,  bilaterally,  first  pre- 
senting as  a  blanching  of  the  epithelium  and  having  a  somewhat  sodden  appearance. 
It  extends  to  a  variable  distance  along  the  vermilion  surface  toward  the  median  line, 
but  usually  only  part  way,  in  some  instances  invading  the  neighboring  skin,  and  in  most 
cases  the  mucous  membrane  of  the  inside  of  the  lips  as  well.  There  is  frequently  some 
underlying  and  surrounding  hyperemia  and  inflammation,  and  the  mouth-angles  are 
sometimes  crusted  over.  Other  parts  of  the  inside  of  the  mouth  may  also  show  in- 
volvement. In  a  large  number  of  cases  the  disease  remains  limited  to  the  angles 
of  the  mouth  and  the  immediately  adjacent  parts.  On  the  true  mucous  surface,  and 
also  in  a  great  measure  at  the  commissures,  the  appearances  presented  are  somewhat 
like  those  of  syphilitic  mucous  patches.  There  is  a  distinct  tendency  at  the  com- 
missures of  the  mouth  to  the  formation  of  a  deep  fissure,  with  often  smaller  ones  nearby, 
and  with  a  disposition  sometimes  to  bleeding.  The  epithelium  of  the  lips  becomes 

1  C.  J.  White,  Jour.  Culan.  Dis.,  March,  1905,  p.  Q7  (a  report  of  65  cases,  with 
histologic  cuts  and  a  complete  review  of  the  subject,  and  literature  with  bibliography). 

2  Lemaistre,  "Etude  sur  1'air  de  la  ville  de  Limoges;  de  la  perleche;  du  strepto- 
coccus plicatilis,"  Jour.  soc.  de  med.  et  de  la  pharm.  de  la  Haute-Vienne,  Limoges,  1886, 
pp.  41,  55,  and  74. 

3  Raymond,  "Etude  clinique  et  bactdriologique  sur  la  perleche,"  Annales,  1893, 
p.  578. 

4  Guibert,  "De  la  perleche,"  These,  No.  142,  Toulouse,  1896. 

5  Planche,  "La  Perleche,"  These  de  Paris,  1897;  N6grie,  "Note  sur  la  perleche," 
Cong.  deGynecol.  d'obstet.  et  de  pediat.,  first  session,  Bordeaux,  Aug.,  1895,  p.  1002. 

77 


J2l8  SUPPLEMENTARY  SECTION 

slightly  thickened,  macerated,  and  more  or  less  readily  detachable.  The  condition  is 
aggravated  by  the  child  frequently  moistening  the  parts  with  the  tongue  in  attempts 
to  relieve  the  dryness  and  parched  and  burning  feeling.  There  is  also  sometimes 
itching. 

The  malady  is  contagious,  and  spreads  quite  rapidly  in  maternity  hospitals,  found- 
ling and  infant  asylums,  and  among  young  school-children  (see  Lemaistre  and  Ray- 
mond's papers).  It  is  thought  to  be  conveyed  through  the  medium  of  the  water-sup- 
ply, drinking-cups  and  spoons,  and  other  utensils.  According  to  Lemaistre,  it  is  due  to 
an  organism  named  by  him  Streptococcus  plicatilis.  Raymond,  on  the  other  hand, 
attributes  it  chiefly  to  the  Staphylococcus  cereus  albus,  although  admitting  that  it 
may  be  produced  by  various  other  organisms,  and  that  the  malady  usually  starts  from 
the  inside  of  the  lips.  This  opinion  is  also  shared  by  Guibert  and  Planche.  Sa- 
bouraud  believes  it  may  result  from  a  streptococcic  salivary  infection  or  be  associ- 
ated with  a  streptococcic  impetigo.  The  resemblance  to  the  mucous  patch  and  fissures 
of  syphilis  is  at  times  so  striking  that  these  several  observers  agree  that  in  some  cases 
the  presence  or  absence  of  other  symptoms  of  syphilis  must  be  the  determining  factor 
in  the  differential  diagnosis.  Raymond  considers  the  diphtheroid-looking  spots  some- 
times seen  in  the  mouths  of  infants  and  young  children  practically  the  same  disease. 

Prognosis  and  Treatment. — The  affection  generally  runs  its  course  in  from  a  few 
weeks  to  one  or  two  months,  with  sometimes  a  marked  disposition  to  relapse.  Treat- 
ment consists  in  frequent  cleansing  and  the  occasional  application  of  a  weak  solution 
of  silver  nitrate,  copper  sulphate,  or  alum,  together  with  mild  ointments  or  such  other 
remedies  as  may  be  indicated.  Attention  is  to  be  given  to  the  nursing-bottles,  drink- 
ing-vessels,  water-supply,  etc. 


INDEX 


ABODE,  etiologic  influence,  76 

Abortive  zoster,  349 

Abrasions,  66 

Absorption  by  skin,  49 

Acanthia  lectularia,  1186 

Acantholysis  bullosa,  389 

Acanthoma  adenoides  cysticum,  652,  654 

Acanthosis  nigricans,  521 

treatment,  524 
Acare  des  follicules,  1197 
Acarodermatitis  urticarioides,  1183 
Acarus,  37 

folliculorum,  1034,  1197 

scabiei,  1190 
Achorion  gallinae,  1 101 

gypseum,  noo,  noi 

Quinckeanum,  noi 

Schonleinii,  1098 
Achroma,  acquired,  610 

congenital,  608 
Achromia  unguium,  959 
Acne,  1036 

agminata,  1055,  1057 

albida,  1028 

artificialis,  1041 

atrophica,  1040 

bacillus,  1043 

bromid,  1041 

bromin,  1041 

cachecticorum,  1040 

clinical  varieties,  1038 

course,  1042 

diagnosis,  1046 

disseminata,  1036 

erythematosa,  1060 

etiology,  1042 

hypertrophica,  1040 

indurata,  1039 

iodid,  1041 

iodin,  1041 

keloid,  643 

keratosa,  1042 

lupoid,  1054 

mentagra,  1014 

necrotica,  1054 

necrotisans    et    exulcerans    serpiginosa 
nasi,  1055 

of  back,  treatment,  1053 

of  trunk,  treatment,  1053 

papulosa,  1039 

pathology,  1044 

picea,  1041 

picealis,  1041 

prognosis,  1046 

punctata,  1032,  1039 

pustulosa,  1039 


Acne  rodens,  1054 

rosacea,  1060 
diagnosis,  1064 
etiology,  1062 
pathology,  1063 
prognosis,  1064 
symptoms,  1060 
treatment,  1064 

scrofulosorum,  1040 

sebacea,  1021 

simplex,  1036 

symptoms,  1036 

syphilitica,  796 

tar,  1041 

telangiectodes,  1055 

treatment,  1047 

local  or  external,  1049 
vaccine,  1048 

urticata,  211,  1041,  1054 

varioliformis,  1054 
treatment,  1059 

vulgaris,  1036 
Acne,  1036 

a  cicatrices  deprimee,  1054 

cheloidienne,  643 

decalvante,  1010 

miliare,  1028 

rosacee,  1060 

ros£e,  1060 

sebacee,  1021 
cornee,  541,  546 
fluente,  1022 

varioliforme,  645 
Acneiform  syphiloderm,  796 
Acnitis,  1054,  1057 
Acrochordon,  696 

Acrodermatite  suppurative  continue,  393 
Acrodermatites  continues,  393,  394 
Acrodermatitis  chronica  atrophicans,  622 

perstans,  393,  394 
Acrodynia,  178 
Acrodynie,  178 
Acromegaly,  596 
Actinomyces,  1158 
Actinomycose,  1155 
Actinomycosis,  1155 

of  skin,  1155 

treatment,  1159 
Actinotherapy,  130 
Acute  circumscribed  edema,  181 
Adamson's  method  of  x-ray  treatment  of 

ringworm  of  scalp,  1142,  1143 
Addison's  keloid,  582 
Adenoma  of  sebaceous  glands,  656 

of  sweat-glands,  652,  659 

sebac6s,  656 

1219 


I22O 


INDEX 


Adenoma  sebaceum,  656 

sudoriparum,  659 
Adenopathy,  syphilitic,  770,  815 
Adeps  lanae,  119 
Adipose  tissue,  25 
Adiposis  dolorosa,  701 
Age,  etiologic  influence,  77 
Agminate  folliculitis,  1112 
Ainhum,  626 
Air,  liquid,  124 
Akne,  1036 
Aktinomykose,  1155 
Albinism,  608 
Albinisme,  608 
Albinismus,  608 

complete,  608 

partial,  608 

semi-,  609 
Albinos,  608 
Alcohol,  etiologic  influence,  81,  82 

in  treatment  of  skin  diseases,  107 
Aleppo  boil,  845 
Algidite  progressive,  589 
Alibert's  keloid,  636 
Alligator  skin,  562 
Alopecia,  987 

adnata,  987 

areata,  995 
diagnosis,  1005 
etiology,  999 
pathology,  1002 
prognosis,  1006 
symptoms,  995 
treatment,  1006 
true,  1003 

bacillary,  1004 

circumscripta,  995 

seu  orbicularis,  998,  1003 

coccogenous,  1004 

congenita,  987 

furfuracea,  991 

hyphogenous,  1004 

localis  seu  neuritica,  1003 

parasitica,  1003 

pityroides,  989,  991 

premature,  989 
idiopathic,  990 
symptomatic,  991 

senilis,  989 

syphilitic,  775 

treatment,  992 

trichophytic,  1004 

universalis,  997,  1003 
Alopecie,  987 
Alopecie,  987 

cicatricielle  innominee,  1010 
Alteratives,  general,  109 

special,  no 
Amboyna  button,  850 
Anal  region,  eczema  of,  327 
Analgesic  paralysis  with  whitlow,  631 
Analgesics,  113 

Anaphylaxis,  etiologic  influence,  80 
Anaplasma  liberum,  382 
Anatomic  tubercle,  712 
Anatomy  of  skin,  17 
Anemias,  143 


Anesthesia,  951 
Anesthetic  leprosy,  922 
Anetodermia,  622 
Angiectases,  68 1 
Angio-elephantiasis,  682 
Angiokeratom,  575 
Angiokeratoma,  575 

treatment,  578 
Angioma,  680 

cavernosum,  68 1,  682 

cavernous,  681 

fissural,  684 

infective,  690 

pigmentosum  atrophicum,  889 

plexiforme,  68 1 

serpiginosum,  690 

simplex  hyperplasticum,  681 
seu  glomeruliforme,  681 

varicosum,  683 
Angiome,  680 

cystique,  663 
Angiomyoma,  703 
Angioneurotic  edema,  191 
Angiosarcoma,  900 
Anidrose,  1074 
Anidrosis,  1074 
Animal  extracts,  no 

parasites,  diseases  due  to,  1173 

scabies,  1190 

Ankylostoma  duodenalis,  1201 
Ankylostomiasis,  1201 
Annular  lichen  planus,  213 

syphilid,  777 

syphiloderm,  777 
Annulus  migrans,  1209 
Anthrax,  412,  418 

benigna,  412 

maligna,  418 

simplex,  412 

Antilithemic  remedies,  109 
Antipruritics,  113,  122 
Antiseptics,  gastro-intestinal,  108 
Ants,  1187 

Anus,  pruritus  of,  943 
Aperients,  108 
Aphthous  sores,  794 
Aplasia  pilorum  intermittens,  978 

moniliformis,  978 
Aplasie  moniliforme  des  cheveux  et  des 

poils,  978 

Appendages,  diseases  of,  952 
Area  Celsi,  995 
Argyria,  511 
Army  itch,  1190 
Arrectores  pilorum,  30 
Arsenical  cancer,  458,  879 

epithelioma,  879 

keratosis,  457,  458 
Arthritic  purpura,  494 
Arthropathia  psoriatica,  239,  243 
Arznei-exantheme,  451 
Aspergillus  lepidophyton,  1146 

Tokelau,  1146 

Asperitudo  epidermidis,  1028 
Asphyxia,  local,  432 
Asphyxie  locale  des  extremites,  432 
Asteatodes,  1028 


INDEX 


1221 


Asteatose,  1028 
Ast6atose,  1028 
Asteatosis,  1028 
Atherom,  1030 
Atheroma,  1030 
Ath6rome,  1030 
Athyroidie,  601 
Atrophia  cutis  linearis,  619 
senilis,  617 
universalis,  622,  623 

maculosa  cutis,  622 
et  striata,  619 

pilorum  propria,  973 

senilis,  617 

unguium,  957 

treatment,  961 
Atrophic  lines  and  spots,  619 

scars,  634 
Atrophies,  608 
Atrophoderma  neuriticum,  616 

pigmentosum,  889 

senile,  617 

striatum  et  maculatum,  619 
Atrophy,  linear,  619 

of  hair,  973 
pigment,  983 

of  nails,  957 

of  skin,  diffuse  idiopathic,  622 
general  idiopathic,  622 
progressive  idiopathic,  622 

senile,  617 

unilateral,  of  face,  585 
Autographism,  180 

Auto-intoxication,  etiologic  influence,  80 
Axillary  region,  chronic  itching  lichenoid 

eruption,  222 


BACILLARY  alopecia,  1004 
Bacillus,  acne,  1043 

gangosae,  858 

Back,  acne  of,  treatment,  1053 
Bacterium  decalvans,  10x23 
Baelz's  disease,  1215 
Bakers'  eczema,  281 

itch,  281 
Bald  ringworm,  1117 

tinea  tonsurans,  1117 
Baldness,  987 
Balggeschwulst,  1030 
Barbadoes  leg,  592 
Barbers'  itch,  1119 
Barley  itch,  1183 
Barn-itch,  1124 
Bartfinne,  1014 
Bath  pruritus,  945 
Bath-house  impetigo,  401 
Bathing  drawers  naevus,  515 
Bathing-trunk  naevus,  515 
Baths,  115 

Bat's-wing  disease,  755 
Beaded  hair,  978 
Beard,  ringworm  of,  1119 
Bearded  region,  302 
eczema  of,  302 
ringworm  of,  1119 
treatment,  1143 


Bed-bug,  1 1 86 

Bed-hairs,  40 

Bed-sores,  437 

Beerschwamm,  850 

Bees,  1187 

Beigel's  disease,  973,  974 

Benign  cystic  epithelioma,  652,  877 

Bettwanze,  1186 

Beule  von  Aleppo,  845 

Bier's  hyperemic  treatment,  134 

Bird-mite,  1187 

Birth-mark,  680,  682 

Biskra  button,  845 

Black  tongue,  1212 

Black-dot  ringworm,  1117 

Blackhead,  1032 

Blaschen,  62 

Blaschenflechte,  343 

Blasen,  63 

Blasenausschlag,  371 

Blastomyces,  1165 

Blastomycetic  dermatitis,  1162 

Blastomycose  cutanee,  1162 

Blastomycosis,  1162 

treatment,  1167 
Blattern,  480 
Blebs,  63 

Bleeding  stigmata,  1080 
Blind  boil,  409 
Blisters,  63 

blood-,  689 

fever,  343,  373 

little,  62 

Blood-blister,  689 
Blood-vessels,  25 
Bloody  sweat,  1080 
Blue  stains,  514 
Blutfleckenkrankheit,  492 
Blutschwar,  408 
Body-lousiness,  1177 
Boil,  408 

Aleppo,  845 

blind,  409 

Delhi,  845 

Oriental,  845 
Borken,  69 
Bot-fly,  1198 

Botryomycose  humaine,  692 
Botryomycosis  hominis,  692 
Bouba,  850 
Bouton  d'Alep,  845 
Bowditch  Island  ringworm,  1144 
Brandschwar,  412 
Brault's  method  of  treating  tattoo-marks, 

5i3 

Breasts,  eczema  of,  326 
Breigeschwulst,  1030 
Bridou,  1217 
Broad  condyloma,  792 
Bromid  acne,  1041 
Bromidrose,  1075 
Bromidrosis,  1069,  1075 

treatment,  1076 
Bromin  acne,  1041 

eruptions,  459,  460 
Bromoderma,  460 
Brown-tail  moth,  1181 


1222 


INDEX 


Brown-tail  moth  dermatitis,  1181 
Buckwar,  1144 
Bucnemia  tropica,  592 
Buds,  farcy,  417 
Bug,  bed-,  1 1 86 

harvest,  1195 
Bulb,  hair-,  38,  43 
Bulb-corpuscles,  29 
Bulbs,  end-,  29 
Bullae,  63 
Bulles,  63 
Bullous  syphiloderm,  802,  815 

urticaria,  181,  182 
Burmese  ringworm,  1144 
Burn,  Rontgen-ray,  \\t\ 

*-ray,  444 
Burrow,  1188 

CACHECTIC  gangrene,  multiple,  427 
Cachexia  strumipriva,  603 

syphilitic,  771 

Cachexie  pachydermique,  601 
Calamin  liniment,  118 
Calamin-and-zinc-oxid  lotion,  118 
Calamin-zinc-oxid  liniment,  118 
Calculi,  cutaneous,  1029 
Callositas,  526 
Callosity,  526 

wart-containing,  547 
Callus,  526 

Calmette's  test  in  tuberculosis  cutis,  740 
Calvities,  987 
Cancer.     See  Carcinoma. 
Cancroid,  870 

ulcer,  872 
Cancrolde,  870 
Canitie  annellee,  984 
Canities,  983 

praematura,  983 

senilis,  983 

treatment,  987 
Caraate,  1153 
Carat6,  1153 
Carboncle,  412 
Carbon-dioxid  snow,  124 
Carbuncle,  412,  418 
Carbunculus,  412 

treatment,  414 
Carbunkel,  412 
Carcinoma,  arsenical,  458,  879 

chimney-sweep's,  880 

cutis,  864 

en  cuirasse,  865 

epithelial,  870 

lenticular,  864 

melanotic,  865 

nodular,  865 

pigmented,  865 

skin,  870 

spider,  688 

tuberose,  865 

tuberosum,  865 
Carrion's  disease,  859 
Cascadoe,  1144 
Caterpillars,  1187 
Cauliflower  excrescence,  550 


Causalgia,  940 
Caustics,  123 
Cautery,  Paquelin,  126 
Cavernous  angioma,  681 

lymphangioma,  663 
Cayenne  pepper  grains,  690 
Cell-nests,  880 
Cells,  lepra,  931,  932 

Merkel's  touch-,  27,  29 

molluscum,  650 

naevus,  518 

of  Langerhans,  22 

plasma,  735 

prickle-,  22 

wandering,  32 

xanthoma,  672,  677 
Cellulitis,  phlegmonous,  414 
Cellulome  epithelial  eruptif  kystique,  652 
Ceratum  simplex,  119 
Chafing,  147 
Chalazion,  1030 
Chalazodermia,  604 
Chalazodermie,  604 
Chaleur  du  foie,  504 
Chancre,  769 

extragenital,  769 

non-venereal,  769 

redux,  811 
Chapping,  68,  274 
Chaps,  68,  274 
Charbon,  418 
Cheilitis  exfoliativa,  334 

glandularis,  1214 

apostematosa,  1214 
Cheiropodalgia,  178 
Cheiropompholyx,  360 
Cheloid,  636 
Cheloide,  636 

Chemical  irritants,  etiologic  influence,  83 
Chicken-louse,  1187 
Chicken-pox,  476 
Chigger,  1195 
Chignon  disease,  980 

fungus,  980 
Chigoe,  1195 
Chilblains,  144,  436 
Chimney-sweep's  cancer,  880 
Chinese  ringworm,  1144 
Chique,  1195 
Chitin,  21 
Chloasma,  504,  1147 

cachecticorum,  506 

caloricum,  505 

diagnosis,  509 

etiology,  508 

gravidarum,  508 

idiopathic,  505 

idiopathicum,  505 

pathology,  508 

prognosis,  510 

symptomatic,  506 

symptomaticum,  506 

symptoms,  504 

toxicum,  505 

traumaticum,  505 

treatment,  510 

uterinum,  507 


INDEX 


1223 


Chloasme,  504 
Chlorosis,  tropical,  1201 
Chromatophores,  32 
Chromidrose,  1077 
Chromidrosis,  1077 

pseudo-,  1077,  1080 

red,  1077,  1080 

treatment,  1079 
Chromophytosis,  1147 
Chyluria,  596 
Cicatrice,  634 
Cicatrices,  72 

false,  619 

Cicatricial  keloid,  637 
Cicatrix,  634 
Cimex  lectularius,  1186 
Circinate  eruption  of  tongue,  1209 

syphilid,  777 

syphiloderm,  777,  784 

tubercular  syphiloderm,  804 
Circumpilar  collarette,  1116,  1129 
Circumscribed  lipoma,  700 

scleroderma,  582 
Claret  stain,  682 
Classification,  136-142 
Clastothrix,  974 
Clavus,  524 
Claw,  leper,  924 
Claw-nails,  953 

Cleavage,  lines  of,  Langer's,  17 
Cleft  tongue,  1209 
Clefts,  67 

Climate,  etiologic  influence,  75 
Clothing,  etiologic  influence,  82 
Clou,  408 

de  Biskra,  845 
Coccogenous  alopecia,  1004 
Coil-ducts,  cysts  of,  1084 
Coil-glands,  33 
Cold  cream,  119 

etiologic  influence,  83 

exposure  to,  dermatitis  from,  436 

freckles,  503 

sweat,  30,  52 
Colloid  degeneration  of  skin,  678 

milium,  678 

Colloide  degeneration,  678 
Colloldome  miliare,  678 
Color  of  hair,  39 
Colored  sweat,  1077 
Columnae  adiposae,  25 
Comedo,  1032 

double,  1032 

extractors,  127 

multiple,  1032,  1034 

treatment,  1035 
Comedon,  1032 
Comedon,  1032 
Compound  papillae,  23 
Condyloma  acuminata,  550 

acuminatum,  550 

broad,  792 

flat,  792 

pointed,  550 
Confluent  variola,  483 
Congenital  achroma,  608 

freckles,  503 


Congenital  ichthyosiform   erythroderma, 

563 

leukasmus,  608 
leukoderma,  608 
leukopathia,  608 
syphilis,  813 
Constitutional  disease,  etiologic  influence, 

77 

treatment,  106 

Constringents,  vasomotor,  113 
Contagion,  etiologic  influence,  84 
Copra  itch,  1192 
Cor,  524 
Corium,  22 
Corn, 524 

suppurating,  524 
Corne  cutanee,  558 

de  la  peau,  558 
Cornu  cutaneum,  558 
treatment,  560 

humanum,  558 
Corona  veneris,  784 
Corps  ronds,  544 
Corpuscles,  bulb-,  29 

Krause's,  27,  29 

molluscum,  648,  650 

herve-,  Krause's  genital,  29 

of  Meissner,  27,  28 

of  Vater,  27 

Pacinian,  27 

tactile,  27,  28 

touch-,  28 

Wagner's,  27,  28 
Coster's  paint,  1137 
Couperose,  1060 
Cow-pox,  486 
Crab-lice,  1179 
Crabs,  1179 
Crackled  eczema,  274 
Cracks,  67 

Crateriform  ulcer,  875 
Craw-craw,  1201 
Creeping  eruption,  1199 
Cretinism,  sporadic,  603 
Cretinoid  edema,  601 
Croutes,  69 
Crusta  lactea,  269 
Crustae,  69 

lamellosae,  69 
Crusted  ringworm,  1093 
Crusts,  69 

milk,  269 

scaly,  69 
Crusty  scales,  69 
Culex  anxifer,  1187 

pipiens,  1187 
Cuniculus,  1 1 88 
Curetting,  126 

Currents,  high-frequency,  134 
Cutaneous  calculi,  1029 

diphtheria,  429 

horn,  558 

paratuberculoses,  228 

psorospermosis,  866 

reaction  test  for  syphilis,  825 
Cute,  1153 
Cuticle,  19 


1224 

Cuticular,  19 
Cuds,  22 

anserina,  31,  228 

hyperelastica,  606 

laxa,  604 

pendula,  604 

vera,  22 

verticis  gyrata,  605 
Cyanidrosis,  1077 

Cystadenomes  epithelieux  benins,  652 
Cystic  epithelioma,  multiple  benign,  652, 

877 

lymphangioma,  663 
Cysticercus  cellulosae,  1197 
Cystoplasma  oviforme,  381 
Cysts,  multiple  dermoid,  1031 

of  coil-ducts,  1084 

sebaceous,  1030 


DACTYLITIS  syphilitica,  814,  815 
Dactylolysis  spontanea,  626 
Dandruff,  1023 
Darier's  disease,  541 
Dartoic  myoma,  703 
Das  Fettsklerem,  589 

Sklerem  der  Neugeborenen,  589 

Sklerodem,  591 
Dead  layer,  20 
Deciduous  skin,  151 
Defluvium  capillorum,  775,  991 
Degeneration,  colloid,  of  skin,  678 

colloide,  678 

Degenerescence  colloide  du  derme,  678 
Delhi  boil,  845 

sore,  845 

Demodex  folliculorum,  37,  1034,  1197 
Dentition,  etiologic  influence,  77 
Der  Aussatz,  914 

flache  Hautkrebs,  872 
Dercum's  disease,  701 
Derma,  22 
Dermalgia,  940 
Dermalgie,  940 
Dermamyiasis  linearis  migrans   cestrosa, 

1200 

Dermanysse  des  oiseaux,  1187 
Dermanyssus  avium  et  gallinae,  1187 
Dermatalgia,  940 
Dermatite  exfoliatrice,  199 

herpetiforme,  364 

polymorphe,  364 
Dermatitis,  acute  general,  199 

ambustionis,  435 
bullosa,  435 
erythematosa,  435 
escharotica,  435 

artefacta,  448 

blastomycetic,  1162 

blastomycotica,  1162 

brown-tail  moth,.  1 181 

calorica,  435 

chronica  atrophicans,  623 

coccidioides,  1165 

congelationis,  436 

contusiformis,  161 

epidemica,  204 


Dermatitis  exfoliativa,  199 

epidemica,  204 

infantum,  206 

neonatorum,  206 

treatment,  203 
factitia,  448 

from  exposure  to  cold,  436 
gangraenosa,  427,  429 

infantum,  427 
general  exfoliative,  199 
grain,  1183 
grain-mite,  945,  1183 
herpetiformis,  364 

diagnosis,  369 

etiology,  366 

in  children,  366 

pathology,  368 

prognosis,  370 

symptoms,  364 

treatment,  370 
hiemalis,  281 

infectiosa  eczematoides,  271 
infectious  eczematoid,  271 
iodoform,  441 
Kaposi,  889 

malignant  papillary,  866 
medicamentosa,  451 
multiformis,  364 
occupation,  281,  442 
papillaris  capillitii,  643 
papillomatosa  capillitii,  643 
pitch,  438 
plant,  438 
primrose,  439 
primula,  439 
pyogenic,  399 
pyogenica,  399 
repens,  393 

treatment,  395 
Rontgen-ray,  444 

treatment,  448 
seborrheic,  276 
seborrhoica,  276,  331 

diagnosis,  340 

etiology,  336 

pathology,  337 

prognosis,  341 

symptoms,  332 

treatment,  341 
straw,  1183 

symmetrica  dysmenorrhoica,  433 
tar,  438 
trade,  442 
traumatica,  437 
uncinarial,  1201 
urticarioides  parasitica,  1183 
vegetans,  387 
venenata,  438 

treatment,  443 
*-ray,  444 

treatment,  448 
Dermatobia  noxialis,  1199 
Dermatographism,  58,  180 
Dermatolysie,  604 
Dermatolysis,  604 
Dermatomycosis  favosa,  1093 
furfuracea,  1147 


INDEX 


1225 


Dermatomycosis  trichophytina,  1104 
Dermatomyom,  702 
Dermatomyoma,  702 
Dermatosclerosis,  578 
Dermatoses,  occupation,  442 

occupational,  281 

psoriasiformes,  224 

vegetating,  388 
Dermatosis,  mucor,  1192 
Dermatosyphilis,  770 
Dermic  sporotrichoses,  1167 
Dermoid  cysts,  multiple,  1031 
Dermolysis,  678 

Desquamation   aberrant  en   aires  de  la 
langue,  1209 

epitheliale  de  la  langue,  1209 
Desquamative  exfoliative  erythema,  150 
Dhobieitch,  374,  1113,  1114 
Diabetes,  saccharine,  etiologic  influence, 

78 

Diabetic  gangrene,  431 
Diagnosis,  general,  87 
Diathesis,  77 

Diet  in  skin  diseases,  107 
Diffuse  idiopathic  atrophy  of  skin,  622 

lipoma,  700 
Digestive  disturbance,  etiologic  influence, 

80 

Dilatations,  acquired  vascular,  688 
Diphtheria  of  skin,  429 
Discoloration,  58 
Dissection  wounds,  415 
Disseminated  gangrene,  429 

ringworm,  1116 
Distichiasis,  966 
Distoma  hepaticum,  1201 
Distribution  as  diagnostic  factor,  88,  89 
Diuretics,  109 
Dochmiasis,  1201 
Dochmius  duodenalis,  1202 
Double  comedo,  1032 
Downy  hair,  38 
Dracontiasis,  1195 
Dracunculus,  1195 

medinensis,  1195 
Dragonneau,  1195 
Dressings,  fixed,  121 
Drug  eruptions,  451 
Drugs,  etiologic  influence,  81 
Dry  eczema,  265 

tetter,  265 

Duhring's  disease,  364 
Duration  as  diagnostic  factor,  88,  93 
Durillon,  526 
Dusting-powders,  117 
Dysidrose,  360 
Dysidrosis,  360 

EAR,  external,  fungous  disease  of,  1154 
Ears,  eczema  of,  319 
Echinococcus  cutis,  1201 

larva,  1201 
Ecthyma,  405 

gangraenosum,  427 

infantile  gangre"neux,  427 
gangrenous,  427 


Ecthyma,  syphilitic,  799 

syphiliticum,  799 

terebrant,  427 

treatment,  406 

vacciniform,  of  infants,  399 
Ecthymaform  syphilid,  799 

syphiloderm,  799 
Ectothrix,  1105 
Eczem,  261 
Eczema,  261 

acute,  264 

ani,  327 

articulorum,  325 

aurium,  319 

bakers',  281 

barbae,  320 

capitis,  315 

chronic,  264 

constitutional  causes,  277 
treatment,  298 

crackled,  274 

craquele,  274,  330 

crurale,  328 

crurum,  328 

crustosum,  271,  272 

diabeticorum,  279 

diagnosis,  287 

differential,  288-296 

dry,  265 

epidemic,  204 

epitheliomatosa,  866 

erythematosum,  265 

essential  characters,  265 

etiology,  276 

external  causes,  280 
treatment,  303 

faciei,  317 

fissum,  274 

fissured,  274 

follicular,  268,  271 

folliculorum,  268,  271 

furrowed,  274 

generalized,  330 

genitalium,  327 

gouty,  278,  1 112 

grocers',  281 

humidum,  265 

ichorosum,  271 

impetiginosum,  271 

infantile,  314 
treatment,  302 

intertrigo,  267,  325 

iodoform,  283,  441 

labiorum,  320 

madidans,  272 

mammas  seu  mammarum,  326 

manuum,  321 

marginatum,  1113 

mercuriale,  283 

moist,  265 

mucosum,  267 

narium,  319 

neurotic,  279 

nummulare,  263 

nurses',  281,  440 

occupational,  281 

cedematosum,  269 


1226 


INDEX 


Eczema  of  adjoining  mucous  surfaces,  330 

of  anal  region,  327 

of  bearded  region,  320 

of  breasts,  326 

of  ears,  319 

of  face,  317 

of  feet,  324 

of  flexures,  325 

of  genital  region,  327 

of  hands,  321 

of  legs,  328 

of  lips,  320 

of  nails,  324 

of  nares,  319 

of  nostrils,  319 

of  scalp,  315 

of  toes,  324 

of  umbilicus,  326 

palmarum,  321 

palpebrarum,  317 

papular,  267 

papulosum,  267 

parasitic,  275 

parasiticum,  275 

pathology,  283 

pedum,  324 

plantarum,  324 

prognosis,  296 

psoriasiforme,  273 

psoriatic,  239,  242,  273 

pustular,  271 

pustulosum,  271 

regional,  314 

rhagadiforme,  274 

rimosum,  274 

rubrum,  272 

sclerosum,  274 

scrofulous,  263 

seborrhoicum,  331 

siccum,  265 

solare,  282 

squamosum,  273 

squamous,  273 

surgeons',  281,  440 

surgical,  281 

sycosiforme,  271 

symptoms,  261 

trade,  281 

treatment,  298 

tuberculous,  263 

tyloticum,  275 

umbilici,  326 

unguium,  324 

universal,  330 

universale,  267,  330 

varicose,  272 

varicosum,  265,  272,  328 

verrucosum,  275 

vesiculosum,  269 

washerwomen's,  281 

weeping,  265 
Eczema,  261 

en  aires  de  la  langue,  1209 

marginee  desquamitif  de  la  langue,  1 209 
Eczematoid  dermatitis,  infectious,  271 

epitheliomatosis  of  nipple,  866 
Eczeme,  261 


Edema,  acute  circumscribed,  181,  191 
non-inflammatory,  191 

angioneurotic,  191 

cretinoid,  601 

febrile  purpuric,  494 

of  newborn,  591 

Ehrlich-Hata  preparation  in  syphilis,  838 
Einrisse,  67 
Ekzem,  261 
Elastic  skin,  606 
Elastic-skin  men,  606 
Electric  needle  operation,  127 
Electricity,  114,  127 
Electrolysis,  127 
Eleidin,  21 
Elephant  leg,  592 

man,  696 
Elephantiasis,  592 

Arabum,  592 

cruris,  594 

diagnosis,  600 

etiology,  597 

genitalium,  594 

Graecorum,  914 

indica,  592 

naevoid,  596 

nostras,  599 

pathology,  598 

prognosis,  600 

streptogenes,  599 

symptoms,  593 

telangiectatic,  596 

telangiectodes,  596,  682 
f  treatment,  600 
Elephantiasis,  592 
Elephantoid  fever,  593 
End-bulbs,  29 
Endemic  ulcer,  847,  854 
Endodermophytons,  1146 
Endo-ectothrix,  1105,  1107 
Endothrix,  1105 
English  sickness,  1091 
Enteritis  leprosa,  927 
Entozoon  folliculorum,  1197 
Ephelide  lentiforme  solaire,  502 
Ephelides,  502 
Ephidrosis,  1068 

cruenta,  1080 

discolor,  1077 
Epidemic  dermatitis,  204 

eczema,  204 

roseola,  474 

skin  disease,  204 
Epidermal  exfoliations,  68 
Epidermic  form  of  sporotrichosis,  1170 
Epidermis,  19 

exfoliating,  68 

living  stratum  of,  21 

of  hair-follicle,  42 
Epidermolysis  bullosa,  389 
hereditaria,  389 
treatment,  393 

Epidermophytie  inguinale,  1113 
Epidermophyton  cruris,  1108 

inguinale,  1108 

Perneti,  1108 

purpureum,  1108 


INDEX 


1227 


Epidermophyton  rubrum,  1108 
Epithelial  cancer,  870 

fibers,  22 

layer,  19 

Epithelialkrebs,  870 
Epithelioma,  870 

adenoides  cysticum,  652 

arsenical,  879 

contagiosum,  645 

deep-seated  variety,  873 

diagnosis,  882 

discoid  form,  871 

etiology,  878 

flat  variety,  871 

molluscum,  645 

morphea-like,  872 

multiple  benign  cystic,  652,  877 

nodular  variety,  873 

of  lip,  876 

papillary  variety,  875 

papillomatosus  variety,  875 

pathology,  880 

prognosis,  883 

superficial  variety,  871 

symptoms,  870 

treatment,  884 

x-ray,  445 

Epitheliomatose  pigmentaire,  889 
Epitheliomatose  s6bacee,  876 
Epitheliomatosis,  eczematoid,  of  nipple, 

866 
Epitheliome,  870 

de  Paget,  866 
Epitrichial  layer,  20 
Eponychium,  44,  45 
Equinia,  416 
Erbgrind,  1093 
Erectores  pilorum,  30 
Erntemilbe,  1195 
Erosions,  66 

Eruption  chronique  circinee  de  la  main, 
170 

circinate,  of  tongue,  1209 

creeping,  1199 

erythematopapular,  57 

erythema  tous,  816 

lichenoid,   chronic   itching,   of  axillary 
and  pubic  regions,  222 

macular,  816 

maculopapular,  57,  816 

papulopustular,  60 

papulosquamous,  60 

papulovesicular,  60 

pustulovesicular,  63 

ringed,  of  extremities,  170 
on  fingers,  170 

summer,  recurrent,  358 

vesicobullous,  63 

vesicopapular,  60 

vesicopustular,  63 
Eruptions,  drug,  451  « 

feigned,  448 

medicamenteuses,  451 

medicinal,  451 

vaccinal,  486 
Eruptive  fevers,  465 
Erysipelas,  421 


Erysipelas  ambulans,  422 

chronic,  422 

faciei  perstans,  758 

migrans,  422 

treatment,  425 

white,  422 
Erysipele,  421 
Erysipeloid,  426 
Erythema,  143 

ab  igne,  144 

annulare,  154 

bullosum,  155 

vegetans,  379,  380 

caloricum,  144,  435 

congestivum,  143 

desquamative  exfoliative,  150 

elevatum  diutinum,  168 

endemicum,  173 

epidemicum,  178 

exsudativum  multiforme,  153 

fugax,  145 

gangraenosum,  427,  430 

gyratum,>iS4 

hyperaemicum,  143 

induratum,  165 
scrofulosorum,  165 
treatment,  168 

infectiosum,  146 

intertrigo,  147 

iris,  154 

keratodes  of  palms  and  soles,  530 

laeve,  145 

marginatum,  154 

migrans,  426,  1209 

multiforme,  153 
perstans,  154,  155 
treatment,  160 

nodosum,  161 
syphiliticum,  163 
treatment,  164 

nuchae,  145 

papulatum,  154 

paratrimma,  145 

pernio,  144 

perstans,  144,  154 

recurrent  exfoliative,  150 

scarlatiniforme,  150 

scarlatinoides,  150 
recidivans,  150 

serpens,  426 

simplex,  143 

solare,  144 

trauma ticum,  145,  437 

tuberculatum,  154 

urticans,  145 

venenatum,  145 

vesiculosum,  155 
Erythematopapular  eruption,  57 
Erythematopapules,  57 
Erythematosclerosis  circinee  du  dos  des 

mains,  170 
Erythematous  eruption,  816 

spots,  57 

syphilid,  776 

syphiloderm,  776 
ErythSme  exsudatif  multiforme,  153 

indur6  des  scrofuleux,  165 


1228 


INDEX 


Erythema  noueux,  161 

chronique  des  membres  inferieurs,  165 

polymorphe,  153 

scarlatiniforme  desquamatif,  150 

scarlatinoide,  150 
Erythemes  tuberculeux,  228 
Erythrasma,  1151 
Erythroderma,  congenital  ichthyosiform, 

563 

Erythrodermia  desquamativa,  206 
Erythrodermias,  chronic  resistant  macu- 
lar,  224 

maculopapular  scaly,  224 
Erythrodermie  exfoliante,  199 
f  pityriasique  en  plaques  disseminees,  225 
Erythrodermie      congenitale      ichthyosi- 

forme,  563 

Erythromelalgia,  941 
Erythromelia,  942 
Etiology,  general,  75 
Euproctis  crysorrhcea,  1181 
Exanthem,  lichenoid,  224 

psoriasiform,  224 
Exanthemata,  465 
Exanthematic  tuberculosis,  711 
Exanthematous  syphilid,  776 

syphiloderm,  776 
Excessive  sweating,  1068 
Excoriationen,  66 
Excoriationes,  66 
Excoriations,  66 
Exfoliating  epidermis,  "68 
Exfoliatio  areata  linguae,  1 209 
Exfoliations,  epidermal,  68 
External  influences,  etiologic  significance, 

82 

Extractors,  comedo,  127 
Extremities,  ringed  eruption  of,  1 70 


FACE,  eczema,  317 

unilateral  atrophy  of,  585 
False  cicatrices,  619 

keloid,  637 

neuroma  of  Virchow,  704 
Family  diseases,  etiologic  influence,  76 
Farcin,  416 
Farcy,  416 

buds,  417 
Fat-globules,  25 
Fatty  neck,  701 

tumor,  700 
Favus,  1093 

circinatus,  1095 

des  Nagels,  961 

des  ongles,  961 

diagnosis,  1101 

etiology,  1097 

herpeticus,  1095 

of  general  surface,  1095 

of  nails,  961 

of  non-hairy  parts,  1095 

of  scalp,  1094 

pathology,  1098 

pilaris,  1094 

prognosis,  1102 

scutulum,  1094 


Favus,  symptoms,  1093 

treatment,  1103 
Febbre  scarlatina,  465 
Febrile  purpuric  edema,  494 
Febris  bullosa,  373 
Feet,  eczema  of,  324 

sore,  of  coolies,  1201 

sweating  of,  1069 
Feigned  eruptions,  448 
Feigwarze,  550 
Fetus,  harlequin,  564 
Feu  sacr6,  421 
Feuergiirtel,  348 
Feuermal,  680,  682 
Fever  blisters,  343,  373 
Fibers,  epithelial,  22 

Herxheimer's  spiral,  22 
Fibrom,  693 
Fibroma,  693 

fungoides,  904 

hard,  697 

lipomatodes,  668 

molluscum,  693 

pendulum,  693,  694 

simplex,  696,  697 

soft,  697 

treatment,  700 

Fibromatosis  tuberculosa  cutis,  714 
Fibrome,  693 
Fibromyoma,  703 
Fibrosarcoma,  900 
Fig- wart,  550 
Filarie  de  Medine,  1195 
Filaria  hominis  nocturna,  598 

medinensis,  1195 
Fingers,  ringed  eruption  on,  170 
Finnen,  1036 
Finsen  hollow  compressing  lens,  131 

lamp,  132 

Finsen-Reyn  lamp,  133 
Fischschuppenausschlag,  561 
Fish-skin  disease,  561 
Fissural  angiomata,  684 
Fissured  eczema,  274 
Fissuren,  67 
Fissures,  67 
Fixed  dressings,  121 
Flat  condyloma,  792 

papular  syphiloderm,  782 

wart,  $48 
Flea,  1 1 86 

sand-,  1195 
Flecke,  57 
Fleckenmal,  515 
Fleecy  hair,  38 
Flesh,  goose-,  30,  31 
Flesh- worms,  1032 
Flexures,  eczema  of,  325 
Flies,  1187 
Flores  unguium,  959 
Fliichtige,  gutartige  Plaques  der  Zungen- 

schleimhaut,  1209 
Fluke,  liver-,  1201 
Flush-patch,  688 
Fluted  tongue,  1209 

Follicle,  hair-,   37,   40.     See  also    Hair- 
follicle. 


INDEX 


1229 


Folliclis,  1054 

Follicular  eczema,  268,  271 

muscles,  30 

xeroderma,  566 
Folliculite  epilante,  1010 
Folliculites  cicatricielles  necrosiques,  1054 

et  perifolliculites  decalvantes  agminees, 

1010 
Folliculitis,  agminate,  1112 

barbae,  1014 

decalvans,  1010 
treatment,  1013 

exulcerans  serpiginosa  nasi,  1055 

necrosing,  1054 

nuchae  sclerotisans,  643 
Follikelcyste,  1030 
Food,  etiologic  influence,  81 
Foot,  fungus,  of  India,  1160 

Madura,   1160 

perforating  ulcer  of,  629 

tubercular  disease  of,  1160 
Football  impetigo,  401 
Fordyce's  disease,  1215 

of  lips  and  oral  mucous  membrane, 

1215 

Formication,  56 
Fowl-mite,  1187 
Fragilitas  crinium,  973 
Frambesia,  850 

treatment,  856 
Framboesia  tropica,  850 
Fraying  of  hair,  975 
Freckles,  502 

cold,  503 

congenital,  503 
French  measles,  474 
Fressende  Flechte,  719 
Frost  itch,  944 
Frost-bites,  436 
Function,  heat-regulating,  of  skin,  50 

protective,  of  skin,  47 

respiratory,  of  skin,  49 

secretory,  of  skin,  51 

sensory,  of  skin,  48 
Fungoid  neoplasm,  inflammatory,  904 
Fungous  disease  of  external  ear,  1154 
Fungus,  chignon,  980 

foot  of  India,  1160 
Furfuraceous  scales,  69 
Furoncle,  408 
Furrowed  eczema,  274 

nails,  958 

tongue,  1209 
Furuncle,  408 
Furunculosis,  409 
Furunculus,  408 

treatment,  410 
Furunkel,  408 


GAD-FLY,  1198 
Gale,  1 1 88 
Galvanocautery,  126 

needle,  knife,  and  spiral  points,  748 
Gangosa,  857 

treatment,  858 
Gangraena  cutis  hysterica,  430 


Gangrene,  diabetic,  431 

disseminated,  429 

hysteric,  429 

juvenile,  430 

multiple  cachectic,  427 

of  skin,  multiple  disseminated,  in  in- 
fants, 427, 
in  adults,  429 
spontaneous,  427,  429 

symmetric,  432 
Gangrenous  ecthyma,  infantile,  427 

varicella,  427 

zoster,  429 
Gassa  button,  845 
Gastro-intestinal  antiseptics,  108 
Gastrophilus  epilepsalis,  1199 
Gefassmal,  680 
Gelappte  zunge,  1209 
Gemeiner  Floh,  1186 
General  exfoliative  dermatitis,  199 
Genital  nerve-corpuscles  of  Krause,  29 

region,  eczema,  327 

Genitals,  serpiginous  ulceration  of,  863 
Genitocrural  region,  ringworm  of,  treat- 
ment, 1135 

Geographic  tongue,  1210 
Germ  layer,  21 
German  measles,  474 
Germicides,  in 
Geschwiilste,  61 
Geschwiire,  70 
Giant  urticaria,  181,  191 
Giant-cells,  xanthoma,  672 
Gift  spots,  959 
of  nails,  43 

Glabrous  skin,  ringworm  of,  1109 
Glanders,  416 
Glandulae  glomiformes,  33 

sebaceae,  35 

sebiferae,  35 

sudoriferae,  33 

Glassy  layer  of  hair-follicle,  42 
Gleoscleroma,  705 
Globes,  880 
Globi,  lepra,  932 
Globules,  fat-,  25 

Glossite  exfoliatrice  margin6e,  1209 
Glossitis  areata  exfoliativa,  1209 

chronic  superficial,  1203 
Glossy  skin,  616 
Gnat,  1187 
Gneis,  1021 
Goose-flesh,  30,  31 
Gouty  eczema,  278,  1112 
Grain  dermatitis,  1183 

itch,  945,  1183 

Grain-mite  dermatitis,  945,  1183 
Grains,  544 
Granular  layer,  19,  21 
Granuloma  annulare,  170 
treatment,  172 

fungoides,  904 
diagnosis,  910 
etiology,  908 
pathology,  908 
prognosis,  910 
symptoms,  905 


1230 


INDEX 


Granuloma  fungpides,  treatment,  910 

inguinale  tropicum,  863 

necrotic,  1054 

pediculatum,  692 

pediculum,  692 

pyogenicum,  692 

sarcomatodes,  904 

telangiectodes,  692 

trichophyticum,  1113,  1118 

ulcerating,  of  pudenda,  863 

venereal,  863 
Granulome  pedicule,  692 
Granulosis  rubra  nasi,  1087 
Gray  hair,  983 
Graying  of  hair,  sudden,  39 
Grayness  of  hair,  983 
Green  soap,  117 
Grocers'  eczema,  281 

itch,  281 

Groin  ulceration,  863 
Grooved  tongue,  1209 
Ground  itch,  1201 
Grubs,  1032 
Grutum,  1028 
Griitzbeutel,  1030 
Guinea-worm,  1195 

disease,  1195 
Gum,  red,  1088 
Gumma,  809,  817 

scrofulous,  718 

tuberculous,  718 
Gummatous  syphiloderm,  809 
Gune,  1144 
Giirtelausschlag,  348 

Gutartiges  Epithelioma,  mit  kolloider  de- 
generation, 652 
Gutta  rosacea,  1060 

rosea,  1060 


HAARBALGMILBE,  1197 
Haarschwund,  987 
Haarzunge,  1212 

Habitation,  etiologic  influence,  76 
Haemorrhcea  petechialis,  492 
Hair,  37 

atrophy  of,  973 

beaded,  978 

bed-,  40 

color  changes,  985 

color  of,  39 

development  of,  first  sign,  39 

diseases  of,  964 

downy,  38 

fleecy,  38 

fraying  of,  975 

gray,  983 

grayness  of,  983 

hypertrophy  of,  964 

knotting  of,  975 

moniliform,  978 

nodose,  978 

pigment,  atrophy  of,  983 

pseudoknotting  of,  975 

ringed,  984 

root-sheath  of,  42 

sudden  graying  of,  39 


Hair,  superfluous,  964 

whiteness  of,  983 
Hair-bulb,  38,  43 
Hair-follicle,  37,  40 

dermic  or  external  coat,  40 

diseases  of,  964 

epidermic  or  inner  coat,  42 

epidermis  of,  42 

glands,  35 

glossy  layer,  42 

hyaline  membrane  of,  40 

prickle-cell  layer  of,  42 

root-sheath  of,  42 

vitreous  membrane  of,  42 
Hairiness,  964 
Hair-papilla,  43 
Hair-root,  38 

Hair-sacs,  37,  40.     See  also  Hair-follicle. 
Hair-shaft,  38 
Hairy  mole,  515 

people,  965 

tongue,  1 21 2 
Hands,  eczema  of,  321 

sweating  of,  1069 
Hard  fibroma,  697 
Harlequin  fetus,  564 
Harnschweiss,  1081 
Harrison's  method  of  treating  ringworm 

of  scalp,  1140 
Harvest  bug,  1195 
Hautabschiirfungen,  66 
Hautblastomykose,  1162 
Hauthorn,  558 
Hautkrebs,  870 
Hautrose,  421 
Hautschrunden,  67 
Head-lice,  1175 
Head-lousiness,  1175 
Heat,  etiologic  influence,  83 

prickly,  1088 
Heat-rash,  1088 

Heat-regulating  function  of  skin,  50 
Hectine  in  syphilis,  839 
Hedge-hog  skin,  565 
Hefenmykose,  1162 
Hematidrose,  1080 
Hematidrosis,  1080 
Hemiatrophia  facialis,  585 
Hemidrosis,  1080 
Hemorragies  cutanees,  492 
Hemorrhages,  492 
Hemorrhagic  sarcoma,  897 

urticaria,  181 

variola,  483 
Henoch's  purpura,  494 
Hereditary  syphilis,  cutaneous  manifesta- 
tions, 813 
treatment,  844 

Heredity,  etiologic  influence,  76 
Herpes,  343 

circinatus,  1115 
bullosus,  364 

desquamans,  1144 

facialis,  344 

gestationis,  364 

iris,  155 

labialis,  344 


INDEX 


1231 


Herpes  phlyctaenodes,  364 
praeputialis,  345 
progenitalis,  345 
simplex,  343 

treatment,  347 
tonsurans,  1104,  1109,  1115 
barbae,  1119 
capillitii,  1115 
circumscriptus,  1109 
maculosus,  194,  197,  mi 
zoster,  348 
diagnosis,  356 
etiology,  352 
gangrsenosus,  350 
haemorrhagicus,  349 
pathology,  353 
prognosis,  356 
symptoms,  348 
treatment,  357 
Herpfes  circine,  1109 
parasitaire,  1109 
parasitaire,  1109 
tonsurant,  1115 
vulgaire,  343 
Herpetic  fever,  345 
Herpetiform  syphilid,  795 
Herxheimer's  spiral  fibers,  22 
Heteropus  ventricosus,  1183 
Hide-bound  skin,  578 
Hidradenitis  suppurativa,  1054 
Hidrocystoma,  1084 
High-frequency  current  134 
Hirsuties,  964 

History  as  diagnostic  factor,  88 
Hives,  179 
Hoariness,  983 
Hodgkin's  disease,  913 
Holzbock,  1187 
Homines  pilosi,  965 
Honey-comb  ringworm,  1093 
Hookworm  disease,  1201 
Horn,  cutaneous,  558 
Hornauswuchs,  558 
Hornplattchen,  68 
Horny  excrescence,  558 
layer,  19,  20 

tumor,  558  , 

Hiihnerauge,  524 
Hungarian  itch,  1190 
Hutchinson's"  teeth,  814,  815 
Hyaline  layer,  21 

membrane  of  hair-follicle,  42 
Hyaloma,  678 

der  Haut,  678 
Hyalome,  678 
Hybrid  measles,  474 
Hydradenomes  e>uptifs,  652 
Hydroa  aestivale,  358 
bulleux,  364 
herpetiforme,  364 
puerorum,  359 
vacciniforme,  358 
Hydrocystoma,  1084 

treatment,  1086 

Hygiene,  personal,  etiologic  influence,  82 
Hyperemias,  143 
Hyperemic  treatment,  134 


Hyperesthesia,  939 
Hyperidrose,  1068 
Hyperidrosis,  1068 

manuum,  1069 

oleosa,  1022 

pedum,  1069 

treatment,  1072 
Hyperkeratose    figur6e    centrifuge    atro- 

phiante,  571 
Hyperkeratosis  eccentrica,  571 

figurata  centrifuga  atrophicans,  571 

linguae,  1212 
Hypertrichiasis,  964 
Hypertrichosis,  964 

acquired,  965 

congenital,  964 

partialis,  964 

transitory,  966 

treatment,  967 

universalis,  964 
Hypertrophia  pilorum,  964 
Hypertrophic  scar,  73,  634,  638 
Hypertrophie  6pitheliale  filiforme,  1212 
Hypertrophies,  502 
Hypertrophy  of  hair,  964 

of  nail,  952 
Hyphogenous  alopecia,  1004 

sycosis,  1119 
Hypoderm,  24 
Hyponomoderma,  1199 
Hyponychium,  44 
Hysteric  gangrene,  429 

stigmata,  1080 


ICHTHYOSE,  561 

Ichthyosiform  erythroderma,  congenital, 

563 

Ichthyosis,  561 
acquired,  567 
congenita,  561,  564 
cornea,  566 
diagnosis,  569 
etiology,  566 
follicularis,  541,  566 
hystrix,  565 
intra-uterine,  564 
linear,  566 

linearis  neuropathica,  516 
linguae,  566,  1203 
mixed  variety,  566 
nacree,  562 
nigricans,  562 
nitida,  562 
palmar,  chronic,  566 
palmaris  et  plantaris,  528 
pathology,  567 
plantar,  chronic,  566 
prognosis,  569 
sauroderma,  563 
scutellata,  563 
sebacea,  564,  565,  1021,  1022 

cornea,  541 
serpentina,  562 
simplex,  561 
symptoms,  561 
treatment,  570 


1232 


INDEX 


Ichthyosis  vera,  561 

Ichtyose,  561 

Idiopathic  atrophy,  diffuse,  of  skin,  622 

chloasma,  505 

keloid,  637 

premature  alopecia,  990 
Idrosis,  1068 
Ignis  sacer,  348 
Immunity  to  ringworm,  1132 
Impetigiform  syphilid,  798 

syphiloderm,  798 
Impetigo,  395 

bath-house,  401 

circinata,  396,  397,  399 

contagiosa,  395,  396,  397 
bullosa,  399 
treatment,  404 
varieties,  397 

figurata,  397,  399 

football,  401 

herpetiformis,  406 

parasitica,  397 

ring-like  type,  399,  400 

rpdens,  1054 

simplex,  395,  397,  399 

sparsa,  395,  397 

staphylogenes,  396,  397,  399 

streptogenes,  396,  397 

syphilitica,  798 

vulgaris,  396,  397,  401 
Impetigos,  the,  395 
India,  fungus  foot  of,  1160 

ringworm,  1144 
India-rubber  men,  606 
Infantile  eczema,  314 
treatment,  302 

gangrenous  ecthyma,  427 

syphilis,  813 

Infectious  eczematoid  dermatitis,  271 
Infective  angioma,  690 
Inflammations,  153 
Inflammatory  fungoid  neoplasm,  904 
Ingrowing  nail,  955 
Insects,  stings  of,  1187 
Insensible  perspiration,  51 
Instruments,  134 

Internal  secretions,  etiologic  influence,  80 
Intertrigo,  147 

Intoxication,  auto-,  etiologic  influence,  80 
Intra-uterine  ichthyosis,  564 
lodid  acne,  1041 
lodin  acne,  1041 
lodoform  dermatitis,  441 

eczema,  283,  241 
Irritants,  chemical,  etiologic  influence,  83 

mechanical,  etiologic  influence,  83 
Italian  itch,  1190 
Itch,  i i 88 

army,  1190 

bakers',  281 

barbers',  1119 

barley,  1183 

barn-,  1124 

copra,  1192 

dhobie,  374,  1113,  1114 

frost,  944 

grain,  945,  1183 


Itch,  grocers',  281 

ground,  1201 

Hungarian,  1190 

Italian,  1190 

laundrymen's,  1114 

lumbermen's,  944,  1184,  1190 

Malabar,  1144 

mattress,  1183 

Norwegian,  1189 

Polish,  1190 

prairie,  944,  1183,  1190 

straw,  945,  1183 

straw-packers',  1183 

swamp,  944,  1184,  1190 

water-,  1201 

winter,  944 
Itching,  56 
Ivy-poisoning,  442 
Ixodes,  1187 

JACOB'S  ulcer,  872 
Jaw,  lumpy,  1155 
Jigger,  1195 
Juckblattern,  208 
Juvenile  gangrene,  430 

KAHLHEIT,  987 
Kakerlaken,  608 
Kandahar  sore,  845 
Kelis,  636 
Keloid,  73,  636 

acne,  643 

Alibert's,  636 

cicatricial,  637 

false,  637 

idiopathic,  637 

of  Addison,  582 

primary,  637 

scar,  637 

secondary,  637 

spontaneous,  637 

spurious,  637 

treatment,  641 
Keloide,  636 
Kelos,  636 

Kerato-angioma,  575 
Keratodermia  blenorrhagica,  532 

eccentrica,  571 

symmetric,  528 
Keratodermie  blenorrhagique,  532 

plantaire  et  palmaire,  528 
Keratohyalin,  21 
Keratolysis  neonatorum,  206 
Keratoma,  526,  528 

diffusum,  564 

palmare  et  plantare  haereditarium,  528 
Keratose  pilaire,  537 
Keratosis,  arsenical,  457,  458 

blenorrhagica,  532 
treatment,  534 

blenorrhoica,  532 

follicularis,  541 
contagiosa,  545 
treatment,  545 

palmaris  et  plantaris,  528 
treatment,  531 


INDEX 


1233 


Keratosis  pigmentosa,  548 
pilaris,  537 
alba,  539 
rubra,  539 
treatment,  539 
senilis,  534 

treatment,  536 
Kerion, 1117 
ringworm,  1117 
tinea,  1117 

Kienbock-Adamson     method     of     #-ray 
treatment  of  ringworm  of  scalp,  1142, 

H43 

Kleienflechte,  1147^ 
Kleinzirzinare  psoriasis,  238 
Knollen,  61 
Knotchen,  59 
Knoten,  60 
Knotting  of  hair,  975 
Kohlenbeule,  412 
Koplik's  spots,  471 
Kratze,  1188 
Kraurosis  vulvae,  625 
Krause's  corpuscles,  27,  29 

genital  nerve-corpuscles,  29 
Kromayer  lamp,  133 
Krusten,  69 

Kummerf eld's  lotion,  1051,  1066 
Kupferfmne,  1060 
Kupferrose,  1060 
Kyste  sebace,  1030 


LA  LE'PRE,  914 

perleche,  1217 

rose,  421 

Verruga,  859 

Lactation,  etiologic  influence,  79 
Lafa  Tokelau,  1 144 
Lamellae,  69 
Lamp,  Finsen,  132 

Finsen-Reyn,  133 

Kromayer,  133 

quartz,  133 
Land  scurvy,  495 
Landkartenzunge,  1209 
Langerhans,  cells  of,  22 
Langer's  lines  of  cleavage,  17 
Langua  pliss6e,  1209 
Langue  montagneuse,  1209 

noire,  1212 
pileuse,  1212 

scrotale,  1209 
Lanolin,  119 
Lanugo,  38 
Larva,  echinococcus,  1201 

migrans,  1199 
Lassar's  paste,  120 
Laundrymen's  itch,  1114 
Lausesucht,  1173 
Laxatives,  vegetable,  108 
Layer,  dead,  20 

epithelial,  19 

epitrichial,  20 

germ,  21 

glossy,  of  hair-follicle,  42 

granular,  19,  21 

78 


Layer,  horny,  19,  20 

hyaline,  21 

Malpighian,  19,  21 

mucous,  19,  21 

papillary,  23 

prickle,  22 

prickle-cell,  of  hair-follicle,  42 

reticular,  24 

shining,  19,  20 

thorny,  22 

translucent,  20 
Le  peta,  1144 
Leberflecken,  504 
Leg,  Barbadoes,  592 

eczema  of,  328 

elephant,  592 

weeping,  272 
Leichdorn,  526 
Leiomyoma,  702,  703 
L'endurcissement  athrepsique,  589 
Lenticular  carcinoma,  864 

papular  syphilid,  782 

syphiloderm,  782 
Lentigo,  502 

maligna,  889 
Lentilles,  502 
Leontiasis,  914 
Leper  claw,  924 
Lepidophyton,  1146 
Lepothrix,  982 
Lepra,  236,  914 

alphos,  236 

anaesthetica,  922 

anesthetic,  922 

Arabum,  914 

cells,  931,  932 

course,  925 

diagnosis,  933 

enteritis,  927 

etiology,  927 

globi,  932 

macular,  918 

maculosa,  918 

mixed  type,  925 

mutilans,  924 

nervorum,  922 

nodular,  919 

pathology,  930 

phthisis,  927 

prognosis,  934 

stage  of  incubation,  916 
of  invasion,  917 

symptoms,  915 

treatment,  935 

tubercular,  919 

tuberculated,  919 

tuberculosa,  919 
Leprolin,  937 
Leprosy,  914 
Lombardian,  173 
Leptus,  1195 

L'eryth£me  pellagreux,  173 
Lesions,  configuration,  distribution,  and 
other  features,  73 

consecutive,  66 

elementary,  57 

primary,  57 


1234 


INDEX 


Lesions,  secondary,  66 
Leucoplasie,  1203 
Leukaemia  cutis,  900 
Leukasmus,  acquired,  610 

congenital,  608 
Leukemia  cutis,  911 
Leukocytozoon  syphilis,  821 
Leukoderma,  608,  610 
congenital,  608 
syphilitic,  778 

Leukokeratosis  buccalis,  1203 
Leukoma,  1203 
Leukonychia,  959 
Leukopathia,  610 
acquired,  610 
congenital,  608 
unguium,  959 
Leukoplakia,  1203 
buccalis,  1203 
treatment,  1208 
Leukoplasia,  1203 
Leukotrichia  annularis,  984 
Lice,  crab-,  1179 

head-,  1175 
Lichen,  60 
agrius,  268 
annularis,  170 
annulatus,  335 
circumscriptus,  268,  335 
gyratus,  335 
lividus,  228 
nitidus,  223 
obtusus,  214 

corneous,  210 
pilaris,  537 

seu  spinulosus,  540 
planus,  213 
annular,  213 
atrophicus,  215 
hypertrophicus,  214 
in  children,  217 
keloidiformis,  215 
morphceicus,  215 
of  mucous  membrane,  216 
treatment,  221 
verrucosus,  214 
psoriasis,  213,  231 
ruber,  231 

acuminatus,  218,  231 
moniliformis,  215 
planus,  213,  218 
simplex,  267 
scrofulosorum,  227 
scrofulosus,  227 

treatment,  230 
spinulosus,  540 
tropicus,  1082 
urticatus,  182 
variegatus,  224 
Lichenification,  60,  223 
Lichenoid,  60 

eruption,  chronic  itching,  of  axillary  and 

pubic  regions,  222 
exanthem,  224 
Lichenoide  lingual,  1209 
Lignieres'  test  in  tuberculosis  cutis,  741 
Lineae  albicantes,  619 


Lineae  gravidarum,  619 
Linear  atrophy,  619 

ichthyosis,  566 

naevus,  516 

scarifications,  126 
Lines  of  cleavage,  Langer's,  17 

Voight's,  520 
Lingua  geographica,  1210 

nigra,  1212 

plica  ta,  1209 
Liniment,  calamin,  118 

calamin-zinc-oxid,  118 
Linimentum  exsiccans,  311 
Linsenflecken,  502 
Linsenmal,  515 
Liodermia    essentialis    cum    melanosi    et 

telangiectasia,  889 

Lip  and  oral  mucous  membrane,  Fordyce's 
disease  of,  1215 

eczema  of,  320 

epithelioma  of,  876 

parasitic  disease  of,  1217 
Lipoma,  700 

circumscribed,  700 

diffuse,  700 
Liquid  air,  124 
Liquor  carbonis  detergens,  306 

picis  alkalinus,  314 
Liver-fluke,  1201 
Liver-spots,  504,  1147 
Living  stratum  of  epidermis,  21 
Local  asphyxia,  432 
Lombardian  leprosy,  173 
Loose  skin,  604,  605 
Lotio  alba,  1050 
Lotion,  calamin-and-zinc-oxid,  118 

Kummerfeld's,  1051,  1066 
Lotions,  117 
Louse,  chicken-,  1187 
Lousiness,  1173 

body-,  1177 

head-,  1175 
Lues,  769 

venera,  769 
Luetin,  825 

reaction  in  syphilis,  825 
Lumberman's  itch,  944,  1184,  1190 
Lumpy  jaw,  1155 
Lunula  of  nail,  44 
Lupoid  acne,  1054 

miliary,  902 
benign,  902 

sycosis,  1010,  1015 
Lupus,  719 

annularis,  726 

disseminatus,  726 

elephantiasicus,  722 

elevatus,  722 

Erythema teux,  753 

erythematodes,  753 

erythematoide,  759 

erythematosus,  753 
acute,  757 
course,  759 
diagnosis,  763 
discoides,  753 
disseminatus,  757 


INDEX 


1235 


Lupus  erythematosus,  etiology,  760 
of  mucous  membrane,  758 
pathology,  761 
prognosis,  764 
symptoms,  753 
treatment,  764 
external,  766 
exedens,  720 
exfoliativus,  721 
exulcerans,  720 
hypertrophicus,  721,  723 
keloides,  722 
lymphaticus,  663 
maculosus,  719 
naevus,  690 
nodosus,  722 
cedematosus,  722 
of  mucous  membranes,  724 
papillomatosus,  722,  724 
pernio,  756 
planus,  722 
sclerosus,  722 
sebaceus,  753 
serpiginosus,  722 
tuberculeux,  719 
tumidus,  722 
verrucosus,  722,  724 
vorax,  719 
vulgaire,  719 
vulgaris,  719 

Calmette's  test  in,  740 
course,  729 
diagnosis,  738 
etiology,  730 
Lignieres'  test  in,  741 
Moro's  test  in,  741 
pathology,  732 
prognosis,  741 

sclerosus  erythematoides,  725 
symptoms,  719 
treatment,  742 
von  Pirquet's  test  in,  741 
Wolf-Eisner  test  in,  740 
Lupus-psoriasis,  728 
Lustseuche,  769 
Lymph  tumors,  596 
Lymphadenie  cutanee,  904 
Lymphadenitis,  syphilitic,  815 
Lymphadenoma  cutis,  913 
Lymphangiectasis,  575,  661 
Lymphangiectodes,  663 
Lymphangioma,  661 
capillare  varicosum,  663 
cavernosum,  663 
cavernous,  663 
circumscriptum,  663 

treatment,  666 
cystic,  663 
simple,  662 
simplex,  663 
superficiale  simplex,  663 
tuberosum  cutis  multiplex,  662 

multiplex,  654 

Lymphangiome  circonscrit  vesiculeux,  663 
Lymphangiomyoma,  703 
Lymphangitis  tuberculosa  cutanea,  715 
Lymphatics,  26 


Lymphodermia  perniciosa,  894,  904 
Lymphosarcoma,  900 
Lymph-scrotum,  596 


MACROCHEILIA,  662 
Macroglossia,  662,  1209 
Maculae,  57 

atrophicae,  619 

caeruleae,  1180 
Macular  eruption,  816 

erythrodermias,  chronic  resistant,  224 

leprosy,  918 

syphilid,  776 

syphiloderm,  776 
Macules,  57 
Maculopapular  eruption,  57,  816 

scaly  erythrodermias,  resistant,  224 
Maculopapules,  57 
Madura  foot,  1160 
Madurafuss,  1160 
Mai  de  los  pintos,  1153 

de  misere,  173 

del  pinto,  *  1 53 
sole,  173 

des  pieds  et  des  mains,  1 78 

perforant  du  pied,  629 

rosso,  173 
Malabar  itch,  1144 
Maladie  de  Carrion,  859 

de  Morvan,  631 

de  Paget,  866 

de  Paris,  178 

pediculaire,  1173 
Malaria,  etiologic  influence,  80 
Malignant  papillary  dermatitis,  866 

pustule,  418 

scarlatina,  468 

syphilis,  772 
Malis  pediculi,  1173 
Malleus,  416 
Malpighian  layer,  19,  21 
Malum  perforans  pedis,  629 
Mammillaris  maligna,  866 
Mange,  Texas,  944,  1184 
Marsden's  paste,  887 
Masern,  471 
Matrix  of  nail,  44 
Mattress  itch,  1183 
Mazamorro,  1201 
Measles,  471 

catarrhal  symptoms,  472 

complications,  473 

diagnosis,  473 

eruption,  471 

fever,  472 

French,  474 

German,  474 

hybrid,  474 

symptoms,  471 
Mechanical  irritants,  etiologic  influence, 

83 

measures,  126 
Medicated  soaps,  117 
Medicinal  eruptions,  451 
Medinawurm,  1195 
Megalosporon,  1105 


1236 


INDEX 


Megalosporon  ectothrix,  1105 

endothrix,  1105 
Meibomian  glands,  36 
Meissner's  corpuscles,  27,  28 
Melanidrosis,  1077 
Melanocarcinoma,  896 
Melanoderma,  505 
Melanoma,  895,  896 
Melanosis  lenticularis  progressiva,  889 
Melanotic  carcinoma,  865 

sarcoma,  895 

whitlow,  897 
Melasma,  505 
Mentagra,  parasitic,  1119 

parasitica,  1119 
Meralgia  paraesthetica,  939 
Mercurial  eczema,  283 
Merkel's  touch-cells,  27,  29 
Microcautery,  126 
Microsporon,  1105,  1106 

Audouini,  1003,  1105,  1106 

canis,  1106 

decalvans,  1003 

dispar,  197 

felineum,  1106 

lanosum,  1106 

tardum,  1106 
Microsporosis,  1104,  1106 

capitis,  1115 
Microvaricella,  1185 
Miiiare,  1088 

crystalline,  1082 
Miliaria,  1088 

alba,  1089 

crystallina,  1082 

papulosa,  1088 

rubra,  1088 

treatment,  1090 

vesiculosa,  1088 

Miliary    acuminated    pustular    syphilo- 
derm,  795 

fever,  1091 

lupoid,  902 
benign,  902 

sweat  rash,  1091 

tuberculosis  of  skin,  709 
Milium,  1028 

colloid,  678 
Milk  crust,  269 

Milky  exudation  of  scrotum,  596 
Milzbrand,  418 
Milzbrandcarbunkel,  418 
Mineral  waters,  natural,  114 
Mite,  bird-,  1187 

fowl-,  1187 

mower's,  1195 
Mitesser,  1032 
Moist  eczema,  265 

papule,  792 

tetter,  265 

wart,  550 
Mole,  515 

hairy,  515 

pigmentary,  515 

warty,  548 

Mollusciform  naevus,  605 
Molluscum  bodies,  545,  648,  649,  650 


Molluscum  cell,  650 

cholesterique,  668 

contagiosum,  645 
treatment,  651 

corpuscles,  649,  650 

epitheliale,  645 

fibrosum,  693 

non-contagiosum,  693 

pendulum,  693 

sebaceum,  645 

simplex,  693 

vrai,  693 
Monilethrix,  978 
Moniliform  hair,  978 
Morbilli,  471 
Morbus  elephas,  592 

maculosus  Werlhoffi,  495 

pedicularis,  1173 

pediculosis,  1173 

pedis  entophyticus,  1160 
Moro's  test  in  tuberculosis  cutis,  741 
Morphea,  582 

Morphea-like  epithelioma,  872 
Morphcea  guttata,  622 
Morvan's  disease,  631 
Morvansche  Krankheit,  631 
Morve,  416 
Mosquito,  1187 
Moth,  brown-tail,  1181 
dermatitis  from,  1181 

patches,  504 
Mother  wart,  547 

yaw,  852 

Mother's  mark,  515,  680 
Motor  nerves,  30 
Mower's  mite,  1195 
Mucor  dermatosis,  1192 
Mucous  layer,  19,  21 

membrane,  lichen  planus  of,  216 
lupus  erythema tosus  of,  758 
lupus  of,  724 
tinea  of,  mi 

orifices,  sebaceous  glands  of,  36 

papule,  792 

patch,  792,  793 

surfaces,  adjoining,  eczema  of,  330 
Mulberry  naevus,  683 
Multiple  benign  cystic  epithelioma,  652, 

877 
treatment,  656 

sarcoid,  902 

tumor-like  new  growths,  667 
cachectic  gangrene,  427 
comedo,  1032,  1034 
dermoid  cysts,  1031 
disseminated  gangrene  of  skin  in  infants, 

427 

gangrene  of  skin  in  adults,  429 
Granulationsgeschwiilste,  904 
pigmented  sarcoma,  897 
Muscles,  30 

arrectores  or  erectores  pilorum,  30 

follicular,  30 

non-striated,  30 

smooth,  30 

striated,  30 

tumor,  702 


INDEX 


1237 


Mycetoma,  1160 
Mycetome,  1160 
Mycomyringitis,  1154 
Mycosis  d'emblee,  907 

fongoide,  904 

fungoides,  904 

microsporina,  1147 
Myelosyringosis,  631 
Myiasis  dermatosa,  1198 
mucosa,  1198 
cestrosa,  1198 
Myom,  702 
Myoma,  702 

dartoic,  703 

multiple,  703 

simple,  703 

single,  703 

telangiectodes,  703 
Myome  cutane,  702 
Myringomycosis,  1154 

aspergillina,  1154 
Myxadenitis  labialis,  1214 
Myxedema,  601 

treatment,  604 
Myxoedem,  601 
Myxcedeme,  601 


NJEVI  epitheliaux  kystiques,  652 

vasculaires  et  papillaires,  656 
Naevoid  elephantiasis,  596 
Naevo-xanthoma-endotheliomata,  670 
Naevus  anaemicus,  681 

araneus,  682,  688 

bathing  drawers,  515 

bathing- trunk,  515 

cells,  518 

flammeus,  682 

lichenoide,  516 

linear,  516 

lipomatodes,  515,  702 

lupus,  690 

mollusciform,  605 

molluscolde,  693 

mulberry,  683 

nervosus,  516 

pigmentaire,  515 

pigmentosus,  515 
treatment,  520 

pilosus,  515 

pulsating,  683 

sanguineus,  680 

simplex,  682 

spider,  682,  688 

spilus,  515 

tuberosus,  683 

unius  lateralis,  516 

vasculaire,  680 

vascularis,  680 

vasculosus,  680 
treatment,  685 

venous,  683 

verrucosus,  515 
Nail-bed,  44 
Nail-body,  43 
Nail-fold,  44 
Nail-groove,  44 


Nail-root,  43 
Nail-skin,  44 
Nail- wall,  44 
Nails,  43 

atrophy  of,  957 

claw-,  953 

development,  45 

diseases  of,  952 

eczema,  324 

favus  of,  961 

furrowed,  958 

gift  spots  of,  43,  959 

hypertrophy  of,  952 

ingrowing,  955 

luriula,  44 

matrix,  44 

ringworm  of,  961 

shedding  of,  959 

spoon-,  958 

supernumerary,  952 

syphilis  of,  775 

white,  959 

spots  of,  43,  959 
Narbe,  634 
Narben,  72 
Nares,  eczema  of,  319 
Nassende-flechte,  261 
Nastin,  937 

B.,  937 

Natal  sore,  845 
Necator  americanus,  1202 
Neck,  fatty,  701 
Necrosing  folliculitis,  1054 
Necrotic  granuloma,  1054 

tuberculides,  712 
Neo-endothrix,  1105,  1107^ 
Neoplasie  nodulaire  et  circinee,  170 
Nerve  tumor,  704 

Nerve-corpuscles,  genital,  of  Krause,  29 
Nervenschmerz  der  Haut,  940 
Nervenschwamm,  704 
Nerves,  27 

motor,  30 

trophic,  of  skin,  49 

vasomotor,  30 

of  skin,  48 
Nervous  papillae,  24 

system,  etiologic  influence,  79 
Nesselausschlag,  179 
Nesselsucht,  179 
Nettlerash,  179 
Neuralgia  of  skin,  940 
Neurodermatitis,  chronic    circumscribed, 

223 

Neurofibromatosis,  696 
Neuroma,  704 

false,  of  Virchow,  704 
Neuron,  704 
Neuroses,  939 
Neurotic  eczema,  279 
Nevrodermite  chronique  circonscrite,  223 
Nevrome,  704 
New  growths,  634 

multiple  benign  tumor-like,  667 
Newborn,  edema  of,  591 

sclerema  of,  589 
Nigritie  de  la  langue,  1212 


1238 


INDEX 


Nipple,   eczematoid   epitheliomatosis   of, 
866 

Paget's  disease,  866 
Nocardiosis,  1158 
Nodal  fever,  163 
Nodose  hair,  978 
Nodosite  des  poils,  978 
Nodular  carcinoma,  865 

leprosy,  919 

syphilid,  803 

syphiloderm,  803 
Nodules,  60 
Noduli  cutanei,  697 

Noguchi's   cutaneous  luetin   reaction   in 
syphilis,  825 

modification  of  Wassermann  test  for 

syphilis,  825 
Noire  and  Sabouraud  method  of  #-ray 

treatment  of  ringworm  of  scalp,  1141 
Noli  me  tangere,  870,  872 
Norwegian  itch,  1189 
Nostrils,  eczema  of,  319 
Notched  teeth  in  syphilis,  814,  815 
Nurses'  eczema,  281,  440 


OCCUPATION  dermatoses,  442 

etiologic  influence,  83 
Occupational  dermatoses,  281 

eczema,  281 

(Edema  angioneuroticum,  191 
treatment,  194 

circumscriptum,  191 

cutis  circumscriptum  acutum,  191 

neonatorum,  591 
CEdeme  aigue,  191 
Oeil  de  perdrix,  524 
CEstrus,  1198 
Ohio  scratches,  944,  1184 
Oidiomycosis  of  skin,  1162 
Oil-glands,  35 
Oils,  121 

Ointment,  stearoglycerid,  994,  1027 
Ointments,  119 
Old  age  of  skin,  534,  617 
Onychatrophia,  957 
Onychauxis,  952 
Onychia,  954 

of  syphilis, -7  75 
Onychogryphosis,  953 
Onychomycose  favique,  961 

trichophytique,  961 
Onychomycosis,  953,  961 

favosa,  961 

tonsurans,  961 

trichophytina,  961 
Oospora  canina,  noi 
Opaline  patches,  793 
Operative  measures,  126 
Opsonins,  113 

Organic  disease,  etiologic  influence,  77 
Oriental  boil,  845 

sore,  845 

treatment,  849 
Orientbeule,  845 
Oroya  fever,  859 
Osmidrosis,  1075 


Otitis  externa  parasitica,  1154 
Otomycosis,  1154 
Oxyuriasis  cutanes,  1199 


PACHYDERMATOCELE,  604 
Pachydermia,  592 
Pacinian  corpuscles,  27 
Paget's  disease,  866 
of  nipple,  866 
treatment,  870 

Krankheit,  866 
Palmar  ichthyosis,  chronic,  566 

syphiloderm,  786 
Panaris  analgesique,  631 
Panighao,  1201 
Panne  hepatique,  504 
Panniculus  adiposus,  25 
Papilla,  hair-,  43 
Papillae,  23 

compound,  23 

fungiformes,  29 

nervous,  24 

vascular,  24 
Papillary  dermatitis,  malignant,  866 

layer,  23 

varices,  689 
Papilloma,  546 

linear e,  516 

neuropathicum  unilaterale,  516,  517 

of  sole,  547 
Papillomatous  syphilid,  806 

syphiloderm,  806 
Papulae,  59 
Papular  eczema,  267 

syphilid,  lenticular,  782 

syphiloderm,  flat,  782 
large  flat,  783 
lenticular,  782 
small  flat,  783 

urticaria,  181,  182 
Papules,  59 

moist,  792 

mucous,  792 

squamous,  60 

vegetating,  792 
Papulopustular  eruption,  60 
Papulopustules,  60,  65 
Papulosquamous  eruption,  60 

syphilid,  786 

syphiloderm,  786 

Papulotubercular  syphiloderm,  803,  805 
Papulovesicles,  60 
Papulovesicular  eruption,  60 
Paquelin  cautery,  126 
Parakeratosis  ostreacea,  239 

psoriaform,  197 

variegata,  224 

Paralysis,  analgesic,  with  whitlow,  631 
Parangi,  850 
Parasporiasis,  224,  226 

guttata,  226 

lichenoides,  226 
Parasitare  Bartfinne,  1119 
Parasites,  animal,  diseases  due  to,  1173 

etiologic  influence,  83 

vegetable,  diseases  due  to,  1093 


INDEX 


1239 


Parasitic  affections,  1093 

disease  of  lips,  1217 

eczema,  275 

mentagra,  1119 

sycosis,  1119 
Parasiticides,  122 
Parasitische  Bartfinne,  1119 
Paratuberculoses,  708 

cutaneous,  228 
Parchment  skin,  890 
Paronychia,  954 

of  syphilis,  775 

simple,  955 
Pars  papillaris,  23 

reticularis,  24 
Paste,  Lassar's,  120,  308 

Marsden's,  887 

salicylated,  308 

salicylic  acid,  308 
Paste-pencils,  122 
Pastes,  120 
Patches,  moth,  504 

ringworm-like,  of  tongue,  1209 

smokers',  1203,  1204 
Pathologic  scars,  634 
Pathology,  general,  85 
Pearls,  880 

Pearly  tubercles,  1028  * 

Peau  lisse,  616 

Pediculoides  ventricosus,  1183 
Pediculosis,  1173 

capillitii,  1175 

capitis,  1175 

corporis,  1177 

pubis,  1179 

vestimenti  seu  vestimentorum,  1177 
Pediculus,  1173 

capitis,  1173 

corporis,  1173 

pubis,  1173 
Peitschenwurm,  1195 
Pelade,  995 

Peliosis  rheumatica,  494 
Pellagra,  173 

treatment,  177 
Pellagre,  173 
Pemphigus,  371 

acutus,  372 
neonatorum,  374 

chronicus,  377 

circinatus,  364 

compos6,  364 

conjunctivae,  377 

contagiosus,  374,  375 

diagnosis,  384 

epidemicus,  374,  375 

etiology,  380 

febrilis,  373 

foliaceus,  378 

gangraenosus,  427 

haemorrhagicus,  377 

hystericus,  373,  381 

neonatorum,  374 
contagiosus,  375 

pathology,  382 

prognosis,  385 

prurigineux,  364 


Pemphigus  pruriginosus,  364,  369,  377 

symptoms,  372 

syphiliticus,  802 

treatment,  385 

vegetans,  379,  382 

virginum,  373 

vulgaris,  377 
Pendjeh  sore,  845 
Perforating  ulcer  of  foot,  629 
Perforirendes  Fussgeschwiir,  629 
Perifolliculitis  suppurative  conglomerata, 

III2 

Perionychium,  44 
Persistent  vernix  caseosa,  565 
Perspiration.     See  Sweat. 
Peruvian  warts,  859 
Petechial  variola,  483 
Petite-verole,  480 

PfannenstiePs  treatment  of  lupus  of  mu- 
cous membranes,  733 
Phlebitis  nodularis  necrotisans,  165 
Phlegmona  diffusa,  414 
Phlegmonous  cellulitis,  414 
Phosphorescent  sweat,  1082 
Phosphoridrosis,  1082 
Phthiriasis,  1173 

capitis,  1175 

corporis,  1177 

seu  pediculosis  palpebrarum,  1179 
Phthisis  leprosa,  927 
Phtiriase,  1173 

de  la  tete,  1175 

du  corps,  1177 
Phymata,  61 
Physiology  of  skin,  17,  47 
Pian,  850 

fongoide,  905 
Piebald  negroes,  608 

skin,  acquired,  610 
Pied  de  Madura,  1160 

negroes,  608 
Piedra,  980 
Pigment,  31 

hair,  atrophy  of,  983 
Pigmentary  mole,  515 

syphilid,  613 

syphiloderm,  778 
Pigmented  carcinoma,  865 

sarcoma,  multiple,  897 
Pigmentflecken,  504 
Pigmentmal,  515 
Pigmentnsevus,  515 
Pili  annulati,  984 
Pimples,  59 
Pinta  disease,  1153 
Pitch  dermatitis,  438 
Pityriasis  capitis,  331,  332 

circin6  et  margin6,  197 

linguae,  1209 

maculata  et  circinata,  194 

pilaris,  231,  537,  566 

rose,  194 

rosea,  194 

treatment,  198 

rubra,  199,  200 
pilaire,  231 
pilaris,  231 


1240 


INDEX 


Pityriasis  rubra  pilaris,  treatment,  235 

steatodes,  331 

versicolor,  1147 

versicolore,  1147 
Plant  dermatitis,  438 
Plantar  ichthyosis,  chronic,  566 

syphiloderm,  786 

Plaques  blanches  de  la  bouche,  1203 
des  fumeurs,  1203 

jaunatres  des  paupiferes,  668 

muqueuses,  792 

opalines,  1203 

ortiees,  58 

transitory  benign,  of  tongue,  1209 
Plasma  cells,  735 
Plaster  muslins,  1 20 
Plaster-mulls,  120 
Plasters,  rubber,  121 
Plica,  1175 

neuropathica,  971 

polonica,  971,  1175 
Pocken,  480 
Podelcoma,  1160 
Polls  accidentels,  964 
Pointed  condyloma,  550 

wart,  550 
Poisoning,  ivy-,  442 

rhus-,  442 
Poliosis,  983 

circumscripta  hereditaria,  983 
Poliothrix,  983 
Polish  itch,  1190 

Pollitzer's  hidradenitis  suppurativa,  1054 
Polyidrosis,  1068 
Polypapilloma  tropicum,  850 
Polytrichia,  964 
Pomphi,  58 
Pompholyx,  360 

treatment,  363 
Porcupine  men,  565 
Pore,  sweat-,  33 
Porokeratose,  571 
Porokeratosis,  571 

treatment,  574 
Porrigo  contagiosa,  397 

decalvans,  995,  1105 

favosa,  1093 

furfurans,  1115 

lavalis,  1093 

lupinosa,  1093 

scutulata,  1093 
Porrigophyta,  1093 
Port-wine  mark,  682 

stain,  682 

Postmortem  pustule,  416 
Potash  soaps,  116 
Pou  de  bois,  1187 
Powders,  dusting-,  117 
Powder-stains,  514 
Pox,  769 

water-,  1021 

Prairie  itch,  944,  1183,  1190 
Predisposition,  76 

Pregnancy,  etiologic  significance,  79 
Premature  alopecia,  989 
idiopathic,  990 
symptomatic,  991 


Prickle  layer,  22 

Prickle-cell  layer  of  hair-follicle,  42 

Prickle-cells,  22 

Prickly  heat,  1088 

Primary  keloid,  637 

Primrose  dermatitis,  439 

Primula  dermatitis,  439 

Progressive  idiopathic  atrophy,  622 

Protective  function  of  skin,  47 

Prurigo,  208 

agria,  208 

ferox,  208 

mitis,  208 

nodularis,  210 
treatment,  212 

summer,  359 

treatment,  210 
Pruritus,  56,  942 

ani,  943 

bath,  945 

diagnosis,  947 

etiology,  945 

generalized,  943 

hiemalis,  944 

local,  943 

pathology,  946 

prognosis,  947 

scroti,  943 

senilis,  943,  945 

symptoms,  942 

treatment,  947 

universalis,  943 

vulvae,  943 

Pseudobotryomycose,  692 
Pseudobotryomycosis,  692 
Pseudochromidrosis,  1077,  1080 
Pseudoknotting  of  hair,  975 
Pseudoleukemia  cutis,  911,  913 
Psoriaform  parakeratosis,  197 
Psoriasiform  exanthem,  224 
Psoriasis,  236 

annulata,  238 

circinata,  238 

course,  242 

diagnosis,  246 

diffusa,  238 

discoidea,  238 

etiology,  243 

guttata,  238 

gyrata,  238 

inveterata,  238 

kleinzirzinare,  238 

lichen,  213,  231 

lupus-,  728 

microgyrata,  238 

nummularis,  238 

of  tongue,  1203 

ostreacea,  239,  534 

pathology,  245 

prognosis,  249 

punctata,  238 

rupioides,  239 

seborrheic,  239,  242 

symptoms,  236 

syphilitic,  786 

syphilitica,  786 

treatment,  250 


INDEX 


1241 


Psoriasis  universalis,  239 

verrucosa,  239 

Psoriatic  eczema,  239,  242,  273 
Psorospermose  folliculaire  vSgetante,  541 
Psorospermosis,  541 

cutaneous,  866 

cuds,  866 
Pubic   region,   chronic   itching  lichenoid 

eruption,  222 
Puce  commune,  1186 

de  sable,  1195 

Pudenda,  ulcerating  granuloma,  863 
Pulex  irritans,  1186 

penetrans,  1195 
Pulsating  naevus,  683 
Punaise  des  lits,  1186 
Punch,  cutaneous,  126,  513 
Punctate  scarifications,  126 
Purpura,  492 

arthritic,  494 

diagnosis,  498 

etiology,  495 

fulminans,  495 

haemorrhagica,  495 

Henoch's,  494 

pathology,  497 

prognosis,  499 

rheumatica,  494 

scorbutica,  500 

senilis,  494 

simplex,  493 

symptoms,  492 

treatment,  499 

urticans,  181,  493 

Purpuric  edema,  494 

febrile,  494 

variola,  483 
Puru,  845 
Pusteln,  63 
Pustula  maligna,  418 

treatment,  420 
Pustulae,  63 
Pustular  eczema,  271 

scrofuloderm,  718 
large  flat,  718 
small,  711,  1055 

syphiloderm,  795,  817 
large  acuminated,  796 

flat,  799 

miliary  acuminated,  795 
small  acuminated,  795 

flat,  798 
Pustule,  malignant,  418 

maligne,  420 

postmortem,  416 
Pustules,  65 
Pustulocrustaceous  syphilid,  799 

syphiloderm,  799 
Pustulo-ulcerative  syphilid,  800 

syphiloderm,  800 
Pustulovesicular  eruption,  63 
Pyodermatitis,  399 

vegetans,  387 
Pyodermia,  399 
Pyodermite  vegdtante,  387 
Pyodermitis,  399 
Pyogenic  dermatitis,  399 


QtTADDELN,   58 

Quartz  lamp,  133 
Quincke's  disease,  191 
Quinquaud's  disease,  ion 
Quirica,  1153 


RACES,  etiologic  influence,  77 
Radiotherapy,  127 
Radium,  130 
Rash,  heat-,  1088 

miliary  sweat,  1091 

tooth,  278 

vaccination,  486 

wandering,  1209 
Raynaud's  disease,  432 _ 
Raynaud'sche  Krankheit,  432 
Recklinghausen's  disease,  696 
Recurrent  exfoliative  erythema,  150 

summer  eruption,  358 
Red  chromidrosis,  1077,  1080 

gum,  1088 

Regional  eczema,  314 
Rents,  67 

Resistant    macular    and    maculopapular 
erythrodermias,  224 

maculopapular    scaly    erythrodermias, 

224 

Respiratory  function  of  skin,  49 
Rete,  19,  21 

Malpighii,  19,  21 

mucosum,  21 
Reticular  layer,  24 
Reticulating  colliquation,  478 
Rhagaden,  67 
Rhagades,  67 
Rheumatism  of  skin,  940 
Rhinoceros  skin,  565 
Rhinochoprion,  1195 
Rhinopharyngitis  mutilans,  857 
Rhinophyma,  1062 
Rhinoscleroma,  705 
Rhinosclerome,  705 
Rhus-poisoning,  442 
Ribbed  tongue,  1209 
Rimae,  67 

Ringed  eruption  of  extremities,  170 
on  fingers,  1 70 

hair,  984 
Ringelhaare,  984 
Ringworm,  1104 

bald,  1117 

black-dot,  1117 

Bowditch  Island,  1144 

Burmese,  1144 

Chinese,  1144 

crusted,  1093 

disseminated,  1116 

etiology,  1124 

hair,  984 

honey-comb,  1093 

immunity  to,  1132 

India,  1144 

kerion,  1117 

of  beard,  1119 

of  bearded  region,  1119 
diagnosis,  1122 


1242 


INDEX 


Ringworm  of  bearded  region,  symptoms, 

1119 
treatment,  1143 

of  body,  1109 

of  general  surface,  1109 
diagnosis,  1115 
symptoms,  1109 
treatment,  1135 

of  genitocrural  region,  treatment,  1135 

of  glabrous  skin,  1109 

of  nails,  961 

of  non-hairy  surface,  1109 

of  scalp,  1115 
diagnosis,  1118 
symptoms,  1115 
treatment,  1136 

pathology,  1129 

prognosis,  1133 

scaly,  1144 

sycosis,  1015 

Tokelau,  1144 

treatment,  1134 

vaccine  in,  1132 

yaws,  853 

Ringworm-like  patches  of  tongue,  1209 
Risipola  Lombarda,  173 
Ritter's  disease,  206 
Rodent  ulcer,  872 
Rontgen-ray  burn,  444 

dermatitis,  444 
treatment,  448 

treatment,  127 
Root-sheath  of  hair,  42 

of  hair-follicle,  42 
Rosacea,  688,  1060 

seborrhoica,  1063 
Rose,  421 
Roseola,  146 

epidemic,  474 

scarlatiniforme,  150 

syphilitica,  776 

variolosa,  480 
Roseola  epidemique,  474 
Rosolia,  471 
Rotheln,  474 
Rothlauf,  421 
Rotz,  416 

Rotzkrankheit,  416 
Rougeole,  471 
Rouget,  1195 
Rubber  plasters,  121 
Rubella,  474 

Rubeola,  471.    See  also  Measles. 
Rupia,  800,  802 

escharotica,  427 


SABOURAUD  and  Noire  method  of  a>ray 

treatment  of  ringworm  of  scalp,  1141 
Saccharine  diabetes,  etiologic  influence,  78 
Saccharomycosis  hominis,  1162 
Salicylated  paste,  308 
Salicylic  acid  paste,  308 
Salines,  108 
Salt  rheum,  261,  265 
Salvarsan  in  syphilis,  838 
Salve-mulls,  120 


Salve-muslins,  120 
Salve-pencils,  122 
Salzfluss,  261 
Sand-flea,  1195 
Sandfloh,  1195 
Sandy  sweat,  1081 
Sapo  mollis,  117 

viridis,  117 
Sarcoid,  902 

multiple  benign,  902 

tumor,  170,  902 
Sarcoma  cutis,  893 
treatment,  901 

generalized  non-pigmented,  894 

hemorrhagic,  897 

localized  non-pigmented,  893 

melanotic,  895 

multiple  pigmented,  897 

of  skin,  893 

primary  single  non-pigmented,  893 
Sarcomatose  cutanee,  893 
Sarcoma tosis  cutis,  893 

generalis,  904 
Sarcome  angioplastique  reticule,  690 

cutane,  893 

Sarcopsylla  penetrans,  1199 
Sarcoptes  hominis,  1190 

scabiei,  1190 
Satyriasis,  914 
Sauriasis,  561,  563 
Savill's  disease,  204 
Scabies,  1188 

animal,  1190 

treatment,  1193 
Scabs,  69 
Scales,  68 

crusty,  69 

furfuraceous,  69 
Scalp,  eczema  of,  315 

favus  of,  1094 

micro-organisms,  1025 

ringworm  of ,  1115 
treatment,  1136 
Scaly  crusts,  69 

erythrodermias,  resistant  maculopapu- 
lar,  224 

ringworm,  1144 
Scar,  72,  634 

atrophic,  634 

hypertrophic,  73,  634,  638 

keloid,  637 

pathologic,  634 

traumatic,  634 
Scarf-skin,  19 
Scarifications,  linear,  126 

punctate,  126 
Scarifier,  multiple,  748 
Scarlatina,  465 

anginosa,  467 

complications,  469 

diagnosis,  470 

malignant  type,  468 

sine  eruptione,  467 

symptoms,  465 
Scarlatine,  465 
Scarlet  fever,  465 
Scar-tissue,  634 


INDEX 


1243 


Scharlachfieber,  465 

Scherende  Flechte,  1104,  1109,  1115 

Schleimhautpapeln,  792 

Schmeerfluss,  1021 

Schonlein's  disease,  494 

Schuppen,  68 

Schuppenflechte,  236 

Schwarze  Haarzunge,  1212 

Schvveissflechte,  1088 

Schweissfrieselausschlag,  1082 

Sclerema,  578 

adultorum,  578 

neonatorum,  589 

of  newborn,  589 
Sclereme  des  adultes,  578 

des  nouveau-nes,  589 
Scleriasis,  578 
Sclerodactylia,  580 
Scleroderma,  578 

circumscribed,  582 

diagnosis,  587 

etiology,  585 

neonatorum,  589 

pathology,  586 

prognosis,  588 

symptoms,  579 

treatment,  588 
Sclerodermie,  578 
Scleronychia,  953 
Scorbuto  alpino,  173 
Scorbutus,  500 
Scratches,  Ohio,  944,  1184 
Scratching,  prolonged,  etiologic  influence, 

83 

Scratch-marks,  66 
Scrofulide  erythemateuse,  753 

tuberculeuse,  719 
Scrofuloderm,  large  flat  pustular,  718 

small  pustular,  711,  1055 
Scrofuloderma,  717 
Scrofulogumma,  718 
Scrofulous  eczema,  263 

gumma,  718 
Scrotal  tongue,  1209 
Scrotum,  lymph-,  596 

milky  exudation  of,  596 

pruritus  of,  943 
Scurvy,  500 

land,  495 

sea,  500 

Sea  scurvy,  500 
Sea-water  injections,  114 
Seasons,  etiologic  influence,  76 
Sebaceous  cyst,  1030 

glands,  35 

adenoma  of,  656 
development  of,  first  sign,  37 
diseases  of,  1021 

matter,  53 

secretion,  53 

tumor,  1030 
Seborrhea,  331,  1021 

treatment,  1025 
Se'borrhe'e,  1021 
Seborrheic  dermatitis,  276 

psoriasis,  239,  242 

wart,  548 


Seborrhcea  capitis,  331,  1022 

congestiva,  753 

corporis,  331,  335 

figured,   335 

nigricans,  1077 

oleosa,  331,  1021,  1022 

papulosa  seu  lichenoides,  335 

sicca,  331,  1021,  1022 

simplex,  1022 
Sebum,  53 

Secondary  keloid,  637 
Secretion,  sebaceous,  53 

sweat,  51 

Secretions,  internal,  etiologic  influence,  80 
Secretory  function  of  skin,  51 
Segmental  tubercular  syphiloderm,  804 
Semi-albinismus,  609 
Senile  alopecia,  989 

atrophy,  617 
Sensible  perspiration,  51 
Sensory  function  of  skin,  48 
Serpiginous  tubercular  syphiloderm,  804 

ulceration  of  genitals,  863 
Sex,  etiologic  influence,  77 
Shedding  of  nails,  959 

of  skin,  151 
Shingles,  348 
Shining  layer,  19,  20 
Silver  nitrate,  discoloration  of  skin  from 

prolonged  use,  511 
Skin,  alligator,  562 

cancer,  870 

deciduous,  151 

elastic,  606 

diphtheria  of,  429 

glossy,  616 

hedge-hog,  565 

hide-bound,  578 

loose,  604,  605 

old  age  of,  534,  617 

piebald,  acquired,  610 

rhinoceros,  565 

wrinkled,  605 
Skin-shedding,  151 
Sklerodermie,  578 
Sleeping  sickness,  1202 
Small-pox,  480.    See  also  Variola. 
Smegma,  37 

Smokers'  patches,  1203,  1204 
Smooth  muscles,  30 
Snow,  carbon-dioxid,  124 
Soaps,  1 1 6 

green,  117 

medicated,  117 

potash,  116 

soda, 116 

superfatty,  116 
Soda  soaps,  116 
Soft  fibroma,  697 
Sommersprossen,  502 
Sore  feet  of  coolies,  1 201 
Sores,  aphthous,  794 

water-,  1201 

Sparganum  proliferum,  1199 
Spargosis,  592 
Spedalskhed,  914 
Sphaceloderma,  427 


1244 


INDEX 


Spider  cancer,  688 

naevus,  682,  688 
Spiders,  1187 
Spindelhaare,  978 
Spiradenoma,  659 
Spiral  fibers,  Herxheimer's,  22 
Spirochaeta  pallida,  817,  820 
Spiroma,  659 
Spitzblattern,  476 
Spitzencondylom,  550 
Spitzenwarze,  550 
Splenic  fever,  418 
Spontaneous  gangrene  of  skin,  427,  429 

keloid,  637 
Spoon-nail,  958 
Sporadic  cretinism,  603 
Sporotrichium,  1171 

Beurmanni,  1171 

indicum,  1171 

Schencki,  1171 
Sporotrichoses,  dermic,  1167 

subcutaneous,  1167 

tuberculoldes,  1167 
Sporotrichosis,  1167 

epidermic  form,  1170 

syphiloid  type,  1170 

treatment,  1172 

tuberculoid  type,  1170 
Spots,  57 

erythematous,  57 

gift,  959 
of  nails,  43 

Koplik's,  471 

liver,  504,  1147 

moth,  504 

white,  959 

of  nails,  43 

Spotted  sickness,  1153 
Spurious  keloid,  637 
Squamae,  68 
Squames,  68 
Squamous  eczema,  273 

papule,  60 

syphilid,  786 

syphiloderm,  786,  805 
St.  Anthony's  fire,  421 
Stains,  58 

blue,  514 

claret,  682 

port-wine,  682 

powder-,  514 

Stearoglycerid  ointment,  994,  1027 
Stearrhea,  1021 
Stearrhoea  nigricans,  1077 
Steatoma,  1030 
Ste"atome,  1030 
Steatorrhea,  1021 
Steatorrhcea  simplex,  1022 
Steatozoon  folliculorum,  1197 
Stigmata,  bleeding,  1080 

hysteric,  1080 
Stings  of  insects,  1187 
Stinking  sweat,  1075 
Stinkschweiss,   1075 
Stratum  adiposum,  25 

corneum,  19,  20 

granulosum,  19,  20 


Stratum,  living,  of  epidermis,  21 

lucidum,  19,  20 
Straw  dermatitis,  1183 

itch,  945,  1183 
Strawberry  tongue,  467 
Strawberry-mark,  683 
Straw-packers'  itch,  1183 
Striae  atrophicae,  619 

et  maculae  atrophicae,  619 

patellares,  620 
Striated  muscles,  30 
Stries  atrophiques,  619 
Strophulus,  1028,  1088 

albidus,  1028,  1029 

prurigineux,  208 
Subcutaneous  sporotrichoses,  1167 

tissue,  24 
Sudamen,  1082 
Sudatoria,  1068 
Sudor  anglicus,  1091 

sanguineosa,  1080 

urinosus,  1081 
Sudoriparous  glands,  33 
Suette  blanche,  1092 

miliare,  1091 
Sulcated  tongue,  1209 
Summer  eruption,  recurrent,  358 

prurigo,  359 
Superfatty  soaps,  116 
Superfluous  hair,  964 
Supernumerary  nails,  952 
Suppurating  corn,  524 
Surgeon's  eczema,  281,  440 
Surgical  eczema,  281 
Swamp  itch,  944,  1184,  1190 
Sweat,  bloody,  1080 

cold,  30,  52 

colored,    1077 

composition,  52 

insensible,  51 

phosphorescent,  1082 

rash,  miliary,  1091 

sandy,  1081 

secretion,  51 

sensible,  51 

stinking,  1075 

urinous,  1081 
Sweat-glands,  33 

adenoma  of,  652,  659 

development  of,  first  recognizable  signs, 

35 

diseases  of,  1068 
Sweating,  excessive,  1068 

of  feet,  1069 

of  hands,  1069 

sickness,  1091 
Sweat-pore,  33 
Sycosis,  1014 

bacillogenes,  1016 

coccogenica,  1014,  1016 

contagiosa,  1119 

framboesiformis,  643 

hyphogenous,  1119 

hyphomycotica,  1119 

lupoid,  1010,  1015 

lupoide,  1015 

non-parasitaire,  1014 


INDEX 


1245 


Sycosis,  non-parasitic,  1014 

parasitaire,  1119 

parasitaria,  1119 

parasitic,  1119 

parasitica,  1119 

ringworm,  1015 

staphylogenes,  1016 

trichophytique,  1119 

vulgaris,  1014 

treatment,  1018 
Symmetric  gangrene,  432 

keratodermia,  528 
Symptomatic  chloasma,  506 

fragilitas  crinium,  974 

premature  alopecia,  991 
Symptoms,  constitutional,  55 

general,  55 

objective,  55,  56 

subjective,  55 
Syphilid,  770 

acuminated  papular,  780 

annular,  777 

circinate,  777 

ecthymaform,  799 

erythematous,  776 

exanthematous,  776 

follicular,  780 

herpetiform,  795 

impetigiform,  798 

lenticular  papular,  782 

macular,  776 

miliary  papular,  780 

nodular,  803 

papillomatous,  806 

papular,  780 

papulosquamous,  786 

pigmentary,  613 

pustulocrustaceous,  799 

pustulo-ulcerative,  800 

squamous,  786 

tuberculogummatous,  811 

varicelliform,  794,  795 

vegetating,  806 
Syphilide  cornee,  788 
Syphilis,  769 

acquired,  cutaneous  manifestations,  770 

benign,  772 

congenital,  813 

cutanea,  770 
bullosa,  802 
gummatosa,  809 
maculosa,  776 
papillomatosa,  806 
squamosa,  786 
tuberculosa,  803 
vegetans,  792,  806 
vesiculosa,  794 

cutaneous  reaction  test  for,  825 

diagnosis,  824 

Ehrlich-Hata  preparation  in,  838 

etiology,  818 

general    observations    and    diagnostic 
characters,  772 

hectine  in,  839 

hereditaria  tarda,  814 

hereditary,    cutaneous    manifestations, 
813 


Syphilis,  hereditary,  treatment,  844 
Hutchinson's  teeth  in,  814,  815 
in  innocent,  818,  819 
infantile,  813 
initial  lesion,  769 
insontium,  819 
Leukocytozoon,  821 
luetin  test  for,  825 
malignant,  772 
Noguchi's  test  for,  825 
notched  teeth  in,  814,  815 
of  nails,  775 
of  skin,  770 
pathology,  821 
pracox,  809 
prognosis,  826 
salvarsan  in,  838 
Spirochaeta  pallida  of,  817,  820 
treatment,  827 

constitutional,  828 

duration,  840 
based  on  serum  test,  841 

external,  842 

mixed,  836 

treponema  pallidum  of,  820 
Wassermann  test  for,  824 

Noguchi's  modification,  825 
Syphilitic  adenopathy,  770,  815 
alopecia,  775 
cachexia,  771 
dactylitis,  814,  815 
ecthyma,  799 
fever,  771 
leukoderma,  778 
lichen,  780 
lymphadenitis,  815 
onychia,  775 
paronychia,  775 
psoriasis,  786 

Syphiloderm,  acneiform,  796 
annular,  777,  784 
bullous,  802,  815 
circinate,  777,  784 

tubercular,  804 
ecthymaform,  799 
erythematous,  776 
exanthematous,  776 
flat  papular,  782 
gummatous,  809 
impetigiform,  798 
large  acuminated  pustular,  796 

flat  papular,  783 

pustular,  799 
lenticular  papular,  782 
macular,  776 

miliary  acuminated  pustular,  795 
nodular,  803 

non-ulcerating  tubercular,  805 
palmar,  786 
papillomatous,  806 
papular,  780 
papulosquamous,  786 
papulotubercular,  805 
pigmentary,  778 
plantar,  786 
pustular,  795,  817 
pustulocrustaceous,  799 


1246 


INDEX 


Syphiloderm,  pustulo-ulcerative,  800 

segmental  tubercular,  804 

serpiginous  tubercular,  804 

small  acuminated  pustular,  795 
flat  papular,  783 
pustular,  798 

squamous,  786,  805 

tubercular,  803,  817 

tuberculogummatous,  806,  811 

tuberculopustular,  805 

tuberculosquamous,  805 

ulcerating  serpiginous  tubercular,  805 

ulcerating  tubercular,  805 

varicelliform,  794 

varioliform,  797 

vegetating,  792,  806 

vesicular,  794,  817 
Syphiloderma,  770 

bullosum,  802 

erythematosum,  776 

frambcesioides,  792 

gummatosum,  809 

maculosum,  776 

pigmentosum,  778 

tuberculosum,  803 

vesiculosum,  794 

Syphiloid  type  of  sporotrichosis,  1170 
Syphiloma,  809 
Syringadenoma,  660 
Syringocystadenome,  652 
Syringocystoma,  652 
Syringoma,  652 
Syringomyelia,  631 


TABOO,  914 
Tache  de  feu,  682 

hSpatique,  504 

pigmentaire,  515 
Taches,  57 

bleuatres,  1180 

de  rousseur,  502 

ombrSes,  1180 
Tactile  corpuscles,  27,  28 

sensibility,  48 
Tar  acne,  438,  1041 

dermatitis,  438 
Tattooing,  512 
Tattoo-marks,  512 
Teeth,  Hutchinson's,  814,  815 

notched,  in  syphilis,  814,  815 
Teigne  du  pauvre,  1093 

faveuse,  1093 

rural,  1093 

tondante  1115 

tonsurante,  1115 
Telangiectasie,  688 
Telangiectasis,  688 
Telangiectatic  elephantiasis,  596 

warts,  576 

Telangiektatische  granulome,  692 
Test,  Calmette's,  in  tuberculosis  cutis,  740 

cutaneous  reaction,  for  syphilis,  825 

Lignieres',  in  tuberculosis  cutis,  741 

luetin,  for  syphilis,  825 

Moro's,  in  tuberculosis  cutis,  741 

Noguchi's,  for  syphilis,  825 


Test,  von  Pirquet's,  in  tuberculosis  cutis, 

74i 

Wassermann's,  for  syphilis,  824 
Noguchi's  modification,  825 
Wolf-Eisner,  in  tuberculosis  cutis,  740 
Tetter,  261 
dry,  265    . 
moist,  265 

Texas  mange,  944,  1184 
Thermal  sense,  48 
Thorny  layer,  22 
Thrombo-angiitis  objiterans,  430 
Tick,  wood-,  1187 
Tina,  1153 
Tinea  axillaris,  1113 
barbae,  1119 
circinata,  1109 
axillaris,  1113 
cruris,  1113 
tropica,  1114 
cruris,  1113,  1114 
decalvans,  995,  1003 
favosa,  1093 
capitis,  1094 
epidermidis,  1095 
unguium,  961 
ficosa,  1093 
imbricata,  1144 
kerion,  1117 
lupinosa,  1093 
maligna,  1093 
nodosa,  981 

of  mucous  membrane,  mi 
sycosis,  1119 
tondens,  1115 
tonsurans,  1115 

bald,  1117 
trichophytina,  1104 
barbae,  1119 
capitis,  1115 
corporis,  1109 
cruris,    1113 
unguium,  961 
vera,  1093 
versicolor,  1147 
alba,  1148 
flava,  1148 
nigra,  1148 
treatment,  1150 
Tique,  1187 
Tissue,  adipose,  25 
subcutaneous,  24 
Toes,  eczema  of,  324 
Tokelau  ringworm,  1144 
Tonga, 850 
Tongue,  black,  1212 

circinate  eruption  of,  1209 

cleft,  1209 

fluted,  1209 

furrowed,  1209 

geographic,  1210 

grooved,  1209 

hairy,  1212 

psoriasis  of,  1203 

ribbed,  1209 

ringworm-like  patches  of,  1 209 

scrotal,  1209 


INDEX 


1247 


Tongue,  strawberry,  467 

sulcated,  1209 

transitory  benign  plaques  of,  1 209 

wrinkled,  1209 
Tonics,  general,  108 
Tooth  rash,  278 
Touch,  sense  of,  48 
Touch-cells,  Merkel's,  27,  29 
Touch-corpuscles,  28 
Toxic  tuberculides,  708 

tuberculoses,  708 
Toxi- tuberculides,  228 
Trade  eczemas,  281 
Transitory  benign  plaques  of  tongue,  1209 

hypertrichosis,  966 
Translucent  layer,  20 
Traumatic  dermatitis,  437 

scars,  634 
Treatment,  constitutional,  106 

general  remarks  on,  105 

local,  115 

Trephine,  cutaneous,  126,  513 
Treponema  pallidum,  820 
Trichauxis,  964 
Trichiasis,  966 
Trichoclasia,  974 
Tricho-epithelioma  papillosum  multiplex, 

652 

Trichomycose  nodulaire,  980 
Trichomycosis  flava,  982 

nigra,  982 

palmellina,  982 

rubra,  982 

Trichomykosis  favosa,  1093 
Trichonodosis,  1775 
Trichonosis  discolor,  983 

furfuracea,  1115 

versicolor,  984 
Trichophytia  capitis,  1115 

unguium,  961 

Trichophytic  alopecia,  1004 
Trichophytie,  1104 

circin£e,  1109,  1115 

de  la  barbe,  1119 

der  unbehaarten  Hautstellen,  1109 

des  parties  glabres,  1109 

du  cuir  chevelu,  1115 

seche,  a  forme  d'ichtyose  pilaire,  1120 

sycosique,  1119 

ungueale,  961 
Trichophytin,  1133 
Trichophyton,  1105,  1107 

acuminatum,  1107 

Castellani,  1108 

cerebriforme,  1107 

crateriforme,  1107 

cruris,  1108 

ectothrix,  1105 

endothrix,  1105 

ochraceum,  1107 

rosaceum,  1107 

rubrum,  1108 

violaceum,  1107 
Trichophytosis,  1104,  1107 

barbae,  1119 

capitis,  1115 

corporis,  1109 


Trichorrhexis  nodosa,  974 
Trichosporosis  nodosa,  980 
Tricoptilose,  974 
Trophic  nerves  of  skin,  49 
Tropical  chlorosis,  1201 

ulcers,  734,  812,  847,  854,  862 
Trunk,  acne  of,  treatment,  1053 
Trypanosomiasis,  1202 
Tubercles,  60 
anatomic,  712 
pearly,  1028 
Tubercula,  60 

Tubercular  disease  of  foot,  1160 
leprosy,  919 
syphiloderm,  803,  817 
circinate,  804 
non-ulcerating,  805 
segmental,  804 
serpiginous,  804 
ulcerating,  805 

serpiginous,  805 
Tuberculated  leprosy,  919 
Tubercules,  60 
Tuberculides,  709,  1054 
angiomateuses,  575 
gommeuses,  718 
necrotic,  712 
toxi-,  228 
toxic,  708 
Tuberculin,  112 

tests,  740 
Tuberculogummatous  syphilid,  811 

syphiloderm,  806,  811 
Tuberculoid  type  of  sporotrichosis,  1170 
Tuberculopustular  syphiloderm,  805 
Tuberculose  ulcereuse,  709 
Tuberculoses,  toxic,  708 
Tuberculosis  cutis,  708 
diagnosis,  738 
Calmette's  test  in,  740 
etiology,  730 
Lignieres,  test  in,  741 
Moro's  test  in,  741 
orificialis,  709 
pathology,  732 
prognosis,  741 
treatment,  742 
constitutional,  742 
local,  744 
operative,  748 
vera,  709 

von  Pirquet's  test  in,  741 
Wolf-Eisner  test  in,  740 
disseminata,  710 
exanthematic,  711 
fungosa  cutis,  714 
of  skin,  708 

miliary,  709 

papillomatosa  cutis,  716 
tests,  740 
ulcerosa,  709 
verrucosa,  712 

cutis,  713 

Tuberculosquamous  syphiloderm,  805 
Tuberculous  eczema,  263 

gumma,  718 
Tuberculum  sebaceum,  1028 


1248 


INDEX 


Tuberose  carcinoma,  865 
Tuberosis  cutis  pruriginosa,  210 
Tumeurs,  61 
Tumor,  61 

fatty,  700 

horny,  558 

lymph,  596 

muscle,  702 

nerve,  704 

sarcoid,  170,  902 

sebaceous,  1030 

small,  60 
Tumores,  61 
Tumor-like  new  growths,  multiple  benign, 

667 

Tyloma,  526 
Tylosis,  526 

gompheux,  524 

linguae,  1203 

palmae  et  plantar,  528 
Tysonian  glands,  36 


ULCER,  70 

cancroid,  872 

crateriform,  875 

endemic,  847,  854 

Jacob's,  872 

perforating,  of  foot,  629 

rodent,  872 

tropical,  734,  812,  847,  854,  862 
Ulcera,  70 
Ulcerating  granuloma  of  pudenda,  863 

serpiginous  tubercular  syphiloderm,  805 

tubercular  syphiloderm,  805 
Ulceration,  groin,  863 

serpiginous,  of  genitals,  863 
Ulcerations,  70 
Ulcere  cancreux,  872 
Ulceres,  70 
Ulcus  exedens,  872 

grave,  1160 

rodens,  872 

varicosum,  272 
Ulerythema  acneiforme,  1055 

centrifugum,  753 

sycosiforme,  1010,  1015 
Umbilicus,  eczema  of,  326 
Uncinaria  americana,  1 202 

duodenalis,  1201 
Uncinarial  dermatitis,  1201 
Uncinariasis,  1201 
Underwood's  disease,  589 
Unguentum  acidi  borici,  120 

aquae  rosae,  119 

simplex,  119 
Unguis,  43 
Uridrose,  1081 
Uridrosis,  1081 
Urinidrosis,  1081 
Urinous  sweat,  1081 
Urticae,  58 
Urticaire,  179 
Urticaria,  179 

acute,  181 

bullosa,  181,  182 

chronic,  181 


Urticaria  factitia,  180 
giant,  181,  191 

hasmorrhagica  seu  purpura  urticans,  182 
hemorrhagic,  181 
cedematosa,  181,  191 
papulosa,  181,  182 
perstans,  155,  181 

annulata  et  gyrata,  154,  181 

pigmentosa,  188 
pigmentosa,  188 

treatment,  190 
treatment,  186 
tuberosa,  181 
vesicopapular,  1183 

Utero-ovarian  system,  diseases  of,  etiologic 
influence,  78 


VACCINAL  eruptions,  486 
Vaccination,  486 

rashes,  486 

Vaccine  in  ringworm,  1132 
Vaccines,  112 
Vaccinia,  486 

Vacciniform  ecthyma  of  infants,  399 
Vagabond's  disease,  1177 
Vajuolo,  480 
Varicella,  476 

gangraenosa,  427 

treatment,  479 
Varicelliform  syphilid,  794,  795 

syphiloderm,  794 
Varices,  papillary,  689 
Varicose  eczema,  272 

veins,  689 
Varicosities,  689 
Variola,  480 

complications,  484 

confluent,  483 

diagnosis,  484 

haemorrhagica  pustulosa,  484 

hemorrhagic,  483 

petechial,  483 

purpuric,  483 

purpurica,  484 

sequels,  484 

symptoms,  480 
Variolae  spuriae,  476 
Variolette,  476 
Varioliform  syphiloderm,  797 
Varioloid,  482 

Variot's  treatment  of  tattoo-marks,  513 
Varix  lymphaticus,  596 
Vascular  dilatations,  acquired,  688 

papillae,  24 
Vasomotor  constringents,  113 

nerves,  30 

of  skin,  48 

Vater's  corpuscles,  27 
Vegetable  laxatives,  108 

parasites,  diseases  due  to,  1093 
Vegetating  dermatoses,  388 

syphilid,  806 

syphiloderm,  792,  806 
Vegetation  dermique,  550 
Vegetations  vasculaires,  656 
Veins,  varicose,  689 


INDEX 


1249 


Venereal  granuloma,  863 

wart,  550 
Venerische  papillome,  550 

warze,  550 
Venous  naevus,  683 
Ver  de  Guinee,  1195 
Verge  noire,  457 
Vergetures,  619 
Verhartung,  526 
Vernix  caseosa,  1022    • 

persistent,  565 
Verole,  769 
Verruca,  546 

acuminata,  550 

digitata,  549 

filiformis,  550  •  ,' 

necrogenica,  712 

plana,  548 
juvenilis,  549 

plantaris,  547 

seborrhoica,  548 

senilis,  548 

treatment,  555 

vulgaris,  546 
Verrue,  546 

mere,  547 
Verrues  filles,  547 

telangiectasiques,  575 
Verruga  peruana,  859 
Vesicles,  62 

Vesicobullous  eruption,  63 
Vesicopapular  eruption,  60 

urticaria,  1183 
Vesicopapules,  60 
Vesicopustular  eruption,  63 
Vesicopustules,  63,  65 
Vesiculae,  62 

Vesicular  syphiloderm,  794,  817 
Vesicules,  62 

Virchow's  false  neuroma,  704 
Vitiligo,  610 

acquisita  syphilitica,  778 

syphilitica,  613 

treatment,  614 
Vitiligoidea,  668 

Vitreous  membrane  of  hair-follicle,  42 
Vleminckx's  solution,  1066 
Vogelmilbe,  1187 
Voight's  lines,  520 

von  Pirquet's  test  in  tuberculosis  cutis,  741 
Vulva,  kraurosis  of,  625 

pruritus  of,  943 


WAGNER'S  corpuscles,  27,  28 
Wandering  cells,  32 

rash,  1209 
Wart,  546 

fig-,  550 

flat,  548 

moist,  550 

mother,  547 

Peruvian,  859 

plantar,  547 

pointed,  550 

seborrheic,  548 

telangiectatic,  576 
79 


Wart,  treatment,  555 

venereal,  550 

Wart-containing  callosity,  547 
Warty  mole,  548 
Warze,  546 

Washerwomen's  eczema,  281 
Wasps,  1187 

Wassermann's  test  for  syphilis,  824 
Noguchi's  modification,  825 
Water,  115 
Water-itch,  1201 
Water-pox,  476,  1201 
Waters,  natural  mineral,  114 
Water-sores,  1201 
Weeping  eczema,  265 

leg,  272 
Wen,  1030 
Wheals,  58 
White  erysipelas,  422 

nails,  959 

spots,  959 

of  nails,  43,  959 
Whiteness  of  hair,  983 
White-spot  disease,  215,  621 
Whitlow,  954 

melanotic,  897 
Winter  itch,  944 
Wolf-Eisner  test  in  tuberculosis  cutis, 

740 

Wood-tick,  1187 
Worm,  guinea-,  1195 
Worms,  flesh-,  1032 
Wounds,  dissection,  415 
Wrinkled  skin,  605 

tongue,  1209 
Wundrose,  421 


XANTHELASMA,  668 
Xanthelasmoidea,  188 
Xanthoma,  668 

cells,  672,  677 

diabeticorum,  674 
treatment,  678 

giant-cells,  672 

multiplex,  669 

palpebrarum,  668 

planum,  668 

treatment,  673 

tuberculatum  sen  tuberosum,  669 
Xanthome,  668 
Xeroderma,  561 

follicular,  566 

ichthyoides,  561 

pigmentosum,  889 
Xerodermie  pilaire,  537 
Xerosis,  561,  1028 
X-ray  burn,  444 

dermatitis,  444 
treatment,  448 

epithelioma,  445 

treatment,  127 


YAWS,  850 
mother,  852 
ringworm,  853 


1250 

ZECKE,  1187 
Zona,  348 
Zoster,  348 

abdominalis,  351 

abortive,  349 

brachialis,  351 

capillitii,  351 

cervicobrachialis,  351 

colli,  351 


INDEX 


Zoster  erythematosus  recidivus,  355 
faciei,  351 
femoralis,  351 
fron tails,  351 
gangrenous,  429 
nuchae,  351 
ophthalmicus,  351 
pectoralis,  351 
vegetans,  355 


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drug  therapy  ;  it  deals  alone  with  physical  or  mechanical  diagnostic  and  thera- 
peutic measures.  The  information  it  gives  is  such  as  you  need  to  know  every 
day — transfusion  and  infusion,  hypodermic  medication,  Bier's  hyperemia,  explora- 
tory punctures,  aspirations,  anesthesia,  etc.  Then  follow  descriptions  of  those 
measures  employed  in  the  diagnosis  and  treatment  of  diseases  of  special  regions  or 
organs:  proctoclysis,  cystoscopy,  etc. 
Journal  American  Medical  Association 

"The  procedures  described  are  those  which  practitioners  may  at  some  time  be  called 
on  to  perform.'' 


SAUNDERS'   BOCKS  ON 


Faught's  Blood-Pressure 

Blood  -  Pressure  from  the  Clinical  Standpoint.  By  FRANCIS  A. 
FAUGHT,  M.  D.,  formerly  Director  of  the  Laboratory  of  Clinical  Medi- 
cine of  the  Medico-Chirurgical  College  of  Philadelphia.  Octavo  of  281 
pages,  illustrated.  Cloth,  $3.00  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Faught's  book  is  designed  for  practical  help  at  the  bedside.  It  meets  the 
urgent  needs  of  the  general  practitioner,  who  heretofore  had  no  book  to  which  to 
turn  in  case  of  emergency.  Every  effort  has  been  made  to  provide  here  a  practical 
guide,  full  of  information  of  a  clinical  nature,  and  presented  in  a  way  readily 
available  for  daily  use  by  the  busy  man.  Besides  the  actual  technic  of  using  the 
sphygmomanometer  in  diagnosing  disease,  Dr.  Faught  has  included  a  brief 
general  discussion  of  the  process  of  circulation.  The  wonderful  strides  made  in 
our  knowledge  of  blood-pressure,  and  the  practical  application  of  sphygmomano- 
metric  findings  within  recent  years,  make  it  imperative  for  every  medical  man  to 
have  close  at  hand  an  up-to-date  work  on  this  subject. 


Anders  &  Boston's  Medical  Diagnosis 


A  Text-Book  of  Medical  Diagnosis.— By  JAMES  M.  ANDERS,  M.D., 
PH.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and  of 
Clinical  Medicine,  and  L.  NAPOLEON  BOSTON,  M.D.,  Adjunct  Professor 
of  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Octavo  of  1 175 
pages,  with  443  illustrations,  a  number  in  colors.  Cloth,  $6.OO  net; 
Half  Morocco,  $7.50  net. 

THE    MODERN  DIAGNOSIS 

This    new  work  is   designed    expressly  for   the    general    practitioner.  The 

methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 

diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory. 

The  Medical  Record 

"  The  association  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  laboratory 
worker  is  most  fortunate.  It  must  long  occupy  a  pre-eminent  position." 


PRACTICE    OF  MEDICINE 


Ward's  Bedside  Hematology 

Bedside  Hematology.  By  GORDON  R.  WARD,  M.D.,  Fellow  oi  the 
Royal  Society  of  Medicine,  London,  England.  Octavo  of  394  pages, 
illustrated.  Cloth,  $3.50  net. 

JUST  OUT— INCLUDING  VACCINES  AND  SERUMS 

Dr.  Ward's  work  is  designed  to  be  of  service  to  the  man  in  general  practice. 
It  gives  you  the  exact  technic  for  obtaining  the  blood  for  examination,  the  making 
of  smears,  making  the  blood-count,  finding  coagulation  time,  etc.  Then  it  takes 
up  each  disease,  giving  you  the  synonyms,  definition,  nature,  general  pathology, 
etiology,  bearings  of  age  and  sex,  the  onset,  symptomatology  (discussing  each 
symptom  in  detail),  course  of  the  disease,  clinical  varieties,  complications,  diag- 
nosis, and  treatment  (drug,  diet,  rest,  vaccines  and  serums,  jr-ray,  operation,  etc. ) . 
There  is  a  special  chapter  devoted  to  the  medical  treatment  of  hemorrhage,  giving 
you  the  exact  doses  of  the  various  drugs  indicated,  and  the  methods  of  their 
administration,  the  strum  treatment,  transfusion,  etc.  Another  chapter  is  devoted 
to  the  value  of  blood  findings  in  surgical  diagnosis,  pointing  out  their  value  in 
differentiating  benign  from  malignant  growths,  infectious  from  other  diseases, 
appendicitis  from  typhoid  fever.  The  final  30  pages  are  given  over  to  a  summary 
of  the  blood  conditions  in  the  various  diseases,  arranged  alphabetically. 


Smith's  What  to  Eat  and  Why 

What  to  Eat  and  Why.  By  G.  CARROLL  SMITH,  M.D.,  Boston. 
I2mo  of  312  pages.  Cloth,  $2.50  net. 

FOR  THE  PRACTITIONER 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be 
dieted — you  will  be  able  to  prescribe  the  suitable  diet  yourself  just  as  you  do 
other  forms  of  therapy.  Dr.  Smith  gives  the  "  why  "  of  each  statement  he 
makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book,  which 
makes  you  feel  that  Dr.  Smith  knows. 

Pennsylvania  Medical  Journal 

"All  through  this  book  Dr.  Smith  has  added  to  his  dietetic  hints  a  great  many  valuable  ones 
of  a  general  nature,  which  will  appeal  to  the  general  practitioner." 


Slade's  Physical  Examination  and  Diagnostic  Anatomy 

PHYSICAL  EXAMINATION  AND  DIAGNOSTIC  ANATOMY. — By  CHARLES  B.  SLADE,  M.D., 
Chief  of  Clinic  in  General  Medicine,  University  and  Bellevue  Hospital  Medical  College. 
I2mo  of  146  pages,  illustrated.  Cloth,  $1.25  net. 

"In  this  volume  is  contained  the  fundamental  methods  and  principles  of  physical  examination,  well 
illustrated,  largely  by  line  drawings.  The  book  is  to  be  strongly  recommended." — Boston  Aledical  and 
Surgical  Journal. 


SAUNDERS'  BOOKS  ON 


Bastedo's   Mater  ia    Me  die  a 

Pharmacology,    Therapeutics,    Prescription     Writing 

Materia  Medica,  Pharmacology,  Therapeutics,  and  Prescription 
Writing.  By  W.  A.  BASTEDO,  PH.  D.,  M.  D.,  Associate  in  Pharma- 
cology and  Therapeutics  at  Columbia  University,  New  York.  Octavo 
of  602  pages,  illustrated.  Cloth,  $3.50  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Bastedo's  discussion  of  his  subject  is  very  complete.  As  an  illustration, 
take  the  pharmacologic  action  of  the  drug.  It  gives  you  the  antiseptic  action,  the 
local  action  on  the  skin,  mucous  membranes,  and  the  alimentary  tract  ;  where  the 
drug  is  obsorbed,  if  at  all — and  how  rapidly.  It  gives  you  the  systemic  action  on  the 
circulatory  organs,  respiratory  organs,  nervous  system,  and  sense  organs.  It  tells 
you  how  the  drug  is  changed  in  the  body.  It  gives  you  the  route  of  elimination 
and  in  what  form.  It  gives  you  the  action  on  the  kidneys,  bladder,  urethra,  skin, 
bowels,  lungs,  and  mammary  glands  during  elimination.  It  gives  you  the  after- 
effects. It  gives  you  the  unexpected — the  unusual — effects.  It  gives  you  the 
tolerance — habit  formation.  Could  any  discussion  be  more  complete,  more 
thorough  ? 

Boston  Medical  and  Surgical  Journal 

"  Its  aim  throughout  is  therapeutic  and  practical,  rather  than  theoretic  and  pharmacologic. 
The  text  is  illustrated  with  sixty  well-chosen  plates  and  cuts.  It  should  prove  a  useful  con- 
tribution to  the  text-book  literature  on  these  subjects." 


McKenzie  on  Exercise  in 
Education    and    Medicine 

Exercise  in  Education  and  Medicine.  By  R.  TAIT  MCKENZIE,  B.  Av 
M.  D.,  Professor  of  Physical  Education  and  Director  of  the  Department, 
University  of  Pennsylvania.  Octavo  of  393  pages,  with  346  original 
illustrations.  Cloth,  $3.50  net. 

D.  A.  Sarg'eant,   M.   D.,  Director  of  Hemenway  Gymnasium,  Harvard  University. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of  an 
expert.  It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 

Bonney's  Tuberculosis  second  Edition 

TUBERCULOSIS.     By  SHERMAN  G.  BONNEY,  M.  D.,  Professor  of  Medi- 
cine, Denver  and  Gross  College  of  Medicine.     Octavo  of  955  pages,  with 
243  illustrations.      Cloth,  $7.00  net;   Half  Morocco,  $8.50  net. 
Maryland  Medical  Journal 

"  Dr.  Bonney's  book  is  one  of  the  best  and  most  exact  works  on  tuberculosis   in  all  its 
aspects,  that  has  yet  been  published." 


THE  PRACTICE   OF  MEDICINE 


A  Text-Book  of  the  Practice  of  Medicine.  By  JAMES  M.  ANDERS, 
M.  D.,  PH.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo,  1335  pages,  fully  illustrated.  Cloth,  $5.50  net;  Half 
Morocco,  $7.00  net. 

JUST  READY— THE  NEW  (llth)  EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration  given 
to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of  distinction 
of  simulating  diseases  being  presented  in  tabular  form.  In  this  new  edition 
Dr.  Anders  has  included  all  the  most  important  advances  in  medicine,  keeping 
the  book  within  bounds  by  a  judicious  elimination  of  obsolete  matter.  A  great 
many  articles  have  also  been  rewritten. 

Wm.  E.  Quine,  M.  D., 

Professor  of  Medicine  and  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession  at 
this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's  Physical   Diagnosis 

Physical  Diagnosis.  By  JOHN  C.  DACosxA,  JR.,  M.  D.,  Associate 
in  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  557  pages,  with  225  original  illustrations.  Cloth,  $3.50  net. 

NEW  (2d)  EDITION 

Dr.  DaCosta's  work  is  a  thoroughly  new  and  original  one.  Every  method 
given  has  been  carefully  tested  and  proved  of  value  by  the  author  himself. 
Normal  physical  signs  are  explained  in  detail  in  order  to  aid  the  diagnostician  in 
determining  the  abnormal.  Both  direct  and  differential  diagnosis  are  emphasized. 
The  cardinal  methods  of  examination  are  supplemented  by  full  descriptions  of 
technic  and  the  clinical  utility  of  certain  instrumental  means  of  research. 

Dr.  Henry  L.   Eisner,   Professor  of  Medicine  at  Syracuse  University. 

"  I  have  reviewed  this  book,  and  am  thoroughly  convinced  that  it  is  one  of  the  best  ever 
written  on  this  subject.  In  every  way  I  find  it  a  superior  production." 


SAUNDERS*   BOOKS  ON 


Sahli's  Diagnostic  Methods 


A  Treatise  on  Diagnostic  Methods  of  Examination.  By  PROF. 
DR.  H.  SAHLI,  of  Bern.  Edited,  with  additions,  by  NATH'L  BOWDITCH 
POTTER,  M.  D.,  Assistant  Professor  of  Clinical  Medicine,  Columbia  Uni- 
versity (College  of  Physicians  and  Surgeons),  New  York.  Octavo  of 
1229  pages,  illustrated.  Cloth,  $6.50  net  ;  Half  Morocco,  $8.00  net. 

THE  NEW  (ad)  EDITION,  ENLARGED  AND  RESET 

Dr.  Sahli's  great  work  is  a  practical  diagnosis,  written  and  edited  by  practical 
clinicians.  So  thorough  has  been  the  revision  for  this  edition  that  it  was  found 
necessary  practically  to  reset  the  entire  work.  Every  line  has  received  careful 
scrutiny,  adding  new  matter,  eliminating  the  old. 

Lewellys  F.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University 
"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in  the 
Johns  Hopkins  Medical  School." 

Friedenwald  and  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  JULIUS  FRIEDENWALD,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  JOHN  RUHRAH,  M.  D.,  Pro- 
fessor of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.  Octavo  of  857  pages.  Cloth,  $4.00  net. 

JUST  READY— THE  NEW  (4th)  EDITION 

This  new  edition  has  been  carefully  revised,  making  it  still  more  useful  than  the  two 
editions  previously  exhausted.  The  articles  on  milk  and  alcohol  have  been  rewritten,  additions 
made  to  those  on  tuberculosis,  the  salt-free  diet,  and  rectal  feeding,  and  several  tables  added, 
including  Winton's,  showing  the  composition  of  diabetic  foods. 

George  Dock,  M.  D. 

Professor  of  Theory  and  Practice  and  of  Clinical  Medicine,    Tulane    University. 
"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  available, 
I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  foods." 

Carter's  Diet  Lists  just  Ready 

DIET  LISTS  OF  THE  PRESBYTERIAN  HOSPITAL  OF  NEW  YORK  CITY. 
Compiled,  with  notes,  by  HERBERT  S.  CARTER,  M.  D.  i2mo  of  129 
pages.  Cloth,  $1.00  net. 

Here  Dr.  Cnrter  has  compiled  all  the  diet  lists  for  the  various  diseases  and  for  conva- 
lescence as  prescribed  at  the  Presbyterian  Hospital.     Recipes  are  also  included. 


PRACTICE   OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and  Pancreas 

Diseases  of  the  Stomach,  Intestines,  and  Pancreas.  By  ROBERT 
COLEMAN  KEMP,  M.  D.,  Professor  of  Gastro-intestinal  Diseases  at  the 
New  York  School  of  Clinical  Medicine.  Octavo  of  1021  pages,  with 
388  illustrations.  Cloth,  $6.50  net ;  Half  Morocco,  $8.00  net. 

NEW  (2d)  EDITIpN 

The  new  edition  of  Dr.  Kemp's  successful  work  appears  after  a  most  search- 
ing revision.  Several  new  subjects  have  been  introduced,  notably  chapters  on 
Colon  Bacillus  Infection  and  on  Diseases  of  the  Pancreas,  the  latter  article  being 
really  an  exhaustive  monograph,  covering  over  one  hundred  pages.  The  section 
on  Duodenal  Ulcer  has  been  entirely  rewritten.  Visceral  Displacements  are  given 
special  consideration,  in  every  case  giving  definite  indications  for  surgical  inter- 
vention when  deemed  advisable.  There  are  also  important  chapters  on  the  Intes- 
tinal Complications  of  Typhoid  Fever  and  on  Diverticulitis. 

The  Therapeutic  Gazette 

"The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and  clinical 
examination  are  adequately  and  correctly  described." 


Deaderick     on     Malaria 

Practical  Study  of  Malaria.  By  WILLIAM  H.  DEADERICK,  M.  D., 
Member  American  Society  of  Tropical  Medicine ;  Fellow  London 
Society  of  Tropical  Medicine  and  Hygiene.  Octavo  of  402  pages, 
illustrated.  Cloth,  $4.50  net ;  Half  Morocco,  $6.00  net. 

Frank  A.  Jones,    M.  D.,  Memphis  Hospital  Medical  College. 

"We  have  been  waiting  for  many  years  for  such  a  work  written  by  a  man  who  sees  malaria 
in  all  its  forms  in  a  highly  malarious  climate." 


Two  Printings 
in  Six  Months 


Niles  on  Pellagra 

Pellagra.  By  GEORGE  M.  NILES,  M.  D.,  Professor  of  Gastro- 
enterology  and  Therapeutics,  Atlanta  School  of  Medicine.  Octavo  of 
253  pages,  illustrated.  Cloth,  $3.00  net. 

This  is  a  book  you  must  have  to  get  in  touch  with  the  latest  advances  con- 
cerning this  disease.  It  is  the  first  book  on  the  subject  by  an  American  author, 
and  the  first  in  any  language  adequately  covering  diagnosis  and  treatment. 
Pathology,  heretofore  an  echo  of  European  views  only,  is  here  presented  from  an 
American  point  of  view  as  well,  much  original  work  being  included.  The  clinical 
description  covers  the  manifestations  of  Pellagra  from  every  angle. 


10 


SAUNDERS'  BOOKS  ON 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

UNDER   THE    EDITORIAL    SUPERVISION   OF 

ALFRED   STENGEL,   M.D. 

Professor  of  Medicine  in  the  University  of  Pennsylvan'0 


Typhoid  and  Typhus  Fevers 

By  DR.  H.  CURSCHMANN,  of  Leipsic,  Edited,  with  additions,  by  WILLIAM 
OSLER,  M.  D.,  F.  R.  C.  P.,  Regius  Professor  of  Medicine,  Oxford  University, 
Oxford,  England.  Octavo  of  646  pages,  illustrated. 

Smallpox  (including  Vaccination),  Varicella,  Cholera  Asiatica, 
Cholera  Nostras,  Erysipelas,  Erysipeloid,  Pertussis,  and 
Hay  Fever 

By  DR.  H.  IMMERMANN,  of  Basle  ;  DR.  TH.  VON  JURGENSEN,  of  Tubingen  ; 
DR.  C.  LIEBERMEISTER,  of  Tubingen ;  DR.  H.  LENHARTZ,  of  Hamburg ; 
and  DR.  G.  STICKER,  of  Giessen.  The  entire  volume  edited,  with  additions, 
by  SIR  j.  W.  MOORE,  M.  D.,  F.  R.  C.  P.  I.,  Professor  of  Practice,  Royal  Col- 
lege of  Surgeons,  Ireland.  Octavo  of  682  pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  WILLIAM  P.  NORTHRUP,  M.  D.,  of  New  York,  and  DR.  TH.  VON  JUR- 
GENSEN,  of  Tubingen.  The  entire  volume  edited,  with  additions,  by  WILLIAM 
P.  NORTHRUP,  M.  D.,  Professor  of  Pediatrics,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  Octavo  of  672  pages,  illustrated,  including 
24  full-page  plates,  3  in  colors. 

Diseases  of  the  Bronchi,  Diseases  of  the  Pleura,  and  Inflam- 
mations of  the  Lungs 

By  DR.  F.  A.  HOFFMANN,  of  Leipsic ;  DR.  O.  ROSENBACH,  of  Berlin ;  and 
DR.  F.  AUFRECHT,  of  Magdeburg.  The  entire  volume  edited,  with  additions, 
by  JOHN  H.  MUSSER,  M.  D.,  University  of  Pennsylvania.  Octavo  of  1029 
pages,  illustrated,  including  7  full-page  colored  lithographic  plates. 

Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

By  DR.  L.  OSER,  of  Vienna  ;  DR.  E.  NEUSSER,  of  Vienna  ;  and  DRS.  H. 
QUINCKE  and  G.  HOPPE-SEYLER,  of  Kiel.  The  entire  volume  edited,  with 
additions,  by  REGINALD  H.  FRITZ,  A.  M.,  M.  D.,  Hersey  Professor  of  the 
Theory  and  Practice  of  Physic,  Harvard  University  ;  and  FREDERICK  A. 
PACKARD,  M.  D.,  Late  Physician  to  the  Pennsylvania  and  Children's  Hos- 
pitals, Philadelphia.  Octavo  of  918  pages,  illustrated. 

.SOLD  SEPARATELY— PER  VOLUME:   CLOTH,   $5.00  NET;    HALF  MOROCCO,  $6.00  NET 


PRACTICE    OF  MEDICINE  II 

AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

Diseases  of  the  Stomach 

By  DR.  F.  RIEGEL,  of  Giessen.  Edited,  with  additions,  by  CHARLES  G. 
STOCKTON,  M.  D. ,  Professor  of  Medicine,  University  of  Buffalo.  Octavo  of 
835  pages,  with  29  text-cuts  and  6  full-page  plates. 

Diseases  of  the  Intestines  and  Peritoneum  Second  Edition 

By  DR.  HERMANN  NOTHNAGEL,  of  Vienna.  Edited,  with  additions,  by 
H.  D.  ROLLESTON,  M.  D.,  F.  R.  C.  P.,  Physician  to  St.  George's  Hospital, 
London.  Octavo  of  noopages,  illustrated. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  DR.  G.  CORNET,  of  Berlin.  Edited,  with  additions,  by  WALTER  B. 
JAMES,  M.  D.,  Professor  of  the  Practice  of  Medicine,  Columbia  University, 
New  York.  Octavo  of  806  pages. 

Diseases  Of  the  Blood   (Anemia,  Chlorosis,  Leukemia,  and  Pseudolcukemia) 

By  DR.  P.  EHRLICH,  of  Frankfort-on-the-Main  ;  DR.  A.  LAZARUS,  of  Char- 
lottenburg ;  DR.  K.  VON  NOORDEN,  of  Frankfort-on-the-Main  ;  and  DR. 
FELIX  PINKUS,  of  Berlin.  The  entire  volume  edited,  with  additions,  by  ALFRED 
STENGEL,  M.D.,  Professor  of  Medicine,  University  of  Pennsylvania.  Octavo 
of  714  pages,  with  text-cuts  and  13  full-page  plates,  5  in  colors. 

Malarial  Diseases,  Influenza,  and  Dengue 

By  DR.  J.  MANNABERG,  of  Vienna,  and  DR.  O.  LEICHTENSTERN,  of  Cologne. 
The  entire  volume  edited,  with  additions,  by  RONALD  Ross,  F.  R.  C.  S.  (ENG.), 
F.  R.  S.,  Professor  of  Tropical  Medicine,  University  of  Liverpool  ;  J.  W.  W. 
STEPHENS,  M.  D.,  D.  P.  H.,  Walter  Myers  Lecturer  on  Tropical  Medicine, 
University  of  Liverpool  ;  and  ALBERT  S.  GRUNBAUM,  F.  R.  C.  P. ,  Professor 
of  Experimental  Medicine,  University  of  Liverpool.  Octavo  of  769  pages, 
illustrated. 

Diseases  of  Kidneys  and  Spleen,  and  Hemorrhagic  Diatheses 

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Practice  of  Medicine,  Rush  Medical  College.  Octavo  of  815  pages,  illust. 

Diseases  of  the  Heart 

By  PROF.  DR.  TH.  VON  JURGENSEN,  of  Tubingen  ;  PROF.  DR.  L.  KREHL, 

of  Greifswaid  ;  and  PROF.   DR.   L.  VON  SCHROTTER,  of  Vienna.     Edited  by 

GEORGE  DOCK,   M.D.,  Professor  of  Theory  and  Practice  of  Medicine  and 

Clinical  Medicine,  Tulane  University.      Octavo,  848  pages,  illustrated. 

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Goepp's    State    Board    Questions 

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Pennsylvania  Medical  Journal 

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The  Medical  Record,  New  York 

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Butler's  Materia  Medica  New  (6th)  Edition 

A  TEXT-BOOK  OF  MATERIA  MEDICA,  THERAPEUTICS,  AND  PHARMA- 
COLOGY. By  GEORGE  F.  BUTLER,  PH.  G.,  M.  D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
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of  the  newer  compounds. 

Medical  Record,  New  York 

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A  TEXT-BOOK  OF  PHARMACOLOGY.  By  TORALD  SOLLMANN,  M.  D., 
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The  author  bases  the  study  of  therapeutics  on  systematic  knowledge  of 
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relation  between  pharmacology  and  practical  medicine. 

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"  The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scientific  a 
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Arny's  Pharmacy 

PRINCIPLES  OF  PHARMACY.  By  HENRY  V.  ARNY,  PH.  G.,  PH.  D., 
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to  be  in  the  hands  of  every  person  who  is  contemplating  the  study  of  pharmacy." 


THERAPEUTICS  AND  MA  TERIA  MEDICA 


Hinsdale's  Hydrotherapy 

Hydrotherapy  :  A  Treatise  on  Hydrotherapy  in  General  ;  Its 
Application  to  Special  Affections  ;  the  Technic  or  Processes  Employee^ 
and  a  Brief  Chapter  on  the  Use  of  Waters  Internally.  By  GUY  HINS- 
DALE,  M.  D.,  Fellow  Royal  Society  of  Medicine  of  Great  Britain. 
Octavo  of  466  pages,  illustrated.  Cloth,  $3.50  net. 

INCLUDING  CROUNOTHERAPY 

The  treatment  of  disease  by  hydrotherapeutic  measures  has  assumed  such  an 
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is  an  essential  in  every  practitioner's  armamentarium.  This  new  work  supplies 
all  needs.  It  describes  fully  the  various  kinds  of  baths,  douches,  sprays  ;  the 
application  of  heat  and  cold  ;  the  internal  use  of  mineral  waters  and  all  other 
procedures  included  under  hydrotherapeutic  measures. 

The  Medical  Record 

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Kelly's  Cyclopedia  of  Ameri- 
can Medical  Biog'raphy 

Cyclopedia  of  American  Medical  Biography.  By  HOWARD  A. 
KELLY,  M.  D.,  Johns  Hopkins  University.  Two  octavos,  averaging  525 
pages  each,  with  portraits.  Per  set:  Cloth,  $10.00  net;  Half  Morocco, 
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IN  TWO  VOLUMES 

Dr.  Kelly,  in  these  two  handsome  volumes,  presents  concise,  yet  complete, 
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advancement  of  medicine  in  America.  Dr.  Kelly's  reputation  for  painstaking 
care  assures  accuracy  of  statement.  There  are  about  one  thousand  biographies 
included. 

Swan' s  Prescription-writing  and  Formulary 

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Director  Glen  Springs  Sanitarium,  Watkins,  N.  Y.  i6mo  of  185  pages.  Flexible 
leather,  $1.25  net. 

Stewart's  Pocket  Therapeutics  and  Dose-book        j$s* 

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KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

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"  Dr.  Dorland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.  No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose-Book.  New(4th)  Edition 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING.       By  E.  Q.  THORNTON,  M.D., 

Assistant  Professor  of  Materia  Medica,  Jefferson  Medical  College,  Philadelphia.  Post- 
octavo,  410  pages,  illustrated.  Flexible  leather,  $2.00  net. 

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mend the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text- 
books."— C.  H.  MILLER,  M.  T).,Professor  of  Pharmacology,  Northwestern  University  Medi- 
cal School. 

Lusk  on  Nutrition  New  (2d)  Edition 

ELEMENTS  OF  THE  SCIENCE  OF  NUTRITION.  By  GRAHAM  LUSK,  PH.  D.,  Professor 
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$3.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the  subject." 
— LFWELLYS  F.  BARKER,  M.  D.,  Johns  Hopkins  University. 

Camac's  "Epoch-making  Contributions" 

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PRACTICE,    MATERIA   MEDICA,   Etc.  15 

The  American  Pocket  Medical  Dictionary  New  (8th)  Edition 

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leather,  with  gold  edges,  $1.00  net;  with  thumb  index,  $1.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

THE  PRACTICAL  APPLICATION  OF  THE  RONTGEN  RAYS  IN  THERAPEUTICS  AND 
DIAGNOSIS.  By  WILLIAM  ALLEN  PUSEY,  A.  M.,  M.  D.,  Professor  of  Dermatology  in 
the  University  of  Illinois ;  and  EUGENE  W.  CALDWELL,  B.  S.,  Director  of  the  Edward 
N.  Gibbs  X-Ray  Memorial  Laboratory  of  the  University  and  Bellevue  Hospital  Medical 
College,  New  York.  Octavo  of  625  pages,  with  200  illustrations.  Cloth,  $5.00  net; 
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Cohen  and  Eshner's  Diagnosis.     Second  Revised  Edition 

ESSENTIALS  OF  DIAGNOSIS.  By  S.  SOLIS-COHEN,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  ESHNER,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages  ;  55 
illustrations.  Cloth,  $1.00  net.  In  Saunders1  Question- Compend  Series. 

Morris*  Materia  Medica  and  Therapeutics.  New  (7th)  Edition 

ESSENTIALS  OF  MATERIA  MEDICA,  THERAPEUTICS,  AND  PRESCRIPTION-WRITING. 
By  HENRY  MORRIS,  M.  D.,  late  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.  Revised  by  W.  A.  BASTEDO,  M.  D.,  Instructor  in  Materia  Medica  and 
Pharmacology  at  Columbia  University.  1 2mo,  300  pages.  Cloth,  $l,oo  net.  In  Saunders' 
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Williams'  Practice  of  Medicine 

ESSENTIALS  OF  THE  PRACTICE  OF  MEDICINE.  By  W.  R.  WILLIAMS,  M.D., 
formerly  Instructor  in  Medicine  and  Lecturer  on  Hygiene,  Cornell  University  ;  and 
Tutor  in  Therapeutics,  Columbia  University,  N.  Y.  I2mo  of  456  pages,  illustrated. 
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Todd's  Clinical  Diagnosis  _     ...      ,_  „  _  .... 

The  New  (2d)  Edition 

A  MANUAL  OF  CLINICAL  DIAGNOSIS.  By  JAMES  CAMPBELL  TODD,  M.  D.,  Professor 
of  Pathology,  University  of  Colorado.  I2mo  of  469 pages,  with  164  text-illustrations 
and  10  colored  plates.  Cloth,  $2.25  net. 

Bridge  on  Tuberculosis 

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Oertel  on  Bright's  Disease  .  illustrated 

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Arnold's  Medical  Diet  Charts 

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Eggleston's  Prescription  Writing  J«'t  Ready 

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1  6  SAUNDERS'    BOOKS   ON  PRACTICE,  Etc. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

ATLAS  AND  EPITOME  OF  INTERNAL  MEDICINE  AND  CLINICAL  DIAGNOSIS.  By  DR. 
CHR.  JAKOB,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  ESHNER,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  182  colored  figures  on 
68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth,  $3.00  net.  In  Sounders' 
Hand-  Atlas  Series. 


Lockwood's  Practice  of  Medicine.  p. 

Revised  and  Enlarged 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.  By  GEO.  ROE  LOCKWOOD,  M.  D., 
Attending  Physician  to  the  Bellevue  Hospital,  New  York  City.  Octavo,  847  pages, 
with  79  illustrations  in  the  text  and  22  full-page  plates.  Cloth,  $4.00  net. 

Barton  and  Wells'  Medical  Thesaurus 

A  THESAURUS  OF  MEDICAL  WORDS  AND  PHRASES.  By  W.  M.  BARTON,  M.  D.,  and 
W.  A.  WELLS,  M.  D.,  of  Georgetown  University,  Washington,  D.  C.  I2rno  of  535 
pages.  Flexible  leather,  $2.50  net  ;  thumb  indexed,  33-  oo  net. 

Jelliffe's  Pharmacognosy 

AN  INTRODUCTION  TO  PHARMACOGNOSY.  By  SMITH  ELY  JELLIFFE,  PH.  D.,  M.  D., 
of  Columbia  University.  Octavo,  illustrated.  Cloth,  $2.50  net. 

Stevens'  Practice  of  Medicine  New  ;9th;  Edition 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.     By  A.  A.  STEVENS,  A.  M.,  M.  D., 

Professor  of   Pathology,   Woman's   Medical   College,    Phila.  Specially   intended  for 

students  preparing  for  graduation  and  hospital  examinations.  Post-octavo,  573  pages, 
illustrated.     Flexible  leather,  $2.50  net. 

Saunders'  Pocket  Formulary  New  (9th)  Edition 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  WILLIAM  M.  POWELL,  M.  D. 
Containing  1831  formulas  from  the  best-known  authorities.  With  an  Appendix  con- 
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Tousey's  Medical  Electricity  and  X-Rays 

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practical  illustrations,  16  in  colors.  Cloth,  $7.00  net  ;  Half  Morocco,  $8.50  net. 

Hatcher  and  Sollmann's  Materia  Medica 

A  TEXT-BOOK  OF  MATERIA  MEDICA  :  including  Laboratory  Exercises  in  the  Histo- 
logic  and  Chemic  Examination  of  Drugs.  By  ROBERT  A.  HATCHER,  PH.  G.,  M.  D., 
and  TORALD  SoLLMANN,  M.  D.  I2mo  of  411  pages.  Flexible  leather,  $2.00  net. 


Date  Due 


PR,NTED,NU.,.*.  CAT.  NO.  24    161 


S82Ht 

1911* 
on  diseases  of  the 


S82U 


Stelwagon  . 

Treatise  on  diseases  of  the  skin 


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UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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